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Two-Year Effects of Quality Improvement Programs on Medication Management for Depression
Jürgen Unützer, MD, MPH;
Lisa Rubenstein, MD, MSPH;
Wayne J. Katon, MD;
Lingqi Tang, PhD;
Naihua Duan, PhD;
Isabel T. Lagomasino, MD;
Kenneth B. Wells, MD, MPH
Arch Gen Psychiatry. 2001;58:935-942.
Background Significant underuse of evidence-based treatments for depression persists
in primary care. We examined the effects of 2 primary care–based quality
improvement (QI) programs on medication management for depression.
Methods A total of 1356 patients with depressive symptoms (60% with depressive
disorders and 40% with subthreshold depression) from 46 primary care practices
in 6 nonacademic managed care organizations were enrolled in a randomized
controlled trial of QI for depression. Clinics were randomized to usual care
or to 1 of 2 QI programs that involved training of local experts who worked
with patients' regular primary care providers (physicians and nurse practitioners)
to improve care for depression. In the QI-medications program, depression
nurse specialists provided patient education and assessment and followed up
patients taking antidepressants for up to 12 months. In the QI-therapy program,
depression nurse specialists provided patient education, assessment, and referral
to study-trained psychotherapists.
Results Participants enrolled in both QI programs had significantly higher rates
of antidepressant use than those in the usual care group during the initial
6 months of the study (52% in the QI-medications group, 40% in the QI-therapy
group, and 33% in the usual care group). Patients in the QI-medications group
had higher rates of antidepressant use and a reduction in long-term use of
minor tranquilizers for up to 2 years, compared with patients in the QI-therapy
or usual care group.
Conclusions Quality improvement programs for depression in which mental health specialists
collaborate with primary care providers can substantially increase rates of
antidepressant treatment. Active follow-up by a depression nurse specialist
in the QI-medications program was associated with longer-term increases in
antidepressant use than in the QI model without such follow-up.
From the Neuropsychiatric Institute, University of California, Los
Angeles (Drs Unützer, Tang, Duan, and Wells); VA Greater Los Angeles
Healthcare System (Dr Rubenstein) and the Department of Psychiatry, Charles
R. Drew University (Dr Lagomasino), Los Angeles, Calif; RAND, Santa Monica,
Calif (Drs Rubenstein and Wells); and the Department of Psychiatry, University
of Washington, Seattle (Dr Katon).
Corresponding author and reprints: Jürgen Unützer, MD,
MPH, Center for Health Services Research, Neuropsychiatric Institute, University
of California, Los Angeles, 10920 Wilshire Blvd, Suite 300, Los Angeles, CA
90024 (e-mail: unutzer{at}ucla.edu).
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