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In 1995 the John D. and Catherine T. MacArthur Foundation assembled a multidisciplinary group of interested scientists, challenging them to “make a difference” in the primary care management of depression. These primary care researchers developed a research agenda around three themes which included understanding current practice patterns, evaluating new depression treatments, and developing new educational and office system strategies for clinicians. Selected studies in each of these areas are described below:

Understanding Current Practices

Evaluating Therapeutics

Educational & Office System Strategies for Clinicians
Understanding Current Practices – These studies carefully evaluated the current diagnostic, treatment, and referral practices for depression in primary care. They identified the important barriers to quality improvement, informing the development of subsequent interventions.

1.   MacArthur Survey of Primary Care Physicians– A national survey of primary care clinicians that addressed current practices in depression recognition and management. The survey found that while many physicians feel responsible for recognizing depression in their patients and many felt confident in their management skills, a substantial proportion lack essential knowledge about the diagnostic assessment of depression and few provided the follow-up recommended in management guidelines. This study served as a model for subsequent surveys of Pediatricians and Obstetrician-Gynecologists. Reference

2.   Pediatric Survey – A national survey of pediatricians found that pediatricians felt responsible for recognizing but not for treating child and adolescent depression. Although the lack of confidence and lack of knowledge and/or skills and time issues are major barriers that limit pediatricians in their treatment of childhood and adolescent depression, pediatricians varied in their readiness to change, with some being more willing to implement new strategies to care for depression. Reference

3.   OB-GYN Survey – This survey assessed the attitudes and behaviors of resident and newly trained obstetrician-gynecologists (OB-Gs) in caring for patients with three common depression diagnoses. It showed that residents are receiving more didactic mental health training than recent graduates, yet changes in training are not yet reflected in practice patterns or confidence. Specific areas for educational interventions were identified.

4.   Standardized Patient study – This study used an innovative approach, unannounced standardized patients (actors portraying real patients offering common depression presentations), to better understand the impact of symptom presentation, gender, and communication style on the recognition and treatment of depression. Reference1 Reference2

5.   Physician Focus Groups on Diagnostic Practices – Physician focus groups in three states were conducted to gain a detailed understanding of physicians approach to depression recognition and diagnosis. This qualitative study informed both the physician surveys and subsequent educational and systems interventions. Reference

6.   Noncompliance with Depression Guidelines: The QID Project – This qualitative study was conducted within the context of a large quality improvement study funded by the NIMH. Using chart-based recall, physicians and nurses describe the circumstances under which depressed patients did not receive guideline concordant care. This groundbreaking study helped to set upper limits on reasonable goals for guideline concordance and identified educational and systems targets for future quality improvement initiatives. Reference

7.   Treatment of Depressed Older Adults in Managed Care – This secondary data analysis examined whether older HMO patients with depression are treated differently than younger patients in terms of diagnosis, treatment by specialty provider, and pharmacotherapy. It showed that older patients received fewer mental health specialty visits, fewer prescriptions for SSRI antidepressants, and more prescriptions for benzodiazepines. Reference

8.   Referral Project in the Dartmouth COOP – Because a significant proportion of mental health referrals are never completed, this pilot study prospectively compared patient referrals to mental health specialist and other medical specialists. It found that mental health referrals were considered more urgent than non-mental health referrals, and that PCPs made greater efforts to schedule definite appointment times. Despite these efforts, patients were more than 50% less likely to have a definitive appointment when they left the PCPs office. At follow-up mental health consultants were significantly less likely to communicate results to the PCP. Reference

Evaluating Therapeutics – These studies identified and addressed knowledge gaps in the treatment of depression. They included a treatment trial for the most common forms of depression in primary care and literature syntheses that informed clinicians about the appropriate use and selection of antidepressants.

1.   Treatment Effectiveness Trial – This multi-center trial evaluated two treatments, the antidepressant medication paroxetine, and Problem Solving Treatment for Primary Care (PST-PC, a cognitive-behavior based psychological treatment) for patients with minor depression or dysthymia. Results showed that for dysthymia (a chronic depression) both paroxetine and PST-PC improved remission compared with placebo plus nonspecific clinical management. For minor depression, the 3 interventions were equally effective suggesting that general clinical management is an appropriate treatment option, that diagnostic specificity is important in primary care, and that psychological treatments can be delivered in primary care settings. Reference

2.   Treatment Effectiveness Trial in Older Adults – Recognizing the importance of primary care treatments for milder forms of depression, the Hartford Foundation funded a companion study to the one described above, but for older adults. Results were similar, with positive treatment effects for patients with dysthymia, but small and inconsistent benefits for patients with minor depression. Reference

3.   New Pharmacological Medications for Depression: A Literature Syntheses – This systematic review evaluated the efficacy of newer vs. older antidepressants in primary care settings. It showed that the two groups were equally efficacious, but that newer agents had a less severe adverse effect profile. Further, both groups were effective in primary care. These data informed the American College of Physicians Clinical Guideline on Depression.

4.   Antidepressant Medications for Unexplained Physical symptoms – This systematic review evaluated the efficacy of newer vs. older antidepressants in primary care settings. It found that antidepressants can be effective for various physical symptoms (e.g. headache) and symptom syndromes (e.g., fibromyalgia). Reference

Educational and Office System Strategies for Clinicians – These studies developed and tested educational and office system strategies for improving the quality of depression care. The Three Component Model (3CM™) and the RESPECT-Depression trial evolved from this group of studies.

Educational Strategies:
1.   Identifying PCPs receptive to Improving Depression Care – This project used items from the “MacArthur PC clinician survey” (above) to develop a measure of physicians' confidence or self-efficacy in caring for depressed patients. This reliable and valid scale can be used as a diagnostic tool to identify physicians who might benefit from interventions. Reference

2.   Identifying strategies to improve Depression Care – This literature syntheses critically evaluated studies designed to improve the recognition or management of mental disorders in primary care. It found mixed success, with greater effects on recognition than management. Reference

3.   Depression Education Program (DEP): A Randomized Trial – This trial tested the efficacy of an 8-hour educational intervention for PCPs showing that the educational intervention was effective in improving physician communication strategies and depression recognition. Reference

4.   Depression Educational Program for OBGYNs – Because depression is more prevalent in women than men and the prevalence peaks in young to mid-life adults, Obstetrician-Gynecologists are an important target for educational interventions. The DEP program described above was modified and tested in 4 residency programs in the Western U.S.A. It has been disseminated to residency programs nationally. Reference

5.   Effective Educational Techniques – An international conference was conducted (with additional support from an unrestricted educational grant from Solvay Pharmaceuticals) on the topic of methods for primary care education for the practicing physician. A special issue of the International Journal of Psychiatry in Medicine published the presentations. Reference

6.   Brief Depression Education Program – Although DEP was effective, it proved impractical for some settings because of the >8-hour time commitment. Therefore, it was abbreviated into a 2-hour version that is both more acceptable to practicing physicians and less costly to deliver. It was used by the Institute for Healthcare Improvement in work for the US Dept. of Health and Human Services Health Resources and Services Administration Health Disparities Collaborative on depression in primary care.

System Strategies:
1.   Depression Toolkit – Recognizing that there was not single resource for practical tools to improve depression care, the steering committee developed the MacArthur Depression Tool Kit. The tool kit is disseminated on this website. The tool kit has been published in two academic venues, including a special supplement to the Journal of Family Practice. The tool kit was used by the Institute for Healthcare Improvement in work for the US Dept. of Health and Human Services Health Resources and Services Administration Health Disparities Collaborative on depression in primary care. The tool kit has been distributed to the membership of the American Academy of Family Physicians through its annual meeting.

2.   Diamond Project – This project tested an implementation strategy in a large Minnesota Health Plan, based on the “continuous quality improvement (CQI)” model. This controlled trial showed minimal positive effects, but was important for understanding strengths and limitations of the CQI approach and giving the initiative implementation experience outside of academic health plans. Reference1 Reference2

3.   Enhancing Physician Systems – We conducted a series of related pilot studies in preparation for the RESPECT-depression trial. The studies were intended to determine: a) explicit and implicit incentives and barriers to implementing proposed changes in office practices related to detecting, treating, and managing depression; b) the feasibility of collecting office-based, patient outcomes (by patient self-reporting) as a measure for the effect of educational programs; c) feasibility and efficacy of academic detailing as a single enabling method to introduce methods of changing office practices to detect and manage depression; and, d) methods of assessing predisposition to manage depression. Reference1 Reference2

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