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A Randomized Trial of Its Impact on Primary Care Physicians' Initial Management of Major Depression

Bruce L. Rollman, MD, MPH; Barbara H. Hanusa, PhD; Trae Gilbert, MA; Henry J. Lowe, MD; Wishwa N. Kapoor, MD, MPH; Herbert C. Schulberg, PhD

Arch Intern Med. 2001;161:189-197.

Background  Inadequate treatments are reported for depressed patients cared for by primary care physicians (PCPs). Providing feedback and evidence-based treatment recommendations for depression to PCPs via electronic medical record improves the quality of interventions.

Methods  Patients presenting to an urban academically affiliated primary care practice were screened for major depression with the Primary Care Evaluation of Mental Disorders (PRIME-MD). During 20-month period, 212 patients met protocol-eligibility criteria and completed a baseline interview. They were cared for by 16 board-certified internists, who were electronically informed of their patients' diagnoses, and randomized to 1 of 3 methods of exposure to guideline-based advice for treating depression (active, passive, and usual care). Ensuing treatment patterns were assessed by medical chart review and by patient self-report at baseline and 3 months.

Results  Median time for PCP response to the electronic message regarding the patient's depression diagnosis was 1 day (range, 1-95 days). Three days after notification, 120 (65%) of 186 PCP responses indicated agreement with the diagnosis, 24 (13%) indicated disagreement, and 42 (23%) indicated uncertainty. Primary care physicians who agreed with the diagnoses sooner were more likely to make a medical chart notation of depression, begin antidepressant medication therapy, or refer to a mental health specialist (P<.001). There were no differences in the agreement rate or treatments provided across guideline exposure conditions.

Conclusions  Electronic feedback of the diagnosis of major depression can affect PCP initial management of the disorder. Further study is necessary to determine whether this strategy, combined with delivery of treatment recommendations, can improve clinical outcomes in routine practice.

From the Division of General Internal Medicine, Center for Research on Health Care (Drs Rollman, Hanusa, and Kapoor), the Center for Biomedical Informatics (Dr Lowe), and the Department of Psychiatry, Western Psychiatric Institute and Clinic (Mr Gilbert and Dr Schulberg), University of Pittsburgh School of Medicine, Pittsburgh, Pa.

Corresponding author: Bruce L. Rollman, MD, MPH, Center for Research on Health Care, University of Pittsburgh School of Medicine, 200 Lothrop St, Suite E-820, Pittsburgh, PA 15213-2582 (e-mail: rollmanbl{at}msx.upmc.edu).

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