Patients with depression frequently do not receive high quality care
Most patients with depression who are treated by primary care physicians do not receive care consistent with quality standards, according to a new RAND Corporation study.
Physicians had high rates of adherence to just one-third of the 20 measures of quality that researchers examined and had low rates of adherence to nearly half of the treatment recommendations studied, according to the report in the Sept. 4 edition of the Annals of Internal Medicine.
“These findings are important for patients since most cases of depression are diagnosed and treated in primary care settings,” said senior author Dr. Lisa V. Rubenstein, the study’s senior author, and a senior scientist at RAND, a nonprofit research organization, and a physician at the Veterans Affairs Greater Los Angeles Healthcare System. “This shows that additional efforts are needed to improve the treatment of depression.”
The study also found that patients who received better-quality care reported fewer symptoms of depression up to two years after the start of treatment. The findings are among the first linking quality guidelines for depression treatment with improved patient outcomes in community settings.
“These are initial findings, but they suggest that programs that encourage doctors to follow treatment guidelines can help improve the long-term outlook for people with depression,” said Rubenstein, who also is affiliated with the David Geffen School of Medicine at UCLA.
Previous studies have shown that primary care providers do a poor job following guidelines for antidepressant use or psychotherapy. The
Researchers from RAND Health examined the experiences of health care providers and patients who took part from 1996 to 1998 in the Quality Improvement for Depression collaboration, which was designed to encourage primary care providers to adopt comprehensive depression treatment guidelines developed by the U.S. Agency for Healthcare Research and Quality.
The
Researchers examined whether physicians and other health providers followed 20 different measures of quality, as well as analyzing patients’ reports about the status of their depression at 12, 18 and 24 months after starting treatment.
The study found that most primary care physicians did a good job of diagnosing and beginning treatment for depression, with guidelines aimed at these issues followed more than 70 percent of the time. These guidelines includes items such as talking to patients about depression and closely monitoring patients newly placed on antidepressant medication.
But researchers found that primary care clinicians did less well following up with treatment over time. Fewer than half of the patients in the study completed the minimal course of treatment for either antidepressant drugs or psychotherapy, and only slightly more than half the depressed patients who were not treated were monitored closely.
The lowest quality of care occurred among the patients who exhibited the most serious symptoms, including patients who showed evidence of suicide or substance abuse. For example, among patients who had a previous suicide attempt, just 35 percent were referred to a mental health specialist over the next six months
“Primary care physicians were good at diagnosing depression, but they did not do as good a good job of managing the sickest patients,” Rubenstein said. “Right now, primary care physicians don’t have the tools necessary to decide which patients to treat and which to refer on to specialized mental health care.”
Receiving higher quality care did not appear to significantly impact the long-term functioning of less-sick patients, according to the study. But sicker patients who received better quality care were significantly less likely to report continuing symptoms of depression on surveys taken up to two years after their treatment began.
“For the people who were sicker, there was a closer relationship between quality and their symptoms over the long term,” Rubenstein said. “This is among the first evidence that following treatment guidelines can help patients over the long term.”
Other authors of the report are Kimberly A. Hepner, Melissa Rowe, Scot C. Hickey, Cathy D. Sherbourne and Lisa S. Meredith of RAND, Kathryn Rost of
The research was supported by the National Institute of Mental Health, the Agency for Healthcare Research and Quality, the John D. and Catherine T. MacArthur Foundation and the Veterans Affairs Health Services Research and Development Service Center of Excellence for the Study of Healthcare Provider Behavior.
Depression more damaging than some chronic illnesses
Reuters
Depression is more damaging to everyday health than chronic diseases such as angina, arthritis, asthma and diabetes, researchers said on Friday.
And if people are ill with other conditions, depression makes them worse, the researchers found.
"We report the largest population-based worldwide study to our knowledge that explores the effect of depression in comparison with four other chronic diseases on health state," the researchers wrote in the Lancet medical journal.
Somnath Chatterji of the World Health Organisation, who led the study, said researchers calculated the impact of different conditions by asking people questions about their capacities to function in everyday situations -- such as moving around, seeing things at a distance and remembering information.
The researchers assigned a number between 0 and 100 reflecting a person's relative health score.
"Our main findings show that depression impairs health state to a substantially greater degree than the other diseases," the researchers wrote.
The team used World Health Organisation data collected from 60 countries and more than 240,000 people to show on average between 9 percent and 23 percent had depression in addition to one or more of four other chronic diseases -- asthma, angina, arthritis and diabetes.
The most disabling combination was diabetes and depression, the researchers said.
"If you live for one year with diabetes and depression together you are living the equivalent of 60 percent of full health," Chatterji said in a telephone interview.
The findings show the need to provide better treatment for depression because it has such a big impact on people with chronic illnesses, Chatterji added.
"What tends to happen is a health provider doesn't look for anything else but the chronic illness," he said.
"What we are saying is, these people will also be depressed and if you don't manage the depression you can't improve a person's health because depression is actually worsening it."
CDC: Suicide rate among U.S. girls soars
Associated Press
The suicide rate among preteen and young teen girls spiked 76 percent, a disturbing sign that federal health officials say they can't fully explain.
For all young people between ages 10 to 24, the suicide rate rose 8 percent from 2003 to 2004 — the biggest single-year bump in 15 years — in what one official called "a dramatic and huge increase."
The report, based on the latest numbers available, was released Thursday by the Centers for Disease Control and Prevention and suggests a troubling reversal in recent trends. Suicide rates had fallen by 28.5 percent since 1990 among young people.
The biggest increase — about 76 percent — was in the suicide rate for 10- to 14-year-old girls. There were 94 suicides in that age group in 2004, compared to 56 in 2003. The rate is still low — fewer than one per 100,000 population.
Suicide rates among older teen girls, those aged 15-19 shot up 32 percent; rates for males in that age group rose 9 percent.
"In surveillance speak, this is a dramatic and huge increase," Dr. Ileana Arias said of the overall picture. She is director of the CDC's National Center for Injury Prevention and Control.
More research is needed to determine whether this is a trend or just a blip, said one child psychiatrist, Dr. Thomas Cummins of Children's Memorial Hospital in Chicago. "We all need to keep our eye on this over time to see if this is a continuing trend."
Overall, there were 4,599 suicides among young people in 2004, making it the third-leading cause of death, surpassed only by car crashes and homicide, Arias said. Males committed suicide far more often than females, accounting for about three-quarters of suicides in this age group.
The study also documented a change in suicide method. In 1990, guns accounted for more than half of all suicides among young females. By 2004, though, death by hanging and suffocation became the most common suicide method. It accounted for about 71 percent of all suicides in girls aged 10-14; about half of those aged 15-19; and 34 percent between 20-24.
"While we can't say (hanging) is a trend yet, we are confident that's an unusually high number in 2004," said Dr. Keri Lubell, a CDC behavioral scientist who was one of the study authors.
Scientists speculated that hanging may have become the most accessible method.
"It is possible that hanging and suffocation is more easily available than other methods, especially for these other groups," Arias said.
The CDC is advising health officials to consider focusing suicide prevention programs on girls ages 10-19 and boys between 15-19 to reverse the trends. It also said the suicide methods suggest that prevention focused solely on restricting access to pills, weapons or other lethal means may be of limited success.
As for why rates are up, Richard Lieberman, who coordinates the suicide prevention program for Los Angeles public schools, said one cause could be a rise in depression during tumultuous adolescent years.
"There's a lot of pressure in and around middle school kids. They're kind of all transition kids. They're turbulent times to begin with," he said. "The hotline's been ringing off the hook with middle school kids experimenting with a wide variety of self-injurious behavior, exploring different ways to hurt themselves."
Arias said the declining use of antidepressants in those age groups might play a role. But it's "not the only factor" that health officials will be studying.
Four years ago, federal regulators warned that antidepressants seemed to raise the risk of suicidal behavior among young people, so black box warnings were put on the drugs' packaging.
When partial teen suicide data was published earlier this year, experts noted at the time that the drop in sales of the drugs corresponded with a rise in the suicide rate. Now there is concern that some children who need the medication aren't getting it.
"Suicide is a multidimensional and complex problem," Arias said. "As much as we'd like to attribute suicide to a single source so we can fix it, unfortunately we can't do that."
More education is needed, some specialists said, so that teachers, parents and others can quickly spot troubled teens.
"It underscores the need for more evaluation methods for school personnel and pediatricians to be able to better identify at-risk youth," said Dr. Alec Miller, director of the adolescent depression and suicide program at Montefiore Medical Center in New York. "They are out there, and everyone needs to be better trained in identification."
He said people who commit suicide tend to have a psychiatric condition, even if it has not been formally diagnosed.
Arias said warning signs include mental illness, alcohol and drug use, family dysfunction and relationship problems.
"For some, talking about suicide is awkward," she said. "Our goal is to stop suicides, and to do that we need everyone's willingness to talk about it.
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