0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Article |

Treatment Process and Outcomes for Managed Care Patients Receiving New Antidepressant Prescriptions From Psychiatrists and Primary Care Physicians FREE

Gregory E. Simon, MD, MPH; Michael Von Korff, SCD; Carolyn M. Rutter, PhD; Do A. Peterson, MS
[+] Author Affiliations

From the Center for Health Studies, Group Health Cooperative (Drs Simon, Von Korff, and Rutter and Mr Peterson), and the Department of Biostatistics, University of Washington (Dr Rutter and Mr Peterson), Seattle.


Arch Gen Psychiatry. 2001;58(4):395-401. doi:10.1001/archpsyc.58.4.395.
Text Size: A A A
Published online

Background  While many studies describe deficiencies in primary care antidepressant treatment, little research has applied similar standards to psychiatric practice. This study compares baseline characteristics, process of care, and outcomes for managed care patients who received new antidepressant prescriptions from psychiatrists and primary care physicians.

Methods  At a prepaid health plan in Washington State, patients receiving initial antidepressant prescriptions from psychiatrists (n = 165) and primary care physicians (n = 204) completed a baseline assessment, including the Structured Clinical Interview for DSM-IV depression module, a 20-item depression assessment from the Symptom Checklist–90, and the Medical Outcomes Survey 36-Item Short-Form Health Survey functional status questionnaire. All measures were repeated after 2 and 6 months. Computerized data were used to assess antidepressant refills and follow-up visits over 6 months.

Results  At baseline, psychiatrists' patients reported slightly higher levels of functional impairment and greater prior use of specialty mental health care. During follow-up, psychiatrists' patients made more frequent follow-up visits, and the proportion making 3 or more visits in 90 days was 57% vs 26% for primary care physicians' patients. The proportion receiving antidepressant medication at an adequate dose for 90 days or more was similar (49% vs 48%). The 2 groups showed similar rates of improvement in all measures of symptom severity and functioning.

Conclusions  In this sample, clinical differences between patients treated by psychiatrists and primary care physicians were modest. Shortcomings in depression treatment frequently noted in primary care (inadequate follow-up care and high rates of inadequate antidepressant treatment) were also common in specialty practice. Possible selection bias limits any conclusions about relative effectiveness or cost-effectiveness.

Figures in this Article

PRIMARY CARE physicians in the United States account for nearly half of all antidepressant-related visits1,2 and 60% or more of first antidepressant prescriptions.3 Restrictions on access to specialty mental health care may further increase the proportion of first-line antidepressant treatment provided in primary care.4

Numerous studies raise questions about the quality of antidepressant treatment in primary care clinics, including early medication discontinuation,3,57 subtherapeutic dosing,3 and inadequate follow-up monitoring.59 Surprisingly, few recent studies have applied similar measures to patients treated by psychiatrists.

Two studies conducted during the 1980s compared depression care by primary care physicians and psychiatrists, but neither focused specifically on pharmacotherapy. Sturm and Wells10 used data from the Medical Outcomes Study to compare quality and cost of depression treatment in primary care and specialty sectors, concluding that specialty care was more effective but more expensive. This comparison, however, considered overall performance of the 2 systems, including differences in recognition and treatment rates. Scott and Freeman11 found that random assignment of depressed patients to amitriptyline prescribed by psychiatrists did not significantly improve outcomes compared with usual primary care, but the sample size was insufficient to detect moderate differences in outcomes.

Three recent studies used prescription data to examine the duration and dose of antidepressant treatment provided by psychiatrists and primary care physicians. Analyses of health maintenance organization data by Simon et al3 and Katzelnick and colleagues6 found that patients receiving initial antidepressant prescriptions from psychiatrists were approximately 10% more likely to receive an adequate dose and duration of short-term treatment—but that 40% to 50% of psychiatrists' patients still received inadequate treatment. Using a nationwide sample of pharmacy claims, Fairman et al12 found that specialty differences in medication adherence and adequacy of dosing disappeared when analyses were limited to patients receiving newer antidepressants. In all 3 of these studies, no data were available regarding clinical differences at baseline or follow-up.

A substantial amount of literature compares the process and outcomes of specialist and generalist care for other major health conditions, including heart disease,1316 diabetes,17,18 hypertension,17 obstructive lung disease,19,20 and human immunodeficiency virus infection.21 In general, specialists showed greater adherence to expert guidelines.22 When patient outcomes were examined, advantages of specialty care appeared greater for hospital care1416,20 than for outpatient management.1719

This report examines baseline characteristics, process of care, and clinical outcomes in cohorts of managed care patients receiving initial antidepressant prescriptions from primary care physicians or psychiatrists. We focus on patients initiating treatment in both settings, rather than examining consequences of nonrecognition or nontreatment. This observational design is an advantage for our first objective (describing baseline characteristics and process of care for patients treated by primary care physicians and psychiatrists under naturalistic conditions) and a disadvantage for our second (comparing outcomes of care for these 2 groups). Outcome comparisons are liable to be biased because of baseline differences, especially differences that cannot be observed or adjusted for.

SETTING

The study was conducted between February 1994 and November 1996 at staff-model clinics of the Group Health Cooperative of Puget Sound, a prepaid health plan serving approximately 450 000 members in western Washington State. Most members are covered through employer-purchased plans, but the enrollment includes approximately 45 000 Medicare members and 35 000 members covered by Medicaid or by Washington's Basic Health Plan (a state program for low-income residents). Group Health Cooperative members are similar to Seattle, Wash, area residents, except for a higher educational level and less representation of high-income residents.23

All mental health and general medical providers are paid by salary, with no individual financial incentives tied to use or referral. Each full-time primary care physician is responsible for a panel of approximately 2200 patients. Six outpatient specialty mental health clinics emphasize short-term individual psychotherapy, pharmacotherapy, and group therapy. Approximate mental health staffing ratios per 100 000 members are 5.5 psychiatrists, 2.5 psychiatric nurse practitioners, 2.5 psychiatric nurses, 2.5 psychologists, and 15 master's-level psychotherapists (ratios similar to other group or staff-model health plans24).

Typical coverage arrangements for outpatient psychotherapy allow 10 to 20 visits per year subject to $10 to $20 copayments. Psychiatric visits for medication management are covered at parity with general medical visits (same copayment level and no annual limits).

Patients seeking depression treatment may visit primary care physicians or self-refer to the nearest specialty mental health clinic. On diagnosing depression, primary care physicians may choose to initiate antidepressant treatment or refer for specialty consultation. Patients self-referring to specialty care may request initial treatment by a psychiatrist or a nonprescribing psychotherapist. Nonprescribing therapists may refer patients for psychiatric evaluation. Consequently, patients may receive an initial antidepressant prescription from a psychiatrist following direct self-referral, referral from a primary care physician, or referral from a nonprescribing psychotherapist.

SAMPLE

Computerized pharmacy records were used to identify a random sample of adult health plan members filling new prescriptions for antidepressants from primary care physicians or psychiatrists (with new defined as no antidepressant prescription during the past 150 days). Computerized visit data were used to select those with diagnoses of depression (major depressive disorder, dysthymia, or depression not otherwise specified) within 30 days before the index prescription. Computerized records were also used to exclude patients with diagnoses of bipolar disorder or psychotic disorder during the prior 2 years. An invitation letter (including a written description of study procedures) was mailed 3 to 7 days after the index prescription. We then attempted to contact all eligible patients for a telephone assessment 5 to 10 days later.

ASSESSMENTS

Following a documented oral consent procedure, eligible and consenting patients completed a baseline assessment, including a 20-item depression assessment extracted from the Hopkins Symptom Checklist–90 or the Symptom Checklist–90 (SCL),25 the current depression module of the Structured Clinical Interview for DSM-IV,26 the Medical Outcomes Survey 36-Item Short-Form Health Survey (SF-36),27 questions regarding past depressive episodes and depression treatment, and questions regarding days of restricted activity or missed work because of illness.28 The baseline assessment focused on the 2-week period before the index prescription. Two and 6 months after the index prescription, all participants were contacted for telephone follow-up assessments, including the SCL depression scale (the primary measure of clinical outcome), the SF-36 questionnaire, and questions regarding restricted activity and missed workdays.

Interviewer training included 8 hours of didactic instruction, observation of 5 interviews, performance of 5 or more interviews under observation, and weekly supervision. Previous research documents excellent agreement between telephone and in-person administration of the Structured Clinical Interview for DSM-IV and the SCL.29

MEASURES OF TREATMENT RECEIVED

Computerized information systems were used to examine treatment received during the 6 months before and the 6 months after the index prescription. We examined 2 measures of treatment quality. First, we used previously developed and validated algorithms30 to examine the proportion of patients receiving at least 90 days of continuous antidepressant treatment at a minimally adequate dose (eg, 75 mg of imipramine hydrochloride or 10 mg of fluoxetine hydrochloride).31,32 Second, we examined the proportion of patients meeting the NCQA's Health Plan Employer Data and Information Set (HEDIS)33 criteria for adequate follow-up care (at least 3 visits in 90 days, and at least 1 to a prescribing provider). Pharmacy records for the 6 months before randomization were used to compute the revised chronic disease score, a measure of medical comorbidity and predicted health care use.34,35

DATA ANALYSIS

All analyses classify patients according to source of the initial prescription regardless of subsequent care. Baseline comparisons used mixed-model analysis of variance (including random effects to account for clustering of patients within physicians). Outcome comparisons used mixed-model analysis of covariance (with physician as random effect) to examine change between baseline and follow-up, with 2- and 6-month assessments considered as repeated measures. Outcome comparisons were adjusted for age, sex, chronic disease score, and baseline value of the relevant outcome measure. The threshold for statistical significance was an α level of .05 (2-sided).

PARTICIPATION

Of 720 eligible patients, 97 could not be contacted by telephone and 254 declined participation, leaving a final sample of 369 (51% of those eligible and 59% of those contacted). Overall, participation was significantly higher among patients treated by primary care physicians than among those treated by psychiatrists (62% vs 42%; χ21 = 26.4; P<.001). Across both groups, participants were similar to nonparticipants in age, sex, and use of general medical or mental health services in the prior 6 months.

Of the 369 patients completing the baseline assessment, 325 (88%) completed the 2-month follow-up and 307 (83%) completed the 6-month follow-up. Follow-up participants and nonparticipants did not differ significantly in age, sex, or severity of depression at baseline. Follow-up participation was similar in the 2 cohorts at 2 months but was slightly higher for patients treated by psychiatrists at 6 months (88% vs 80%; χ21 = 4.02; P = .04). Analyses of interview data included all patients participating at each point. All analyses of treatment received (ie, visits made and prescriptions filled) were limited to the 93% of participants enrolled in the health plan throughout follow-up. The probability of disenrollment did not vary between the 2 groups.

BASELINE CHARACTERISTICS

At baseline, patients treated by psychiatrists were younger, more often men, had slightly (but not significantly) higher SCL depression scores, and had significantly lower (more impaired) scores on several subscales of the SF-36 (Table 1). As expected, patients treated by psychiatrists more often reported prior use of inpatient and outpatient specialty mental health care. The 2 groups did not differ in severity of comorbid medical illness (as measured by the chronic disease score).

Table Graphic Jump LocationTable 1. Baseline Characteristics of Patients Receiving an Initial Antidepressant Prescription From Primary Care Physicians and Psychiatrists*
TREATMENT RECEIVED

Psychiatrists' patients made a mean of 2.86 more visits during follow-up (95% confidence interval, 1.78-3.94), but this group also had a higher visit rate before beginning treatment (Table 2). After controlling for number of visits in the prior 6 months, the mean difference during the follow-up period was 0.64 visit (95% confidence interval, 0.50-0.78). Visit data also showed modest rates of "crossover" during follow-up: approximately 6% of patients treated by primary care physicians made a medication follow-up visit in the specialty clinic and 23% of patients treated initially by psychiatrists made depression-related primary care visits during follow-up. Psychiatrists' patients were significantly more likely to visit nonprescribing psychotherapists before (56% vs 6%; χ21 = 106; P<.001) and after (49% vs 16%; χ21 = 45.1; P<.001) starting antidepressant treatment. The proportion meeting the HEDIS standard for adequate follow-up care was 26% among patients treated by primary care physicians and 57% among those treated initially by psychiatrists (χ21 = 34.5; P<.01).

Table Graphic Jump LocationTable 2. Outpatient Visits Made 6 Months Before and 6 Months After the Initial Antidepressant Prescription*

The proportion of patients receiving 90 days of adequate pharmacotherapy (see the "Measures of Treatment Received" subsection of the "Participants and Methods" section) was 48% in the primary care group and 49% among patients treated by psychiatrists.

OUTCOMES

Average SCL depression scores showed similar improvement over time in both groups (Figure 1). After adjustment for age, sex, chronic disease score, and baseline SCL score, the 2-month SCL score was slightly higher among psychiatrists' patients (mean difference, 0.14; 95% confidence interval, 0.00-0.27), but no significant difference was seen at 6 months. The proportion of patients reporting a 50% or greater decrease in SCL depression score from baseline to 6-month follow-up was 70% in the primary care group and 62% among patients treated initially by psychiatrists. Scores on the emotional role subscale of the SF-36 (Figure 2) showed the same pattern seen for SCL depression score: similar improvement over time in the primary care and psychiatry groups. Results for the mental health, social functioning, and vitality subscales of the SF-36 showed a similar pattern (details available on request). Analyses of days missed from work due to illness (Figure 3) were limited to those working at each point. As with other measures, the 2 groups showed similar rates of improvement, with no significant difference in adjusted follow-up scores.

Place holder to copy figure label and caption
Figure 1.

Symptom Checklist–90 (SCL) depression scores over time for patients receiving initial antidepressant prescriptions from psychiatrists (n = 165) or primary care physicians (n = 204). An SCL depression score of 0.5 or less indicates remission; 0.5 to 1.3, mild depression; and 1.3 to 2.2, moderate depression.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Medical Outcomes Survey 36-Item Short-Form Health Survey (SF-36) emotional role subscale scores over time for patients receiving initial antidepressant prescriptions from psychiatrists (n = 165) or primary care physicians (n = 204).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Workdays missed per month over time for patients receiving initial antidepressant prescriptions from psychiatrists (n = 119) or primary care physicians (n = 139). The sample is limited to those working at each point.

Graphic Jump Location

We compared cohorts of managed care patients receiving initial antidepressant prescriptions from psychiatrists and primary care physicians. At baseline, patients of psychiatrists were slightly more symptomatic and more impaired. During 6 months of follow-up, only 26% of primary care physicians' patients and 57% of psychiatrists' patients met HEDIS standards for adequate follow-up care. Fewer than half of patients received at least 90 days of pharmacotherapy at a minimally adequate dose. The rate of clinical and functional improvement was similar in the 2 groups.

The most significant limitation of this study is its observational design, including self-selection of patients into primary or specialty care. The 2 cohorts differed on several measured factors (age, sex, treatment history, depression severity, and willingness to participate in research) and probably differed in ways we were unable to measure (eg, treatment preferences and expectations). A truly unbiased comparison of outcomes would require random assignment, but we doubt such a study would prove acceptable to patients or practical to conduct.

We should also acknowledge several other limitations. First, our findings may not generalize to health care systems with different structure, financial incentives, or provider training. Second, we are not able to separate the specific effects of antidepressant treatment from the effects of formal psychotherapy or nonspecific support. Third, our baseline assessment was conducted 1 to 3 weeks after the initiation of treatment (although all baseline measures did focus on the period before the initial prescription). Finally, many patients declined to participate. Our analyses of available data do not suggest significant bias due to nonresponse, but we cannot exclude this possibility.

Baseline differences between the 2 groups were modest in clinical terms. Contrary to expectation, medical comorbidity was not significantly greater among primary care physicians' patients. The modest clinical differences between groups may reflect relatively free access to psychiatric care in this health system. Limits on self-referral might restrict the psychiatric group to the more severely ill patients. We should emphasize that we selected psychiatrists' patients initiating antidepressant treatment, excluding those referred after unsuccessful primary care treatment. A cross-sectional sample of psychiatrists' patients (rather than a cohort of treatment initiators) would reflect the accumulation of more severely ill patients via referral.

Analyses of follow-up visits and prescription refills demonstrate significant shortcomings in the primary care and psychiatry cohorts. We doubt that these findings reflect managed care restrictions in general or the characteristics of this managed care organization. Our findings regarding primary care pharmacotherapy are consistent with recent studies in this setting3,5,36 and in other managed care and fee-for-service settings.6,7,12,37 The proportion of primary care physicians' patients in our sample meeting the HEDIS standard for adequate follow-up care (26%) was quite similar to the average of 23% for health plans participating in HEDIS.38 The limited data available regarding pharmacotherapy in specialty practice (from managed care and fee-for-service settings) show similar rates of inadequate treatment.3,6,12,39 Furthermore, the specific aspects of care we examine—antidepressant refills and medication follow-up visits—were available without limit and covered at parity with general medical care. The shortcomings we observe would be less concerning if confined to patients with mild or transient depression. Unfortunately, this was not the case in either the primary care or the psychiatry group (details available on request).

While patients treated by psychiatrists were somewhat more severely ill, the intensity and continuity of pharmacotherapy were no greater. High rates of inadequate pharmacotherapy among patients treated by psychiatrists may appear inconsistent with psychiatrists' clinical experience. In fact, we found that psychiatrists' patients receiving inadequate pharmacotherapy were largely invisible in everyday practice: only 29% made any psychiatric visit during the second half of the follow-up period. For most patients receiving inadequate pharmacotherapy, there was no chance for this problem to be detected or corrected.

Patients beginning antidepressant treatment with primary care physicians and psychiatrists showed similar patterns of improvement over time in depressive symptoms, functional impairment, and disability. While most experienced significant improvement, approximately 40% remained at least moderately symptomatic. Our comparison of change in SCL depression scores had sufficient statistical power to detect a difference of 0.15 to 0.20 between the 2 groups (ie, approximately 15% of the change seen in both groups from baseline to follow-up).

The most striking difference between the 2 cohorts was in visits to nonprescribing psychotherapists before and after starting antidepressant treatment. These differences, however, could be used to argue for and against the benefits of specialty treatment. On the one hand, specialty patients could be considered more treatment resistant (more depressive symptoms at baseline despite ongoing psychotherapy). On the other hand, specialty patients showed similar rates of improvement despite much higher rates of combined treatment.

Our data do not support firm conclusions regarding the relative effectiveness or cost-effectiveness of treatment provided by psychiatrists and primary care physicians. Given differences in baseline characteristics and concomitant use of psychotherapy, comparisons of outcomes should be made cautiously. Even if outcome findings are ignored, however, the patterns of medication use and follow-up visits in both groups are concerning. We present these findings to address a significant gap in recent research and to stimulate discussion regarding the need for systematic follow-up care in psychiatric practice.

Shortcomings in primary care depression treatment have been attributed to deficiencies in primary care physicians' knowledge, skills, or motivation. We observed similar shortcomings among patients treated by psychiatrists (a group presumed to have significantly greater knowledge, skill, and motivation to treat depression). We believe that shortcomings in primary care and psychiatry practice reflect systemic problems40 that are unlikely to be overcome by educational approaches alone.41 In a recent review of research on primary vs specialty care for various chronic medical conditions, Donohoe42 reached a similar conclusion: differences between primary care and specialty practice are less important than the gaps in long-term illness management common to all physicians.

After comparing overall performance of the primary care and specialty sectors, Sturm and Wells10 concluded that quality improvement (rather than a shift from the primary care to the specialty sector) is the most efficient strategy for improving depression treatment at the population level. We reach the same conclusion, but for different reasons. The shortcomings previously observed in primary care were also seen in specialty practice. In both groups of patients, fewer than half received the minimal recommended levels of antidepressant treatment, and 40% to 70% did not receive the minimal recommended levels of follow-up care. These 2 gaps in treatment were associated; patients receiving "inadequate" pharmacotherapy were also less likely to make follow-up visits, where inadequate treatment might be detected and corrected. It appears that shifting primary care physicians' patients to specialists will not adequately address widespread undertreatment of depression.43 Several recent studies9,4446 have demonstrated that organized treatment programs (including systematic monitoring of adherence and patient outcomes and active follow-up) can significantly improve the quality and outcomes of depression treatment in primary care. Our findings suggest that similar monitoring and follow-up programs should be evaluated in specialty practice.

Accepted for publication November 27, 2000.

This study was supported by grant 51338 from the National Institute of Mental Health, Rockville, Md.

Presented at the National Institute of Mental Health 13th International Conference on Mental Health in the General Health Care Sector, Washington, DC, July 12, 1999.

Corresponding author and reprints: Gregory E. Simon, MD, MPH, Center for Health Studies, Group Health Cooperative, 1730 Minor Ave, Suite 1600, Seattle, WA 98101-1448 (e-mail: simon.g@ghc.org).

Olfson  MKlerman  GL Trends in the prescription of psychotropic medications: the role of physician specialty. Med Care. 1993;31559- 564
Link to Article
Pincus  HTanielian  TMarcus  SOlfson  MZarin  DThompson  JZito  J Prescribing trends in psychotropic medications: primary care, psychiatry, and other medical specialties. JAMA. 1998;279526- 531
Link to Article
Simon  GVonKorff  MWagner  EHBarlow  W Patterns of antidepressant use in community practice. Gen Hosp Psychiatry. 1993;15399- 408
Link to Article
Barsky  ABorus  JF Somatization and medicalization in the era of managed care. JAMA. 1995;2741931- 1934
Link to Article
Katon  WVonKorff  MLin  EBush  TOrmel  J Adequacy and duration of antidepressant treatment in primary care. Med Care. 1992;3067- 76
Link to Article
Katzelnick  DKobak  KJefferson  JGreist  JHH Prescribing patterns of antidepressant medications for depression in an HMO. Formulary. 1996;31374- 388
Wells  KKaton  WRogers  BCamp  P Use of minor tranquilizers and antidepressant medications by depressed outpatients: results from the Medical Outcomes Study. Am J Psychiatry. 1994;151694- 700
Katz  SKessler  RLin  EWells  K Medication management of depression in the United States and Canada. J Gen Intern Med. 1998;1377- 85
Link to Article
Simon  GVonKorff  MRutter  CWagner  E A randomized trial of monitoring, feedback, and management of care by telephone to improve depression treatment in primary care. BMJ. 2000;320550- 554
Link to Article
Sturm  RWells  KB How can care for depression become more cost-effective? JAMA. 1995;27351- 58
Link to Article
Scott  AFreeman  C Edinburgh primary care depression study: treatment outcome, patient satisfaction, and cost after 16 weeks. BMJ. 1992;304883- 887
Link to Article
Fairman  KDrevets  WKreisman  JTeitelbaum  F Course of antidepressant treatment, drug type, and prescriber's specialty. Psychiatr Serv. 1998;491180- 1186
Jollis  JDelong  EPeterson  EMuhlbaier  LFortin  DCaliff  RMark  D Outcome of acute myocardial infarction according to the specialty of the admitting physician. N Engl J Med. 1996;3351880- 1887
Link to Article
Chen  JRadford  MWang  YKrumholz  H Care and outcomes of elderly patients with acute myocardial infarction by physician specialty: the effects of comorbidity and functional limitations. Am J Med. 2000;108460- 469
Link to Article
Go  ARao  RDauterman  KMassie  B A systematic review of the effects of physician specialty on the treatment of coronary disease and heart failure in the United States. Am J Med. 2000;108216- 316
Link to Article
Auerbach  AHamel  MDavis  RConnors  AJRegueiro  CDesbiens  NGoldman  LCaliff  RDawson  NWenger  NVidaillet  HPhillips  R Resource use and survival of patients hospitalized with congestive heart failure: differences in care by specialty of the attending physician. Ann Intern Med. 2000;132191- 200
Link to Article
Greenfield  SRogers  WMangotich  MCarney  MTarlov  A Outcomes of patients with hypertension and non-insulin dependent diabetes treated by different systems and specialties: results of the Medical Outcomes Study. JAMA. 1995;2741436- 1444
Link to Article
Chin  MZhang  JMerrell  K Specialty differences in the care of older patients with diabetes. Med Care. 2000;38131- 140
Link to Article
Vollmer  WO'Hollaren  MEttingger  KStibolt  TWilkins  JBuist  ALinton  KOsborne  M Specialty differences in the management of asthma: a cross-sectional assessment of allergists' patients and generalists' patients in a large HMO. Arch Intern Med. 1997;1571201- 1208
Link to Article
Regueiro  CHamel  MDavis  RDesbiens  NConnors  AJPhillips  R A comparison of generalist and pulmonologist care for patients hospitalized with severe chronic obstructive pulmonary disease: resource intensity, hospital costs, and survival. Am J Med. 1998;105366- 372
Link to Article
Aiken  LSloane  DLake  ESochalski  JWeber  A Organization and outcomes of inpatient AIDS care. Med Care. 1999;37760- 762
Link to Article
Harrold  LField  TGurwitz  J Knowledge, patterns of care, and outcomes of care for generalists and specialists. J Gen Intern Med. 1999;14499- 511
Link to Article
Simon  GVonKorff  MBarlow  WPabiniak  CWagner  E Predictors of chronic benzodiazepine use in a health maintenance organization sample. J Clin Epidemiol. 1996;491067- 1073
Link to Article
Dial  TBergsten  CHaviland  MPincus  H Psychiatrist and nonphysician mental health provider staffing levels in health maintenance organizations. Am J Psychiatry. 1998;155405- 408
Derogatis  LRickels  KUhlenhuth  EHCovi  L The Hopkins Symptom Checklist: a measure of primary symptom dimensions. Pichot  Ped.Psychological Measurements in Psychopharmacology Problems in Psychopharmacology. Basel, Switzerland Kargerman1974;79- 110
First  MSpitzer  RGibbon  MWilliams  J Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), Clinician Version.  Washington, DC American Psychiatric Press1997;
Ware  JSnow  KKKosinski  MGandek  B The MOS SF-36 Health Survey: Manual and Interpretation Guide.  Boston, Mass Health Institute, New England Medical Center1993;
Chyba  MMWashington  LR Questionnaires from the National Health Interview Survey, 1985-89. Vital Health Stat 1. 1993;311- 412
Simon  GVonKorff  MRevicki  D Telephone assessment of depression severity. J Psychiatr Res. 1993;27247- 252
Link to Article
Simon  GLin  EHBKaton  WSaunders  KVonKorff  MWalker  EBush  TRobinson  P Outcomes of "inadequate" antidepressant treatment in primary care. J Gen Intern Med. 1995;10663- 670
Link to Article
Not Available, Clinical Practice Guideline Number 5: Depression in Primary Care, 2: Treatment of Major Depression.  Rockville, Md Agency for Health Care Policy and Research, US Dept of Health and Human Services1993;AHCPR publication 93-0551.
Saunders  KSimon  GBush  TGrothaus  L Assessing the accuracy of computerized pharmacy refill data to monitor antidepressant treatment on a population basis: a comparison of automated and self-report data. J Clin Epidemiol. 1998;51883- 890
Link to Article
Coltin  KLBeck  A The HEDIS antidepressant measure. Behav Healthc Tomorrow. 1999;840- 4147
VonKorff  MWagner  ESaunders  K A chronic disease score from automated pharmacy data. J Clin Epidemiol. 1992;45197- 203
Link to Article
Clark  DVonKorff  MSaunders  KBaluch  WMSimon  GE A chronic disease score with empirically derived weights. Med Care. 1995;33783- 795
Link to Article
Simon  GVonKorff  MHeiligenstein  JHRevicki  DAGrothaus  LKaton  WWagner  EH Initial antidepressant selection in primary care: effectiveness and cost of fluoxetine vs tricyclic antidepressants. JAMA. 1996;2751897- 1902
Link to Article
Melfi  CChawla  ACroghan  THanna  MKennedy  SSredl  K The effects of adherence to antidepressant treatment guidelines on relapse and recurrence in depression. Arch Gen Psychiatry. 1998;551128- 1132
Link to Article
Not Available, HEDIS 1999 New Measure National Results: HEDIS Users Group Monthly Update.  Washington, DC National Committee for Quality Assurance1999;
Keller  MBLavori  PWKlerman  GLAndreasen  NCEndicott  JCoryell  WFawcett  JRice  JPHirschfield  RMA Low levels and lack of predictors of somatotherapy and psychotherapy received by depressed patients. Arch Gen Psychiatry. 1986;43458- 466
Link to Article
Wagner  EAustin  BVonKorff  M Organizing care for patients with chronic illness. Milbank Q. 1996;74511- 544
Link to Article
Thompson  CKinmonth  AStevens  LPeveler  RStevens  AOstler  KPickering  RBaker  NHenson  APreece  JCooper  DCampbell  M Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial. Lancet. 2000;355185- 191
Link to Article
Donohoe  M Comparing generalist and specialty care: discrepancies, deficiencies, and excesses. Arch Intern Med. 1998;1581596- 1608
Link to Article
Hirschfeld  RKeller  MBPanico  SArons  BSBarlow  DDavidoff  FEndicott  JFroom  JGoldstein  MGorman  JMGuthrie  DMarek  RSMaurer  TAMeyer  RPhillips  KRoss  JSchwenk  TLSharfstein  SSThase  MEWyatt  RJ The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression. JAMA. 1997;277333- 340
Link to Article
Katon  WVonKorff  MLin  EWalker  ESimon  GBush  TRobinson  PRusso  J Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA. 1995;2731026- 1031
Link to Article
Katon  WRobinson  PVonKorff  MLin  EBush  TLudman  ESimon  GWalker  E A multifaceted intervention to improve treatment of depression in primary care. Arch Gen Psychiatry. 1996;53924- 932
Link to Article
Hunkeler  EMMeresman  JFHargreaves  WAFireman  BBerman  WHKirsch  AJGroebe  JHurt  SWBraden  PGetzell  MFeigenbaum  PAPeng  TSalzer  M Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care. Arch Fam Med. 2000;9700- 708
Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Symptom Checklist–90 (SCL) depression scores over time for patients receiving initial antidepressant prescriptions from psychiatrists (n = 165) or primary care physicians (n = 204). An SCL depression score of 0.5 or less indicates remission; 0.5 to 1.3, mild depression; and 1.3 to 2.2, moderate depression.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Medical Outcomes Survey 36-Item Short-Form Health Survey (SF-36) emotional role subscale scores over time for patients receiving initial antidepressant prescriptions from psychiatrists (n = 165) or primary care physicians (n = 204).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Workdays missed per month over time for patients receiving initial antidepressant prescriptions from psychiatrists (n = 119) or primary care physicians (n = 139). The sample is limited to those working at each point.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Baseline Characteristics of Patients Receiving an Initial Antidepressant Prescription From Primary Care Physicians and Psychiatrists*
Table Graphic Jump LocationTable 2. Outpatient Visits Made 6 Months Before and 6 Months After the Initial Antidepressant Prescription*

References

Olfson  MKlerman  GL Trends in the prescription of psychotropic medications: the role of physician specialty. Med Care. 1993;31559- 564
Link to Article
Pincus  HTanielian  TMarcus  SOlfson  MZarin  DThompson  JZito  J Prescribing trends in psychotropic medications: primary care, psychiatry, and other medical specialties. JAMA. 1998;279526- 531
Link to Article
Simon  GVonKorff  MWagner  EHBarlow  W Patterns of antidepressant use in community practice. Gen Hosp Psychiatry. 1993;15399- 408
Link to Article
Barsky  ABorus  JF Somatization and medicalization in the era of managed care. JAMA. 1995;2741931- 1934
Link to Article
Katon  WVonKorff  MLin  EBush  TOrmel  J Adequacy and duration of antidepressant treatment in primary care. Med Care. 1992;3067- 76
Link to Article
Katzelnick  DKobak  KJefferson  JGreist  JHH Prescribing patterns of antidepressant medications for depression in an HMO. Formulary. 1996;31374- 388
Wells  KKaton  WRogers  BCamp  P Use of minor tranquilizers and antidepressant medications by depressed outpatients: results from the Medical Outcomes Study. Am J Psychiatry. 1994;151694- 700
Katz  SKessler  RLin  EWells  K Medication management of depression in the United States and Canada. J Gen Intern Med. 1998;1377- 85
Link to Article
Simon  GVonKorff  MRutter  CWagner  E A randomized trial of monitoring, feedback, and management of care by telephone to improve depression treatment in primary care. BMJ. 2000;320550- 554
Link to Article
Sturm  RWells  KB How can care for depression become more cost-effective? JAMA. 1995;27351- 58
Link to Article
Scott  AFreeman  C Edinburgh primary care depression study: treatment outcome, patient satisfaction, and cost after 16 weeks. BMJ. 1992;304883- 887
Link to Article
Fairman  KDrevets  WKreisman  JTeitelbaum  F Course of antidepressant treatment, drug type, and prescriber's specialty. Psychiatr Serv. 1998;491180- 1186
Jollis  JDelong  EPeterson  EMuhlbaier  LFortin  DCaliff  RMark  D Outcome of acute myocardial infarction according to the specialty of the admitting physician. N Engl J Med. 1996;3351880- 1887
Link to Article
Chen  JRadford  MWang  YKrumholz  H Care and outcomes of elderly patients with acute myocardial infarction by physician specialty: the effects of comorbidity and functional limitations. Am J Med. 2000;108460- 469
Link to Article
Go  ARao  RDauterman  KMassie  B A systematic review of the effects of physician specialty on the treatment of coronary disease and heart failure in the United States. Am J Med. 2000;108216- 316
Link to Article
Auerbach  AHamel  MDavis  RConnors  AJRegueiro  CDesbiens  NGoldman  LCaliff  RDawson  NWenger  NVidaillet  HPhillips  R Resource use and survival of patients hospitalized with congestive heart failure: differences in care by specialty of the attending physician. Ann Intern Med. 2000;132191- 200
Link to Article
Greenfield  SRogers  WMangotich  MCarney  MTarlov  A Outcomes of patients with hypertension and non-insulin dependent diabetes treated by different systems and specialties: results of the Medical Outcomes Study. JAMA. 1995;2741436- 1444
Link to Article
Chin  MZhang  JMerrell  K Specialty differences in the care of older patients with diabetes. Med Care. 2000;38131- 140
Link to Article
Vollmer  WO'Hollaren  MEttingger  KStibolt  TWilkins  JBuist  ALinton  KOsborne  M Specialty differences in the management of asthma: a cross-sectional assessment of allergists' patients and generalists' patients in a large HMO. Arch Intern Med. 1997;1571201- 1208
Link to Article
Regueiro  CHamel  MDavis  RDesbiens  NConnors  AJPhillips  R A comparison of generalist and pulmonologist care for patients hospitalized with severe chronic obstructive pulmonary disease: resource intensity, hospital costs, and survival. Am J Med. 1998;105366- 372
Link to Article
Aiken  LSloane  DLake  ESochalski  JWeber  A Organization and outcomes of inpatient AIDS care. Med Care. 1999;37760- 762
Link to Article
Harrold  LField  TGurwitz  J Knowledge, patterns of care, and outcomes of care for generalists and specialists. J Gen Intern Med. 1999;14499- 511
Link to Article
Simon  GVonKorff  MBarlow  WPabiniak  CWagner  E Predictors of chronic benzodiazepine use in a health maintenance organization sample. J Clin Epidemiol. 1996;491067- 1073
Link to Article
Dial  TBergsten  CHaviland  MPincus  H Psychiatrist and nonphysician mental health provider staffing levels in health maintenance organizations. Am J Psychiatry. 1998;155405- 408
Derogatis  LRickels  KUhlenhuth  EHCovi  L The Hopkins Symptom Checklist: a measure of primary symptom dimensions. Pichot  Ped.Psychological Measurements in Psychopharmacology Problems in Psychopharmacology. Basel, Switzerland Kargerman1974;79- 110
First  MSpitzer  RGibbon  MWilliams  J Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), Clinician Version.  Washington, DC American Psychiatric Press1997;
Ware  JSnow  KKKosinski  MGandek  B The MOS SF-36 Health Survey: Manual and Interpretation Guide.  Boston, Mass Health Institute, New England Medical Center1993;
Chyba  MMWashington  LR Questionnaires from the National Health Interview Survey, 1985-89. Vital Health Stat 1. 1993;311- 412
Simon  GVonKorff  MRevicki  D Telephone assessment of depression severity. J Psychiatr Res. 1993;27247- 252
Link to Article
Simon  GLin  EHBKaton  WSaunders  KVonKorff  MWalker  EBush  TRobinson  P Outcomes of "inadequate" antidepressant treatment in primary care. J Gen Intern Med. 1995;10663- 670
Link to Article
Not Available, Clinical Practice Guideline Number 5: Depression in Primary Care, 2: Treatment of Major Depression.  Rockville, Md Agency for Health Care Policy and Research, US Dept of Health and Human Services1993;AHCPR publication 93-0551.
Saunders  KSimon  GBush  TGrothaus  L Assessing the accuracy of computerized pharmacy refill data to monitor antidepressant treatment on a population basis: a comparison of automated and self-report data. J Clin Epidemiol. 1998;51883- 890
Link to Article
Coltin  KLBeck  A The HEDIS antidepressant measure. Behav Healthc Tomorrow. 1999;840- 4147
VonKorff  MWagner  ESaunders  K A chronic disease score from automated pharmacy data. J Clin Epidemiol. 1992;45197- 203
Link to Article
Clark  DVonKorff  MSaunders  KBaluch  WMSimon  GE A chronic disease score with empirically derived weights. Med Care. 1995;33783- 795
Link to Article
Simon  GVonKorff  MHeiligenstein  JHRevicki  DAGrothaus  LKaton  WWagner  EH Initial antidepressant selection in primary care: effectiveness and cost of fluoxetine vs tricyclic antidepressants. JAMA. 1996;2751897- 1902
Link to Article
Melfi  CChawla  ACroghan  THanna  MKennedy  SSredl  K The effects of adherence to antidepressant treatment guidelines on relapse and recurrence in depression. Arch Gen Psychiatry. 1998;551128- 1132
Link to Article
Not Available, HEDIS 1999 New Measure National Results: HEDIS Users Group Monthly Update.  Washington, DC National Committee for Quality Assurance1999;
Keller  MBLavori  PWKlerman  GLAndreasen  NCEndicott  JCoryell  WFawcett  JRice  JPHirschfield  RMA Low levels and lack of predictors of somatotherapy and psychotherapy received by depressed patients. Arch Gen Psychiatry. 1986;43458- 466
Link to Article
Wagner  EAustin  BVonKorff  M Organizing care for patients with chronic illness. Milbank Q. 1996;74511- 544
Link to Article
Thompson  CKinmonth  AStevens  LPeveler  RStevens  AOstler  KPickering  RBaker  NHenson  APreece  JCooper  DCampbell  M Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial. Lancet. 2000;355185- 191
Link to Article
Donohoe  M Comparing generalist and specialty care: discrepancies, deficiencies, and excesses. Arch Intern Med. 1998;1581596- 1608
Link to Article
Hirschfeld  RKeller  MBPanico  SArons  BSBarlow  DDavidoff  FEndicott  JFroom  JGoldstein  MGorman  JMGuthrie  DMarek  RSMaurer  TAMeyer  RPhillips  KRoss  JSchwenk  TLSharfstein  SSThase  MEWyatt  RJ The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression. JAMA. 1997;277333- 340
Link to Article
Katon  WVonKorff  MLin  EWalker  ESimon  GBush  TRobinson  PRusso  J Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA. 1995;2731026- 1031
Link to Article
Katon  WRobinson  PVonKorff  MLin  EBush  TLudman  ESimon  GWalker  E A multifaceted intervention to improve treatment of depression in primary care. Arch Gen Psychiatry. 1996;53924- 932
Link to Article
Hunkeler  EMMeresman  JFHargreaves  WAFireman  BBerman  WHKirsch  AJGroebe  JHurt  SWBraden  PGetzell  MFeigenbaum  PAPeng  TSalzer  M Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care. Arch Fam Med. 2000;9700- 708
Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 95

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles