Quality of care for primary care patients with depression in managed care

Objective: To evaluate the process and quality of care for primary care patients with depression under managed care organizations. Method: Surveys of 1204 outpatients with depression at the time of and after a visit to 1 of 181 primary care clinicians from 46 primary care clinics in 7 managed care organizations. Patients had depressive symptoms in the previous 30 days, with or without a 12-month depressive disorder by diagnostic interview. Process indicators were depression counseling, mental health referral, or psychotropic medication management at index visit and the use of appropriate antidepressant medication during the last 6 months. Results: Of patients with depressive disorder and recent symptoms, 29% to 43% reported a depression-specific process of care in the index visit, and 35% to 42% used antidepressant medication in appropriate dosages in the prior 6 months. Patients with depressive disorders rather than symptoms only and those with comorbid anxiety had higher rates of depression-specific processes and quality of care (P<.005). Recurrent depression, suicidal ideation, and alcohol abuse were not uniquely associated with such rates. Patients visiting for old problems or checkups received more depression-specific care than those with new problems or unscheduled visits. The 7 managed care organizations varied by a factor of 2-fold in rates of depression counseling and appropriate antidepressant use. Conclusions: Rates of process and quality of care for depression as reported by patients are moderate to low in managed primary care practices. Such rates are higher for patients with more severe forms of depression or with comorbid anxiety, but not for those with severe but "silent" symptoms like suicide ideation. Visit context factors, such as whether the visit is scheduled, affect rates of depression-specific care. Rates of care for depression are highly variable among managed care organizations, emphasizing the need for process monitoring and quality improvement for depression at the organizational level.