Primary Care Research

Despite improvements in access to medications and psychotherapy, many depressed primary care patients are not treated

The majority of depressed patients seen in primary care believe that depression requires professional treatment, and they prefer psychotherapy over medication. Yet, after a quality improvement (QI) program that eased access to medication and psychotherapy among managed care patients, only a third of them received any medication or counseling for their depression, according to a Partners in Care (PIC) Patient Outcomes Research Team (PORT) study supported by the Agency for Healthcare Research and Quality (HS08349).

The researchers randomly assigned 46 managed care clinics to usual depression care (UC), QI-Therapy, or QI-Meds. Both the QI psychotherapy and medication programs promoted education about depression and its treatment for both patients and providers. They also permitted choice of medication, psychotherapy, or both, via education and joint decisionmaking between the patient, nurse specialist, and primary care provider. QI-Therapy facilitated access to cognitive behavioral therapy by providing training to the usual practice therapist and reducing patient copayments for use of these therapists. QI-Meds provided nurses for followup on medication management.

QI-Therapy and QI-Meds patients reported more treatment overall (therapy or medication) than UC patients at 6 months, and this effect persisted in the QI-Meds clinics until 12 months. QI-Therapy patients reported more therapy than UC or QI-Meds patients at 6 months, demonstrating the utility of this approach to increasing rates of care. However, despite reduced barriers to psychotherapy (reduced copayment, on-site or near-site therapy, and setting up the first appointment when possible) and high rates of referral to psychotherapy within the QI-Therapy clinics (81 percent), only 30 percent of patients actually attended a psychotherapy session within the QI intervention. Outreach by psychotherapists and coordination between psychotherapists and primary care providers are needed to further improve access to specialty care for depressed patients.

More details are in "Impact of a primary care quality improvement intervention on use of psychotherapy for depression," by Lisa H. Jaycox, Ph.D., Jeanne Miranda, Ph.D., Lisa S. Meredith, Ph.D., and others, in the June 2003 Mental Health Services Research 5(2), pp. 109-120.

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