A randomized controlled clinical trial comparing "guideline exposed" and "guideline naive" physicians in respect to dosage selection and treatment outcome with doxepin in depressive disorders.
BACKGROUND
Can prescribing of insufficient dosages and outcome of treatment with antidepressants in routine care be improved by guidelines?


METHODS
161 general practitioners and 162 psychiatrists in private practice documented 1319 patients, receiving doxepin for individual clinical reasons. Physicians were randomly divided into a guideline exposed and a control group. All physicians treated their patients according to individual clinical considerations.


RESULTS
Average maximum daily dosage was 83 mg/d in the control and 95 mg/d in the intervention group (F=19.15; p<0). Only 3% of patients in both groups got the recommended dosage of 150 mg/d. Guideline exposure resulted in increased dosages preferably for milder forms of depression and in comparatively lower rates of improvement.


CONCLUSIONS
Guideline exposure did not reach its goal in respect to the recommended dosage. It missed its goal in respect to improvement of outcome and even showed negative effects. Guidelines should be evidence-based not only by referring to literature reviews but by testing their clinical effects in controlled clinical trials.
Linden
M
M
Research Group Psychosomatic Rehabilitation at the Charité, University Medical School, Berlin, Germany. michael.linden@charite.de
Schotte
K
K
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000929:Antidepressive Agents, Tricyclic / Q000008:administration & dosage* / Q000627:therapeutic use; D003866:Depressive Disorder / Q000188:drug therapy*; D004316:Doxepin / Q000008:administration & dosage* / Q000627:therapeutic use; D004363:Drug Utilization; D005194:Family Practice; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D011570:Psychiatry
D000929:Antidepressive Agents, Tricyclic; D004316:Doxepin