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

Objective: To evaluate the process and quality of care for primary care pat ients with depression under managed care organizations. Method: Surveys of 1204 outpatients with depression at the time of and afte r 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 pr evious 30 days, with or without a 12-month depressive disorder by diagnosti c interview. Process indicators were depression counseling, mental health r eferral, or psychotropic medication management at index visit and the use o f appropriate antidepressant medication during the last 6 months. Results: Of patients with depressive disorder and recent symptoms, 29% to 4 3% reported a depression-specific process of care in the index visit, and 3 5% to 42% used antidepressant medication in appropriate dosages in the prio r 6 months. Patients with depressive disorders rather than symptoms only an d those with comorbid anxiety had higher rates of depression-specific proce sses and quality of care (P<.005). Recurrent depression, suicidal ideation, and alcohol abuse were not uniquely associated with such rates. Patients v isiting for old problems or checkups received more depression-specific care than those with new problems or unscheduled visits. The 7 managed care org anizations varied by a factor of 2-fold in rates of depression counseling a nd appropriate antidepressant use. Conclusions: Rates of process and quality of care for depression as reporte d by patients are moderate to low in managed primary care practices. Such r ates are higher for patients with more severe forms of depression or with c omorbid anxiety, but not for those with severe but "silent" symptoms like s uicide ideation. Visit context factors, such as whether the visit is schedu led, 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 organ izational level.