The Effect of Adherence to Practice Guidelines on Depression Outcomes

BACKGROUND: Few studies have assessed clinician adherence to depression practice guidelines and the relationship between clinician adherence and depression outcomes. OBJECTIVE: To estimate how frequently specific guideline recommendations are followed and to assess whether following guideline recommendations is linked to improved depression outcomes. DESIGN: Observational analysis of data collected from 1996 to 1998 in 3 randomized clinical trials. SETTING: 45 primary care practices in 13 U.S. states. PATIENTS: 1131 primary care patients with depression. MEASUREMENTS: Expert panel methods were used to develop a patient survey-based index that measured adherence to clinical practice guidelines on depression. Rates of adherence to the 20 indicators that form the index were evaluated. Multivariable regression that controlled for case mix was used to assess how index scores predicted continuous and dichotomous depression measures at 12, 18, and 24 months. RESULTS: Quality of care was high (clinician adherence 79%) for 6 indicators, including primary care clinician detection of depression. Quality of care was low (adherence, 20% to 38%) for 8 indicators, including management of suicide risk (3 indicators), alcohol abuse (2 indicators), and elderly patients; assessment of symptoms and history of depression; and treatment adjustment for patients who did not respond to initial treatment. Greater adherence to practice guidelines significantly predicted fewer depressive symptoms on continuous measures (P < 0.001 for 12 months, P < 0.01 for 18 months, and P < 0.001 for 24 months) and dichotomous measures (P < 0.05 for 18 and 24 months). LIMITATIONS: Data are based on patient self-report. Possible changes in practice since 1998 may limit the generalizability of the findings. CONCLUSIONS: Adherence to guidelines was high for one third of the recommendations that were measured but was very low for nearly half of the measures, pointing to specific needs for quality improvement. Guideline-concordant depression care appears to be linked to improved outcomes in primary care patients with depression.