Receiving Guideline-Concordant Pharmacotherapy for Major Depression: Impact on Ambulatory and Inpatient Health Service Use

Abstract

French

Objective:

This study aimed to determine the associations between guideline-concordant pharmacotherapy for depression and the use of health services in the year following diagnosis.

Method:

This population-based, retrospective cohort study examined Quebec drug plans between 1999 and 2002. We included beneficiaries aged 18 to 64 years who were newly diagnosed with an episode of depression by primary care physicians and psychiatrists between October 1, 2000, and March 31, 2001, and who made at least one psychotropic pharmacy claim within 31 days of diagnosis. We defined guideline concordance as the receipt of recommended medication, starting dosage, and treatment duration as defined by the Canadian Network for Mood and Anxiety Treatments guidelines. We measured outcomes on use of ambulatory (number of visits to prescribing physician, other physicians, or emergency departments) and inpatient (hospitalization) services.

Results:

There were 2742 patients (mean age 42 years; 64% female patients) who met the study criteria. Of the 2047 (75%) patients to whom an antidepressant was dispensed, 1958 (71%) received a recommended first-line medication, 1297 (63%) received a recommended starting dosage, and 304 (15%) received a recommended duration. According to the 3 criteria, only 8% were treated appropriately; 21% received benzodiazepines rather than antidepressants. There were 2 median visits (inferquartile range [IQR] 1 to 3) to prescribing physicians, 0 visits (IQR 0 to 1) to other physicians, and 0 visits (IQR 0 to 0) to emergency departments; 497 (18%) patients were hospitalized. In separate multivariate models for repeated measures, recommended first-line medication, dosage, and duration were associated with more prescribing physician visits. Recommended first-line medication reduced the odds of hospitalization.

Conclusion:

Guideline concordance was associated with more visits to prescribing physicians and lower odds of hospitalization.

Keywords

adults Canada depression guidelines pharmacotherapy population-based health service use

References

American Psychiatric Association. Practice guidelines for the treatment of patients with major depressive disorder (revised). American Journal of Psychiatry. 2000;1574(4):1–45.

Stephens

Joubert

The economic burden of mental health problems in Canada. Chronic Dis Can. 2001; 22(1):18–23.

Beaudet

. Psychological health-depression. Health Rep 2000;11:63–75.

Parikh

Lam

, CANMAT Depression Work Group. Clinical guidelines for the treatment of depressive disorders, I. Definitions, prevalence, and health burden. Can J Psychiatry. 2001;46(Suppl 1):S13–S20.

World Health Organization. The global burden of disease, vol 1. Geneva (CH): World Health Organization; 1996.

Judd

Akiskal

Zeller

Psychosocial disability during the long-term course ofunipolar major depressive disorder. Arch Gen Psychiatry. 2000;(4):57:375–380.

Broadhead

Blazer

George

Depression, disability days, and days lost from work in a prospective epidemiologic survey. JAMA. 1990;264(19):2524–2528.

Kessler

Frank

. The impact of psychiatric disorders on work loss days. Psychol Med. 1997;27(4):861–873.

Kessler

Barber

Birnbaum

Depression in the woirkplace: Effects on short-term disability. Health Affairs. 1999;18(5):163–171.

10.

Johnson

Weissman

Klerman

. Service utilization and social morbidity associated with depressive symptoms in the community. JAMA. 1992;267(11):1478–1483.

11.

Ensinck

KTJL

Schuurman

van den Akker

Is there an increased risk of dying after depression?

Am J Epidemiol. 2002;156(11):1043–1048.

12.

Harris

Barraclough

Suicide as an outcome for mental disorders. A meta-analysis. Br J Psychiatry. 1997;170:205–228.

13.

Appleby

Shaw

Amos

Suicide within 12 months of contact with mental health services: National clinical survey. BMJ. 1999;318(7193):1235–1239.

14.

Angst

Gerber-Weder

RGA

. Suicide in 406 mood-disorder patients with and without long-term medication: A 40 to 44 years' follow-up. Arch Suicide Res. 2005;9(3):279–300.

15.

Von Korff

Ormel

Katon

Disability and depression among high utilizers of health care. A longitudinal analysis. Arch Gen Psychiatry. 1992;49(2):91–100.

16.

Schulberg

Block

Madonia

Treating major depression in primary care practice. Eight-month clinical outcomes. Arch Gen Psychiatry. 1996;53(10):913–919.

17.

Markowitz

Kocsis

Bleiberg

A comparative trial of psychotherapy and pharmacotherapy for ‘pure’ dysthymic patients. J Affect Disord. 2005;89(1–3):167–175.

18.

Pattern

Beck

Major depression and mental health care utilization in Canada: 1994 to 2000. CMAJ. 2004; 170:1811–1812.

19.

Olfson

Marcus

Druss

National trends in the outpatient treatment of depression. JAMA. 2002;287(2):203–209.

20.

Skaer

Sclar

Robinson

Trends in the rate of depressive illness and use of antidepressant pharmacotherapy by ethnicity/race: An assessment of office-based visits in the United States, 1992–1997. Clin Ther. 2000;22(12):1575–1589.

21.

Parikh

Lesage

Kennedy

Depression in Ontario: Under-treatment and factors related to antidepressant use. J Affect Disord. 1999;52(1–3):67–76.

22.

Wells

Katon

Rogers

Use of minor tranquilizers and antidepressant medications by depressed outpatients: Results from the medical outcomes study. Am J Psychiatry. 1994;151(5):694–700.

23.

Sirey

Meyers

Bruce

Predictors of antidepressant prescription and early use among depressed outpatients. Am J Psychiatry. 1999;156(5):690–696.

24.

Eisenberg

Treating depression and anxiety in primary care. Closing the gap between knowledge and practice. N Engl J Med. 1992;326:1080–1084.

25.

Adler

Improving the quality of depression treatment in primary care. Medical Outcomes Trust Monitor. 2000;5:3–5.

26.

Lin

Katon

Simon

Low-intensity treatment of depression in primary care: Is it problematic?

Gen Hosp Psychiatry. 2000;22(2):78–83.

27.

Sood

Treglia

Obenchain

Determinants of antideprssant treatment outcome. Am J Manag Care. 2000;6(12):1327–1336.

28.

Katz

Kessler

Lin

Medication management of depression in the United States and Ontario. J Gen Intern Med. 1998;13(2):77–85.

29.

Young

Klap

Sherbourne

The quality of care for depressive and anxiety disorders in the United States. Arch Gen Psychiatry. 2001;58(1):55–61.

30.

Donoghue

Taylor

. Suboptimal use of antidepressants in the treatment of depression. CNS Drugs. 2000;13(5):365–383.

31.

Mann

. The medical management of depression. N Engl J Med. 2005;353(17):1819–1834.

32.

Canadian Network for Mood and Anxiety Treatments (CANMAT). Guidelines for the diagnosis and pharmacological treatment of depression. 1st ed. Toronto (ON): CANMAT; 1999. p. 1–76.

33.

Agency for Health Care Policy and Research. Depression in primary care: Detection and diagnosis. Rockville (MD): US Department of Health and Human Services; 1993.

34.

Blais

Grégoire

J-P

Rouleau

Ambulatory use of inhaled B(2)-agonists for the treatment of asthma in Quebec. A population-based utilization review. Chest. 2001;119(5):1316–1321.

35.

World Health Organization. International classification of diseases 9th revision. Geneva (CH): World Health Organization; 1975.

36.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. DSM-IV 4th ed. Washington (DC): American Psychiatric Association; 1994.

37.

Von Korff

Wagner

Saunders

A chronic disease score from automated pharmacy data. J Clin Epidemiol. 1992;45(2):197–203.

38.

Moride

Du Fort

G Galbaud

Monette

Sub-optimal duration of antidepressant treatments in the older ambulatory population of Quebec: Association with selected physician characteristics. J Am Geriatr Soc 2002;50(8):1365–1371.

39.

SAS Institute. SAS Version 8.02. Cary (NC): SAS Institute; 2001.

40.

Liang

K-Y

Zeger

. Longitudinal data analysis using generalized linear models. Biometrika. 1986;73:13–22.

41.

SAS Institute. The GENMOD procedure in SAS/STAT software: Changes and enhancements for release 6.12. Cary (NC): SAS Institute; 1996.

42.

Haggerty

Reid

Freeman

Continuity of care: A multidisciplinary review. BMJ. 2003;327(7425):1219–1221.

43.

Menec

Sirski

Attawar

Does continuity of care matter in a universally insured population?

Health Serv Rese. 2005;40(2):389–400.

44.

Tylee

Jones

Managing depression in primary care. Public confidence needs to be restored after concerns over the safety of SSRIs. BMJ. 2005;330(7495):800–801.

45.

Valenstein

Taylor

Austin

Benzodiazepine use among depressed patients treated in mental health settings. Am J Psychiatry. 2004;161(4):654–661.

46.

Furukawa

Streiner

Young

. Antidepressant and benzodiazepine for major depression. Cochrane Database of Systematic Reviews; 2005.

47.

Smith

Londborg

Glaudin

Short-term augmentation of fluoxetine with clonazepam in the treatment of depression: A double-blind study. Am J Psychiatry. 1998;155(11):1339–1345.

48.

Nutt

Treatment of depression and concomitant anxiety. Eur Neuropsychopharmacol 2000;10(suppl 4):S433–S437.

49.

Katon

Von Korff

Lin

Distressed high utilizers of medical care. DSM-III-R diagnoses and treatment needs. Gen Hosp Psychiatry. 1990;12:355–362.

50.

Montano

. Recognition and treatment of depression in a primary care setting. J Clin Psychiatry. 1994;55(Suppl):18–34.

51.

Rost

Smith

Matthews

The deliberate misdiagnosis of major depression in primary care. Arch Fam Med. 1994;3(4):333–337.

52.

Broadhead

. Misdiagnosis of depression. Physicians contribute to the stigmatization of mental illness. Arch Fam Med. 1994;3(4):319–320.

53.

Kwon

Bungay

Pei

Antidepressant use. Concordance between self-report and claims records. Med Care. 2003;41(3):368–374.

54.

Saunders

Simon

Bush

Assessing the feasibility of using computerized pharmacy claims refill data to monitor antidepressant treatment on a population basis: A comparison of automated and self-report data. J Clin Epidemiol. 1998;51(10):883–890.

55.

Beck

Patten

Williams

JVA

Antidepressant utilization in Canada. Soc Psychiatry Psychiatr Epidemiol. 2005;40(10):799–807.