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Treatment Process and Outcomes for Managed Care Patients Receiving New Antidepressant Prescriptions From Psychiatrists and Primary Care Physicians
Gregory E. Simon, MD, MPH;
Michael Von Korff, ScD;
Carolyn M. Rutter, PhD;
Do A. Peterson, MS
Arch Gen Psychiatry. 2001;58:395-401.
ABSTRACT
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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.
INTRODUCTION
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, 5, 6, 7 subtherapeutic
dosing,3 and inadequate follow-up monitoring.5, 6, 7, 8, 9
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,13, 14, 15, 16
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 care14, 15, 16, 20
than for outpatient management.17, 18, 19
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.
PARTICIPANTS AND METHODS
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 
level of .05 (2-sided).
RESULTS
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%;  21 = 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%; 21 =
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).
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Table 1. Baseline Characteristics of Patients Receiving an Initial
Antidepressant Prescription From Primary Care Physicians and Psychiatrists*
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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%; 21 = 106; P<.001) and after (49% vs 16%; 21 = 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 (21 =
34.5; P<.01).
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Table 2. Outpatient Visits Made 6 Months Before and 6 Months After
the Initial Antidepressant Prescription*
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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.
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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.
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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).
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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.
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COMMENT
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, 44, 45, 46
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.
AUTHOR INFORMATION
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.
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.
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{at}ghc.org).
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