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Treating Major Depression in Primary Care Practice: Eight-Month Clinical Outcomes

Treating Major Depression in Primary Care Practice: Eight-Month Clinical Outcomes Abstract Background: We studied whether standardized treatments of major depression whose efficacy was established with psychiatric patients are equally effective when provided to primary care patients, and whether standardized treatments are more effective than a primary care physician's usual care. Methods: A randomized controlled trial was conducted, in which primary care patients meeting DSM-III-R criteria for a current major depression were assigned to nortriptyline (n=91) or interpersonal psychotherapy (n=93) provided within well-structured parameters, or a physician's usual care (n=92). The main outcome measures were degree and rate of improvement in severity of depressive symptoms and proportion of patients recovered at 8 months. Results: Severity of depressive symptoms was reduced more rapidly and more effectively among patients randomized to pharmacotherapy or psychotherapy than among patients assigned to a physician's usual care. Among treatment completers, approximately 70% of patients participating in the full pharmacotherapy or psychotherapy protocol but only 20% of usual care patients were judged as recovered at 8 months. Conclusions: Pharmacotherapy and psychotherapy effectively treat major depression among primary care patients when provided within specific parameters and for the full acute and continuation phases. Treatment principles recommended by the Depression Guideline Panel of the Agency for Health Care Policy and Research are supported. References 1. Katon W, Schulberg H. Epidemiology of depression in primary care . Gen Hosp Psychiatry . 1992;14:237-242.Crossref 2. Simon G, Von Korff M, Barlow W. Health care costs of primary care patients with recognized depression . Arch Gen Psychiatry . 1995;52:850-856.Crossref 3. Broadhead E, Blazer D, George L, Tse C. Depression, disability days, and days lost from work in a prospective epidemiologic survey . JAMA . 1990;264:2524-2528.Crossref 4. Wells K, Stewart A, Hays R, Burnam A, Rogers W, Daniels M, Berry S, Greenfield S, Ware J. The functioning and well-being of depressed patients . JAMA . 1989;252.914-919.Crossref 5. Spitzer R, Kroenke K, Linzer M, Hahn S, Williams J, deGruy F, Brody D, Davies M. Health-related quality of life in primary care patients with mental disorders . JAMA . 1995;274:1511-1517.Crossref 6. Eisenberg L. Treating depression and anxiety in primary care . N Engl J Med . 1992;326:1080-1084.Crossref 7. Schulberg H, Coulehan J, Block M, Scott C, Imber S, Perel J. Strategies for evaluating treatments for major depression in primary care patients . Gen Hosp Psychiatry . 1991;13:9-18.Crossref 8. Depression Guideline Panel. Clinical Practice Guideline Number 5: Depression in Primary Care, 2: Treatment of Major Depression . Rockville, Md: US Dept of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1993. AHCPR publication 93-0551. 9. Munoz R, Hollon S, McGrath E, Rehm L, Vande Bos G. On the AHCPR Depression in Primary Care Guidelines . Am Psychol . 1994;49:42-61.Crossref 10. Brown C, Schulberg H. The efficacy of psychosocial treatments in primary care: a review of randomized clinical trials . Gen Hosp Psychiatry . 1995;17:414-424.Crossref 11. Clarke G. Improving the transition from basic efficacy research to effectiveness studies . J Consult Clin Psychol . 1995;63:718-725.Crossref 12. Katon W, Von Korff M, Lin E, Walker E, Simon G, Bush T, Robinson P, Russo J. Collaborative management to achieve treatment guidelines . JAMA . 1995;273:1026-1031.Crossref 13. Schulberg H, Coulehan J, Block M, Lave J, Rodriguez E, Scott C, Madonia M, Imber S, Perel J. Clinical trials of primary care treatments for major depression: issues in design, recruitment, and treatment . Int J Psychiatry Med . 1993;23:29-42.Crossref 14. Radloff L. The CES-D scale: a self-report depression scale for research in the general population . Appl Psychol Measur . 1977;1:385-401.Crossref 15. Robins L, Helzer J, Croughan J, Ratcliff K. National Institute of Mental Health Diagnostic Interview Schedule . Arch Gen Psychiatry . 1981;38:381-389.Crossref 16. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised . Washington, DC: American Psychiatric Association; 1987. 17. Schulberg H, Madonia M, Block M, Coulehan J, Scott C, Rodriguez E, Black A. Major depression in primary care practice . Psychosomatics . 1995;36:129-137.Crossref 18. Roose S, Glassman A, Siris S, Walsh T, Bruno R, Wright L. Comparison of imipramine- and nortriptyline-induced orthostatic hypotension: a meaningful difference . J Clin Psychopharmacol . 1981;1:316-319.Crossref 19. Fawcett J, Epstein P, Fiester S, Elkin I, Autry J. Clinical management: imipramine/ placebo administration manual . Psychopharmacol Bull . 1987;23:309-324. 20. Reynolds C, Frank E, Perel J, Imber S, Cornes C, Morycz R, Mazumdar S, Miller M, Pollock B. Riffai H, Stack J, George C, Houck P, Kupfer, D. Combined pharmacotherapy and psychotherapy in the acute and continuation treatment of elderly patients with recurrent major depression: preliminary report . Am J Psychiatry . 1992;149:1687-1692. 21. Schulberg H, Block M, Madonia M, Rodriguez E, Scott C, Lave J. Applicability of clinical guideline pharmacotherapy for major depression in primary care settings . Arch Fam Med . 1995;4:106-112.Crossref 22. Kupfer D, Perel J, Frank E. Adequate treatment with imipramine in continuation treatment . J Clin Psychiatry . 1989;50:250-255. 23. Beck A, Ward C, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression . Arch Gen Psychiatry . 1961;4:53-63.Crossref 24. Klerman G, Weissman M, Rounsaville B, Chevron E. Interpersonal Psychotherapy of Depression . New York, NY: Basic Books; 1984. 25. Elkin I, Shea T, Watkins J, Imber S, Sotsky S, Collins J, Glass D, Pilkonis P, Leber W, Docherty J, Fiester S, Parloff M, for National Institute of Mental Health Treatment of Depression Collaborative Research Program. General effectiveness of treatments . Arch Gen Psychiatry . 1989;46:971-982.Crossref 26. Klerman G, Budman S, Berwick D, Weissman M, Damico-White J, Demby A, Feldstein M. Efficacy of a brief psychosocial intervention for symptoms of stress and distress among patients in primary care . Med Care . 1987;25:1078-1088.Crossref 27. Klerman G, Weissman M, eds. New Applications of Interpersonal Psychotherapy . Washington, DC: American Psychiatric Press, 1993. 28. Endicott J. Spitzer R, Fleiss J, Cohen J. The Global Assessment Scale: a procedure for measuring the overall severity of psychiatric disturbance . Arch Gen Psychiatry . 1976;33:766-771.Crossref 29. Parkerson G, Broadhead W, Tse C. The Duke Severity of Illness Checklist (DUSOI) for measurement of severity and comorbidity . J Clin Epidemiol . 1993;46:379-393.Crossref 30. Hamilton M. The Hamilton Rating Scale for Depression . In: Sartorius N, Banto T, eds. Assessment of Depression . New York, NY: Springer-Verlag NY Inc; 1986. 31. Dixon W, Merdian K. ANOVA and Regression With BMDP5V . Los Angeles, Calif: Dixon Statistical Association; 1992. 32. Mehta C, Patel N. Stat Xact Turbo: Statistical Software for Exact Nonparametric Inference: User Manual . Cambridge, Mass: Cytel Software Corp; 1992. 33. Gibbons R, Hedeker D, Elkin I, Waternaux C, Kraemer H, Greenhouse J, Shea T, Imber S, Sotsky S, Watkins J. Some conceptual and statistical issues in analysis of longitudinal psychiatric data . Arch Gen Psychiatry . 1993;50:739-750.Crossref 34. Coyne J, Fechner-Bates S, Schwenk T. Prevalence, nature, and comorbidity of depressive disorders in primary care . Gen Hosp Psychiatry . 1994;16:267-276.Crossref 35. Frank E, Prien R, Jarrett R, Keller M, Kupfer D, Lavori P, Rush A, Weissman M. Conceptualization and rationale for consensus definitions of terms in major depressive disorder . Arch Gen Psychiatry . 1991;48:851-855.Crossref 36. Myers E, Branthwaithe A. Out-patient compliance with antidepressant medication . Br J Psychiatry . 1992;160:83-86.Crossref 37. Katon W, Von Korff M, Lin E, Bush T, Ormel J. Adequacy and duration of antidepressant treatment in primary care . Med Care . 1992;30:67-76.Crossref 38. Simon G, Von Korff M, Wagner E, Barlow W. Patterns of antidepressant use in community practice . Gen Hosp Psychiatry . 1993;15:399-408.Crossref 39. Clark L. Improving compliance and increasing control of hypertension: needs of special hypertensive populations . Am Heart J . 1991;121:664-669.Crossref 40. Wells K, Burnam M, Rogers W, Hays R, Camp P. The course of depression in adult outpatients . Arch Gen Psychiatry . 1992;49:788-794.Crossref 41. Ormel J, Oldehinkel T, Brilman E, Vanden Brink W. Outcome of depression and anxiety in primary care . Arch Gen Psychiatry . 1993;50:759-766.Crossref 42. Scott I, Freeman C. Edinburgh primary care depression study: treatment outcome, patient satisfaction, and cost after 16 weeks . BMJ . 1992;304:883-887.Crossref 43. Watkins J, Leber W, Imber S, Collins J, Elkin I, Pilkonis P, Sotsky S, Shea M, Glass D. Temporal course of change in depression . J Consult Clin Psychol . 1993;61:858-864.Crossref 44. Shapiro D, Barkham M, Rees A, Hardy G, Reynolds S, Startup M. Effects of treatment duration and severity of depression on the effectiveness of cognitivebehavioral and psychodynamic-interpersonal psychotherapy . J Consult Clin Psychol . 1994;62:522-534.Crossref 45. Sturm R, Wells K. How can care for depression become more cost-effective? JAMA . 1995;273:51-58.Crossref 46. Narrow W, Regier D, Rae D, Manderscheid R, Locke B. Use of services by persons with mental and addictive disorders . Arch Gen Psychiatry . 1993;50:95-107.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of General Psychiatry American Medical Association

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Publisher
American Medical Association
Copyright
Copyright © 1996 American Medical Association. All Rights Reserved.
ISSN
0003-990X
eISSN
1598-3636
DOI
10.1001/archpsyc.1996.01830100061008
Publisher site
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Abstract

Abstract Background: We studied whether standardized treatments of major depression whose efficacy was established with psychiatric patients are equally effective when provided to primary care patients, and whether standardized treatments are more effective than a primary care physician's usual care. Methods: A randomized controlled trial was conducted, in which primary care patients meeting DSM-III-R criteria for a current major depression were assigned to nortriptyline (n=91) or interpersonal psychotherapy (n=93) provided within well-structured parameters, or a physician's usual care (n=92). The main outcome measures were degree and rate of improvement in severity of depressive symptoms and proportion of patients recovered at 8 months. Results: Severity of depressive symptoms was reduced more rapidly and more effectively among patients randomized to pharmacotherapy or psychotherapy than among patients assigned to a physician's usual care. Among treatment completers, approximately 70% of patients participating in the full pharmacotherapy or psychotherapy protocol but only 20% of usual care patients were judged as recovered at 8 months. Conclusions: Pharmacotherapy and psychotherapy effectively treat major depression among primary care patients when provided within specific parameters and for the full acute and continuation phases. Treatment principles recommended by the Depression Guideline Panel of the Agency for Health Care Policy and Research are supported. References 1. Katon W, Schulberg H. Epidemiology of depression in primary care . Gen Hosp Psychiatry . 1992;14:237-242.Crossref 2. Simon G, Von Korff M, Barlow W. Health care costs of primary care patients with recognized depression . Arch Gen Psychiatry . 1995;52:850-856.Crossref 3. Broadhead E, Blazer D, George L, Tse C. Depression, disability days, and days lost from work in a prospective epidemiologic survey . JAMA . 1990;264:2524-2528.Crossref 4. Wells K, Stewart A, Hays R, Burnam A, Rogers W, Daniels M, Berry S, Greenfield S, Ware J. The functioning and well-being of depressed patients . JAMA . 1989;252.914-919.Crossref 5. Spitzer R, Kroenke K, Linzer M, Hahn S, Williams J, deGruy F, Brody D, Davies M. Health-related quality of life in primary care patients with mental disorders . JAMA . 1995;274:1511-1517.Crossref 6. Eisenberg L. Treating depression and anxiety in primary care . N Engl J Med . 1992;326:1080-1084.Crossref 7. Schulberg H, Coulehan J, Block M, Scott C, Imber S, Perel J. Strategies for evaluating treatments for major depression in primary care patients . Gen Hosp Psychiatry . 1991;13:9-18.Crossref 8. Depression Guideline Panel. Clinical Practice Guideline Number 5: Depression in Primary Care, 2: Treatment of Major Depression . Rockville, Md: US Dept of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1993. AHCPR publication 93-0551. 9. Munoz R, Hollon S, McGrath E, Rehm L, Vande Bos G. On the AHCPR Depression in Primary Care Guidelines . Am Psychol . 1994;49:42-61.Crossref 10. Brown C, Schulberg H. The efficacy of psychosocial treatments in primary care: a review of randomized clinical trials . Gen Hosp Psychiatry . 1995;17:414-424.Crossref 11. Clarke G. Improving the transition from basic efficacy research to effectiveness studies . J Consult Clin Psychol . 1995;63:718-725.Crossref 12. Katon W, Von Korff M, Lin E, Walker E, Simon G, Bush T, Robinson P, Russo J. Collaborative management to achieve treatment guidelines . JAMA . 1995;273:1026-1031.Crossref 13. Schulberg H, Coulehan J, Block M, Lave J, Rodriguez E, Scott C, Madonia M, Imber S, Perel J. Clinical trials of primary care treatments for major depression: issues in design, recruitment, and treatment . Int J Psychiatry Med . 1993;23:29-42.Crossref 14. Radloff L. The CES-D scale: a self-report depression scale for research in the general population . Appl Psychol Measur . 1977;1:385-401.Crossref 15. Robins L, Helzer J, Croughan J, Ratcliff K. National Institute of Mental Health Diagnostic Interview Schedule . Arch Gen Psychiatry . 1981;38:381-389.Crossref 16. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised . Washington, DC: American Psychiatric Association; 1987. 17. Schulberg H, Madonia M, Block M, Coulehan J, Scott C, Rodriguez E, Black A. Major depression in primary care practice . Psychosomatics . 1995;36:129-137.Crossref 18. Roose S, Glassman A, Siris S, Walsh T, Bruno R, Wright L. Comparison of imipramine- and nortriptyline-induced orthostatic hypotension: a meaningful difference . J Clin Psychopharmacol . 1981;1:316-319.Crossref 19. Fawcett J, Epstein P, Fiester S, Elkin I, Autry J. Clinical management: imipramine/ placebo administration manual . Psychopharmacol Bull . 1987;23:309-324. 20. Reynolds C, Frank E, Perel J, Imber S, Cornes C, Morycz R, Mazumdar S, Miller M, Pollock B. Riffai H, Stack J, George C, Houck P, Kupfer, D. Combined pharmacotherapy and psychotherapy in the acute and continuation treatment of elderly patients with recurrent major depression: preliminary report . Am J Psychiatry . 1992;149:1687-1692. 21. Schulberg H, Block M, Madonia M, Rodriguez E, Scott C, Lave J. Applicability of clinical guideline pharmacotherapy for major depression in primary care settings . Arch Fam Med . 1995;4:106-112.Crossref 22. Kupfer D, Perel J, Frank E. Adequate treatment with imipramine in continuation treatment . J Clin Psychiatry . 1989;50:250-255. 23. Beck A, Ward C, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression . Arch Gen Psychiatry . 1961;4:53-63.Crossref 24. Klerman G, Weissman M, Rounsaville B, Chevron E. Interpersonal Psychotherapy of Depression . New York, NY: Basic Books; 1984. 25. Elkin I, Shea T, Watkins J, Imber S, Sotsky S, Collins J, Glass D, Pilkonis P, Leber W, Docherty J, Fiester S, Parloff M, for National Institute of Mental Health Treatment of Depression Collaborative Research Program. General effectiveness of treatments . Arch Gen Psychiatry . 1989;46:971-982.Crossref 26. Klerman G, Budman S, Berwick D, Weissman M, Damico-White J, Demby A, Feldstein M. Efficacy of a brief psychosocial intervention for symptoms of stress and distress among patients in primary care . Med Care . 1987;25:1078-1088.Crossref 27. Klerman G, Weissman M, eds. New Applications of Interpersonal Psychotherapy . Washington, DC: American Psychiatric Press, 1993. 28. Endicott J. Spitzer R, Fleiss J, Cohen J. The Global Assessment Scale: a procedure for measuring the overall severity of psychiatric disturbance . Arch Gen Psychiatry . 1976;33:766-771.Crossref 29. Parkerson G, Broadhead W, Tse C. The Duke Severity of Illness Checklist (DUSOI) for measurement of severity and comorbidity . J Clin Epidemiol . 1993;46:379-393.Crossref 30. Hamilton M. The Hamilton Rating Scale for Depression . In: Sartorius N, Banto T, eds. Assessment of Depression . New York, NY: Springer-Verlag NY Inc; 1986. 31. Dixon W, Merdian K. ANOVA and Regression With BMDP5V . Los Angeles, Calif: Dixon Statistical Association; 1992. 32. Mehta C, Patel N. Stat Xact Turbo: Statistical Software for Exact Nonparametric Inference: User Manual . Cambridge, Mass: Cytel Software Corp; 1992. 33. Gibbons R, Hedeker D, Elkin I, Waternaux C, Kraemer H, Greenhouse J, Shea T, Imber S, Sotsky S, Watkins J. Some conceptual and statistical issues in analysis of longitudinal psychiatric data . Arch Gen Psychiatry . 1993;50:739-750.Crossref 34. Coyne J, Fechner-Bates S, Schwenk T. Prevalence, nature, and comorbidity of depressive disorders in primary care . Gen Hosp Psychiatry . 1994;16:267-276.Crossref 35. Frank E, Prien R, Jarrett R, Keller M, Kupfer D, Lavori P, Rush A, Weissman M. Conceptualization and rationale for consensus definitions of terms in major depressive disorder . Arch Gen Psychiatry . 1991;48:851-855.Crossref 36. Myers E, Branthwaithe A. Out-patient compliance with antidepressant medication . Br J Psychiatry . 1992;160:83-86.Crossref 37. Katon W, Von Korff M, Lin E, Bush T, Ormel J. Adequacy and duration of antidepressant treatment in primary care . Med Care . 1992;30:67-76.Crossref 38. Simon G, Von Korff M, Wagner E, Barlow W. Patterns of antidepressant use in community practice . Gen Hosp Psychiatry . 1993;15:399-408.Crossref 39. Clark L. Improving compliance and increasing control of hypertension: needs of special hypertensive populations . Am Heart J . 1991;121:664-669.Crossref 40. Wells K, Burnam M, Rogers W, Hays R, Camp P. The course of depression in adult outpatients . Arch Gen Psychiatry . 1992;49:788-794.Crossref 41. Ormel J, Oldehinkel T, Brilman E, Vanden Brink W. Outcome of depression and anxiety in primary care . Arch Gen Psychiatry . 1993;50:759-766.Crossref 42. Scott I, Freeman C. Edinburgh primary care depression study: treatment outcome, patient satisfaction, and cost after 16 weeks . BMJ . 1992;304:883-887.Crossref 43. Watkins J, Leber W, Imber S, Collins J, Elkin I, Pilkonis P, Sotsky S, Shea M, Glass D. Temporal course of change in depression . J Consult Clin Psychol . 1993;61:858-864.Crossref 44. Shapiro D, Barkham M, Rees A, Hardy G, Reynolds S, Startup M. Effects of treatment duration and severity of depression on the effectiveness of cognitivebehavioral and psychodynamic-interpersonal psychotherapy . J Consult Clin Psychol . 1994;62:522-534.Crossref 45. Sturm R, Wells K. How can care for depression become more cost-effective? JAMA . 1995;273:51-58.Crossref 46. Narrow W, Regier D, Rae D, Manderscheid R, Locke B. Use of services by persons with mental and addictive disorders . Arch Gen Psychiatry . 1993;50:95-107.Crossref

Journal

Archives of General PsychiatryAmerican Medical Association

Published: Oct 1, 1996

References

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