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John L. Coulehan, MD, MPH; Herbert C. Schulberg, PhD; Marian R. Block, MD; Michael J. Madonia, MSW; Eric Rodriguez, MD

Arch Intern Med. 1997;157(10):1113-1120.

Abstract
Background
This study describes the functioning of primary care patients with major depressive disorder, the relationship of medical comorbidity to functional status, and the effects of depression-specific treatment on functional status after 8 months.

Methods
Patients were randomized to a protocol intervention (nortriptyline hydrochloride or interpersonal psychotherapy) or to usual care with the patient's physician in a clinical trial of primary care treatments of depression. Their functional status was evaluated using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) and the Global Assessment Scale. Medical comorbidity was assessed with the Duke Severity of Illness Checklist. The Hamilton Rating Scale for Depression and Beck Depression Inventory were used to measure depressive severity. Assessments were conducted at baseline and at 1, 2, 4, and 8 months after randomization.

Results
At baseline, patients reported substantial impairments in the functional domains as assessed by the SF-36 and Global Assessment Scale. Severity of general medical illness and depression were not correlated. Greater medical comorbidity was associated with diminished physical, but not psychological, functioning. Mean scores on SF-36 scales and the Global Assessment Scale improved significantly during the 8 months of follow-up. Patients assigned to protocol treatments showed greater improvement, compared with those assigned to usual care, on the SF-36 mental summary scale and most individual scales but not on the SF-36 physical summary scale. However, patients who completed protocol treatment also experienced significant improvement on the physical summary scale. Medical comorbidity was only a weak predictor of outcome.

Conclusions
Primary care patients with major depressive disorder report substantial impairments in physical, psychological, and social functioning on initial assessment. Severity of baseline medical comorbidity did not correlate with severity of depression and only weakly correlated with functional status at 8 months. Functional impairments improve with time, but standardized depression-specific treatment is associated with greater improvement in more domains of functioning than is a physician's usual care.

Arch Intern Med. 1997;157:1113-1120

Author Affiliations
From the Departments of Preventive Medicine and Internal Medicine, State University of New York at Stony Brook, School of Medicine (Dr Coulehan); the Departments of Psychiatry and Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pa (Drs Schulberg and Rodriguez); and the Department of Family Practice, The Western Pennsylvania Hospital, Pittsburgh (Dr Block and Mr Madonia).

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