Patients with "almost absent" or severe depression symptoms
were more likely to receive adequate depression treatment in primary care
settings than were those with mild or moderate symptoms, according to one
When depressive symptoms were either almost absent or extremely severe, 91
percent of patients were adequately managed by primary care physicians.
But when symptoms were mild or moderate, just 69 percent of primary care
physicians received an adequate rating for the treatment, according to the
findings, which appear in the December 2005 Psychiatric Services.
In addition, certain antidepressant medications were associated with a
lower likelihood of adequate depression treatment.
Researchers gathered data on 389 patients between June and September 2002
as part of a quality-assurance project studying patients treated for
depression in the primary care setting.
The patients were diagnosed and treated by primary care physicians at
community-based private practices owned by the University of Pittsburgh
Medical Center Community Medicine Inc.
One way researchers measured the adequacy of depression care for each
patient was with the Antidepressant Treatment and History Form (ATHF), a
validated instrument used to rate the adequacy with which primary care
physicians treat patients with antidepressants, based on medication dosages
and duration of medication trials.
They also gathered data from prospective tracking forms physicians
completed for patients they were currently treating with an antidepressant and
who were enrolled in the study. The forms gathered information on a number of
variables, including the type and dosage of antidepressants used and the
severity of a patient's depression.
In addition, physicians were asked to report what they planned to do next
regarding each patient's treatment—that is, whether they would continue
prescribing the same medication, switch to another antidepressant, change the
dosage, or refer the patient to a mental health clinician.
Researchers designated treatment regimens as adequate when physicians
decided to continue medication trials beyond four weeks; switched patients'
medication due to side effects; when depression symptoms disappeared or were
almost absent during treatment; or when physicians increased the dosage, added
a medication, or referred patients to mental health specialists because of
Patients were deemed to receive "inadequate" care when
physicians continued treatment with a certain medication even though
depressive symptoms were present after four weeks, or when physicians
increased a dosage or added a new medication before the efficacy of the
current one could be determined.
Researchers designated depression treatment as "equivocal"
under two conditions: when there was no evidence of adverse effects and a
physician switched a medication before an eight-week period, or when
depressive symptoms were absent or almost absent and physicians increased
patients' medication dosages, switched medications, or referred the patient to
a mental health specialist.
"Adequacy ratings varied depending on the severity of [depressive]
symptoms," the report noted.
For patients with symptoms that physicians classified as absent, almost
absent, or extremely severe, almost all (91 percent) received adequate
However, among those with symptoms classified as mild, mild to moderate, or
moderate, only 69 percent received adequate depression management.
According to Eric Lenze, M.D., one of the study's investigators and an
assistant professor of psychiatry at the University of Pittsburgh School of
Medicine, when depressive symptoms fall into the range of almost absent or
severe, the steps that primary care physicians take to manage the symptoms are
much more "clear cut" than when those symptoms are mild or
There was also an association between the use of certain antidepressants
and adequate ATHF scores. For instance, while 98 percent of those who received
citalopram or paroxetine had adequate ATHF scores, just 80 percent of those
who received fluoxetine and 29 percent of those who received sertraline
The investigators speculated that sertraline use was associated with lower
ATHF scores because the ATHF required a daily dosage of 100 mg or more for an
adequate rating, while the package insert recommended a daily dosage of 50 mg
They noted that one limitation of the study may be that the sample of
primary care physicians may not be "indicative of typical antidepressant
treatment adequacy, because this group received a lecture about antidepressant
treatment as part of the quality-assurance initiative."
Lenze said the findings suggest that, on the whole, patients can be treated
adequately with antidepressants—particularly selective serotonin
reuptake inhibitors—in primary care settings. However, educating primary
care physicians about the importance of treating mild depression is crucial,
"Even mild symptoms are active symptoms of an illness and need to be
treated and managed," he said.
Primary care physicians can also benefit from education about adequate
dosage ranges, according to Lenze.
"Predictors of Adequacy of Depression Management in the
Primary Care Setting" is posted at<ps.psychiatryonline.org/cgi/content/full/56/12/1524>.▪