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Improving Patient Care |

The Effect of Adherence to Practice Guidelines on Depression Outcomes

Kimberly A. Hepner, PhD; Melissa Rowe, PhD; Kathryn Rost, PhD; Scot C. Hickey, MA; Cathy D. Sherbourne, PhD; Daniel E. Ford, MD; Lisa S. Meredith, PhD; and Lisa V. Rubenstein, MD, MSPH
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From RAND Health Program, Santa Monica, California; Florida State University, Tallahassee, Florida; Johns Hopkins School of Medicine, Baltimore, Maryland; and Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California.

Acknowledgments: The authors thank the MacArthur Foundation Initiative on Depression and Primary Care for assisting with the development of the quality review criteria; Bernadette Benjamin and Jose Arbelaez for expert programming; Jeff Smith, Maureen Carney, Chantal Avila, and Carole Oken for data collection and data management; Kathryn Magruder and Paul Nutting for their work on the overall collaborations; and Bob Bell for statistical consultation. They also thank the organizations participating in the studies: Kaiser Permanente Medical Care Programs in the Northern California Region, Oakland, California; Veterans Affairs Greater Los Angeles, Los Angeles, California; Ambulatory Sentinel Practice Network, Denver, Colorado; and NYL Care Health Plans of the Mid-Atlantic, Greenbelt, Maryland. Finally, they thank the clinicians and patients who contributed their time and effort for these studies.

Grant Support: By the National Institute of Mental Health (grants R01MH64658, P50MH54623, R01 MH54444, and MH 63651), the Agency for Healthcare Research and Quality (grant R01-HS08349), the John D. and Catherine T. MacArthur Foundation (grant 96-42 901 A-HE), and the Veterans Affairs Health Services Research and Development Service Center of Excellence for the Study of Healthcare Provider Behavior (grant LIP 65-030).

Potential Financial Conflicts of Interest: Consultancies: K. Rost, D.E. Ford (Pfizer Inc.). Honoraria: K. Rost. Grants pending: K. Rost.

Requests for Single Reprints: Kimberly A. Hepner, PhD, RAND Health Program, 1776 Main Street, Santa Monica, CA 90407; e-mail, hepner@rand.org.

Current Author Addresses: Drs. Hepner, Rowe, Sherbourne, and Meredith and Mr. Hickey: RAND Health Program, 1776 Main Street, Santa Monica, CA 90407.

Dr. Rost: Department of Medical Humanities and Social Sciences, Florida State University, 1115 West Call Street, Tallahassee, FL 32306.

Dr. Ford: Department of General Internal Medicine, Johns Hopkins School of Medicine, 733 North Broadway, Suite 115, Baltimore, MD 21205.

Dr. Rubenstein: Veterans Affairs Greater Los Angeles (152), 16111 Plummer Street, Sepulveda, CA 91343.

Author Contributions: Conception and design: K.A. Hepner, M. Rowe, K. Rost, C.D. Sherbourne, D.E. Ford, L.S. Meredith, L.V. Rubenstein.

Analysis and interpretation of the data: K.A. Hepner, M. Rowe, K. Rost, S.C. Hickey, C.D. Sherbourne, D.E. Ford, L.V. Rubenstein.

Drafting of the article: K.A. Hepner, C.D. Sherbourne, L.V. Rubenstein.

Critical revision of the article for important intellectual content: K.A. Hepner, M. Rowe, K. Rost, C.D. Sherbourne, D.E. Ford, L.S. Meredith, L.V. Rubenstein.

Final approval of the article: K.A. Hepner, M. Rowe, K. Rost, S.C. Hickey, C.D. Sherbourne, D.E. Ford, L.V. Rubenstein.

Provision of study materials or patients: L.S. Meredith, L.V. Rubenstein.

Obtaining of funding: K. Rost, D.E. Ford, L.S. Meredith, L.V. Rubenstein.

Administrative, technical, or logistic support: M. Rowe, S.C. Hickey, L.V. Rubenstein.

Collection and assembly of data: M. Rowe, K. Rost, S.C. Hickey, D.E. Ford, L.S. Meredith, L.V. Rubenstein.

Ann Intern Med. 2007;147(5):320-329. doi:10.7326/0003-4819-147-5-200709040-00007
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We performed secondary analysis of data collected through the Quality Improvement for Depression (QID) collaboration (11) between 1996 and 1998. The 4 studies in this collaboration used cluster randomized designs to evaluate encouragement strategies for implementing Agency for Healthcare Research and Quality guidelines for depression (13) in primary care. One QID study used self-administered surveys (12), which had some questions that were worded differently from questions in the other 3 studies. We included only the 3 QID studies that used virtually identical telephone-administered surveys. Among these 3 studies, only 1 showed statistically significant improvement in depression-specific outcomes (1314). In the QID studies, experimental-group clinician leaders were given training, materials, and protocols to encourage them to provide collaborative care for depression-based quality improvement (Figure). Additional details on the encouragement approach used by each study are published elsewhere (1114). For our observational analyses, we combined the usual care and experimental groups. The study was approved by the institutional review board at each study site.

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Quasi-experimental design of studies in the Quality Improvement for Depression collaboration.
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The importance of efficient depression management in primary care
Posted on September 18, 2007
Christos G Theleritis
Athens University Medical School, Department of Psychiatry, Eginition Hospital
Conflict of Interest: None Declared

In their recent article (1), Kimberly Hepner and colleagues mention that depression rarely leads to death. This is astonishing, since patients with major depression have an increased overall relative risk of dying (1.81, 95% CI: 1.58 - 2.07) compared with people without depression (2); even for sub-clinical depression this risk is no smaller than the relative risk in clinical depression (2). A large part of the increased mortality in depression is due to the risk of suicide (4-16 times higher compared to non-depressed individuals) (3).

In this context, we consider the results of the Hepner and colleagues' study (1) quite alarming. Complex interventions that combine clinician education, an enhanced management role of the nurse, a better integration between primary-secondary care and telephone medication counselling by trained clinicians might help considerably in improving depression management in primary care setting (1, 4). On the other hand, simple educational strategies and the mere implementation of treatment guidelines might not be so effective (4, 5).


1. Hepner KA, Rowe M, Rost K, Hickey SC, Sherbourne CD, Ford DE, et al. The effect of adherence to practice guidelines on depression outcomes. Ann Intern Med. 2007;147:320-9.

2. Cuipers P, Smit F. Excess mortality in depression. A meta-analysis of community studies. J Affect Disord. 2002;72:227-36.

3. Bostwick JM, Pankratz VS. Affective disorders and suicide risk: a re-examination. Am J Psychiatry. 2000;157:1925-32.

4. Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and organizational interventions to improve the management of depression in primary care. A systematic review. JAMA. 2003;289:3145-51.

5. Dobscha SK, Corson K, Hickam DH, Perrin NA, Kraemer DF, Gerrity MS. Depression decision support in primary care. Ann Intern Med. 2006;145:477-87.

We declare that we have no conflict of interest.

Conflict of Interest:

None declared

Diagnosis of depression in clinical practice
Posted on September 25, 2007
giuseppe colloca
UCSC Roma Dipartimento di scienze geriatriche fisiatriche gerontologiche
Conflict of Interest: None Declared

In their article Kimberly Hepner and coll.(1) talk about the relationship between clinician adherence to depression practice guidelines and depression outcomes. The observational analysis of data shows as adherence to guidelines was high only for one third of the recommendations that were measured. This aspect points to specific needs for quality improvement. It's true, and will be important improving educational strategies for implementation of treatment guidelines. But as for the question to treat grief reaction differently than reactions to other losses in the diagnostic criteria for major depressive disorder (DSM IV)(2), is valid the answer of D.Regier (director of the APA's Division of Research): a diagnosis "“ and decision to treat or not treat a patient "“ cannot be made simply by checking off a list of diagnostic criteria; treatment decision should be born out of a thorough history and examination and should take into consideration any precipitating events as well as the individuals coping capacities and support system.(3)


1. Kimberly A. Hepner, Melissa Rowe, Kathryn Rost, Scot C. Hickey, Cathy D. Sherbourne, Daniel E. Ford, Lisa S. Meredith, and Lisa V. Rubenstein The Effect of Adherence to Practice Guidelines on Depression Outcomes Ann Intern Med 2007; 147: 320-329

2. Wakefield JC, Schmitz MF, First MB, Horwitz AV. Extending the bereavement exclusion for major depression to other losses: evidence from the National Comorbidity Survey. Arch Gen Psychiatry. 2007 Apr;64(4):433- 40.

3. Darrel Regier In response: Diagnosing depression using DSM IV criteria. Am J. Psychiatry 2007 Apr.

Conflict of Interest:

None declared

In Response
Posted on October 21, 2007
Lisa V. Rubenstein
RAND Health Program, Santa Monica, California
Conflict of Interest: None Declared

Dear Dr. Theleritis:

Thank you for pointing out the importance of depression in causing increased mortality due to suicide. In addition, as you allude to, the adverse effects of depression on cardiovascular health and on other chronic disease outcomes are well-documented. We agree with you that these effects, in combination with the low quality of care we observed, are cause for alarm. Our comments on mortality related to depression come from a different perspective, however, and we are grateful for the opportunity to clarify.

For many conditions, avoidance of death and hospitalization are critical drivers for quality improvement. For patients hospitalized with congestive heart failure, for example, the observed short term high death and repeat hospitalization rates have enabled studies to validate quality improvement programs against both economic and mortality outcomes. In the case of depression, in contrast, hospitalization is relatively rare and impacts on death occur over a prolonged period of time. Also, in our studies, we protect people from death due to suicide by intervening if they disclose significant suicidal risk. So, in this study, despite having screened more than 50,000 patients to identify our samples, and enrolling more than 1000 with major depression, we have no documented episodes of suicide and few deaths during our period of observation. Hospitalizations during a six month period ranged from 19% at the VA to around 5% to 7% for the remaining organizations, with very few admissions being due to mental health. In the immediate term, we therefore must validate our quality measures or improvements against outcomes such as depression symptoms, as we did in this paper, or against intermediate consequences of those symptoms such as functional status deficits or employment loss.

You point out that effective care models for improving depression outcomes have been developed and validated in a large number of randomized trials. We found it interesting that the quality deficits we identify in essence predict why education and reminders alone do not improve care. Had the quality deficits been in primary care clinician recognition of depression, we might have expected trials testing reminders to have had significant effects. In our study, however, the deficits were in areas not easily addressed through reminders. Improving primary care clinician assessment of depression, for example, requires time for and experience with psychological interviewing or testing, something not easily accomplished within a 10 minute multipurpose primary care visit. Improving patient completion of depression treatment requires methods for actively monitoring and encouraging adherence, for objectively monitoring symptoms, and for changing medications when necessary"”a set of processes that are not consistent with the usual primary care three to six months return visit pattern. In studies such as those reviewed by Gilbody in the study you reference, most effective interventions provided primary care clinicians with access to depression care management and mental health specialty collaboration.

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