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Benchmarking Patterns in the Pharmacologic Treatment of MDD

Charbonneau A, Rosen A, Kader B, Ash A, Owen R, Spiro III, Pugh M, Berlowitz D. Benchmarking Patterns in the Pharmacologic Treatment of MDD. Paper presented at: VA HSR&D National Meeting; 2002 Feb 23; Washington, DC.


Objectives: Depression is a common mental illness, and is associated with increased morbidity and mortality. Pharmacotherapy has proven effective, but is not adequately used among depressed patients. The VA Depression Guidelines were published in 1997 to promote effective treatment. The purpose of this study is to classify adherence to the guidelines, and to explore patient factors associated with non-adherence.Methods: We identified all patients with depression in VISNs 1 and 2 during FY 98 and FY 99 from the Outpatient Care File (OPC) and the Patient Treatment File. Patients had at least one diagnosis of depression (ICD-9-CM codes 296.2x, 296.3x, 311.xx); those with coexisting schizophrenia or bipolar disease were excluded. We identified patients who had antidepressant prescriptions from 6/1/99 through 8/31/99 in the Pharmacy Benefits Management file. Guideline adherence was measured using two criteria. Dosage adequacy was measured by comparing average strength (mg) per day over the three months with minimum recommended daily dosages. Duration adequacy was a dichotomous variable designed to capture whether or not patients missed more than two weeks of therapy. Multivariate regression models were used to assess predictors for each measure of guideline adherence.Results: 12,667 patients who had antidepressants prescribed from 6/1/99 through 8/31/99. Of these, 9,776 (77%) had adequate dosage; 4,371 (38%) had adequate duration. Only 3,467 (30%) had adequate dosage and duration. Dosage adequacy differed substantially among medication classes. Patients younger than 65 were less likely to have adequate dosage (OR .32, 95% CI .28, .35) duration (OR .83, 95% CI .71, .91) compared to patients older than 65. Women were less likely to have adequate dosage (OR .83, 95% CI .71, .96) compared with men. Non-white patients were less likely to have adequate dosage (OR .83, 95% CI .71, .98) and duration (OR .69, 95% CI .58, .82) compared with white patients. Conclusions: Under-treatment of depression in the VA is still substantial, despite the well-known risks of worse outcomes. Younger, women, and non-white patients are at especially high risk. Further work is needed to determine reasons for under-treatment.Impact Statements: Dissemination of guidelines for depression treatment does not necessarily lead to 100% adherence. The VA needs to translate guideline recommendations into practice.

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