Skip to main content

Advertisement

Log in

A randomized trial using computerized decision support to improve treatment of major depression in primary care

  • Original Articles
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

OBJECTIVE: To examine whether feedback and treatment advice for depression presented to primary care physicians (PCPs) via an electronic medical record (EMR) system can potentially improve clinical outcomes and care processes for patients with major depression.

DESIGN: Randomized controlled trial.

SETTING: Academically affiliated primary care practice in Pittsburgh, PA.

PATIENTS: Two hundred primary care patients with major depression on the Primary Care Evaluation of Mental Disorders (PRIME-MD) and who met all protocol-eligibility criteria.

INTERVENTION: PCPs were randomly assigned to 1 of 3 levels of exposure to EMR feedback of guideline-based treatment advice for depression: “active care” (AC), “passive care” (PC), or “usual care” (UC).

MEASUREMENTS AND MAIN RESULTS: Patients’ 3- and 6-month Hamilton Rating Scale for Depression (HRS-D) score and chart review of PCP reports of depression care in the 6 months following the depression diagnosis. Only 22% of patients recovered from their depressive episode at 6 months (HRS-D ≤7). Patients’ mean HRS-D score decreased regardless of their PCPs’ guideline-exposure condition (20.4 to 14.2 from baseline to 6-month follow-up; P<.001). However, neither continuous (HRS-D ≤7: 22% AC, 23% PC, 22% UC; P=.8) nor categorical measures of recovery (P=.2) differed by EMR exposure condition upon follow-up. Care processes for depression were also similar by PCP assignment despite exposure to repeated reminders of the depression diagnosis and treatment advice (e.g., depression mentioned in ≥3 contacts with usual PCP at 6 months: 31% AC, 31% PC, 18% UC; P=.09 and antidepressant medication suggested/prescribed or baseline regimen modified at 6 months: 59% AC, 57% PC, 52% UC; P=.3).

CONCLUSIONS: Screening for major depression, electronically informing PCPs of the diagnosis, and then exposing them to evidence-based treatment recommendations for depression via EMR has little differential impact on patients’ 3- or 6-month clinical outcomes or on process measures consistent with high-quality depression care.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Katon W, Schulberg HC. Epidemiology of depression in primary care. Gen Hosp Psychiatry. 1992;14:237–47.

    Article  PubMed  CAS  Google Scholar 

  2. Broadhead E, Blazer D, George L, Tse C. Depression, disability days, and days lost in a prospective epidemiologic survey. JAMA. 1990;264:2524–8.

    Article  PubMed  CAS  Google Scholar 

  3. Wells KB, Stewart A, Hays RD, et al. The functioning and well-being of depressed patients. Results from the Medical Outcomes Study. JAMA. 1989;262:914–9.

    Article  PubMed  CAS  Google Scholar 

  4. Hays RD, Wells KB, Sherbourne CD, Rogers W, Spritzer K. Functioning and well-being outcomes of patients with depression compared with chronic general medical illnesses. Arch Gen Psychiatry. 1995;52:11–9.

    PubMed  CAS  Google Scholar 

  5. Katon W, Sullivan MD. Depression and chronic medical illness. J Clin Psychiatry. 1990;51:3–11.

    PubMed  Google Scholar 

  6. Lin EH, Von Korff M, Wagner EH. Identifying suicide potential in primary care. J Gen Intern Med. 1989;4:1–6.

    Article  PubMed  CAS  Google Scholar 

  7. Schulberg HC, Block MR, Madonia MJ, et al. The ‘usual care’ of major depression in primary care practice. Arch Fam Med. 1997;6:334–9.

    Article  PubMed  CAS  Google Scholar 

  8. Simon GE, VonKorff M. Recognition, management, and outcomes of depression in primary care. Arch Fam Med. 1995;4:99–105.

    Article  PubMed  CAS  Google Scholar 

  9. Schulberg HC, Katon W, Simon GE, Rush AJ. Treating major depression in primary care practice: an update of the Agency for Health Care Policy and Research Practice Guidelines. Arch Gen Psychiatry. 1998;55:1121–7.

    Article  PubMed  CAS  Google Scholar 

  10. Perez-Stable EJ, Miranda J, Munoz RF, Ying YW. Depression in medical outpatients. Underrecognition and misdiagnosis. Arch Intern Med. 1990;150:1083–8.

    Article  PubMed  CAS  Google Scholar 

  11. Garrett LE Jr, Hammond LE, Stead WW. The effects of computerized medical records on provider efficiency and quality of care. Methods Inf Med. 1986;25:151–7.

    PubMed  Google Scholar 

  12. Young DW. Improving the consistency with which investigations are requested. Med Inform (Lond). 1981;6:13–7.

    Google Scholar 

  13. Pestotnik SL, Classen DC, Evans RS, Burke JP. Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes. Ann Intern Med. 1996;124:884–90.

    PubMed  CAS  Google Scholar 

  14. McDonald CJ. Protocol-based computer reminders, the quality of care and the non-perfectability of man. N Engl J Med. 1976;292:1351–5.

    Article  Google Scholar 

  15. Safran C, Rind DM, Davis RB, et al. Guidelines for management of HIV infection with computer-based patient’s record. Lancet. 1995;346:341–6.

    Article  PubMed  CAS  Google Scholar 

  16. McAlister NH, Covvey HD, Tong C, Lee A, Wigle ED. Randomized controlled trial of computer assisted management of hypertension in primary care. BMJ. 1986;293:670–4.

    Article  PubMed  CAS  Google Scholar 

  17. Barnett GO, Winickoff RN, Morgan MM, Zielstorff RD. A computer-based monitoring system for follow-up of elevated blood pressure. Med Care. 1983;21:400–9.

    Article  PubMed  CAS  Google Scholar 

  18. McDonald CJ, Hui SL, Tierney WM. Effects of computer reminders for influenza vaccination on morbidity during influenza epidemics. MD Comput. 1992;9:304–12.

    PubMed  CAS  Google Scholar 

  19. Dexter PR, Wolinsky FD, Gramelspacher GP, et al. Effectiveness of computer-generated reminders for increasing discussions about advance directives and completion of advance directive forms. A randomized, controlled trial. Ann Intern Med. 1998;128:102–10.

    PubMed  CAS  Google Scholar 

  20. Dexter PR, Perkins S, Overhage JM, Maharry K, Kohler RB, McDonald CJ. A computerized reminder system to increase the use of preventive care for hospitalized patients. N Engl J Med. 2001;345:965–70.

    Article  PubMed  CAS  Google Scholar 

  21. Tierney W, Overhage J, Murray M, et al. Effects of computerized guidelines for outpatient management of ischemic heart disease and heart failure. J Gen Intern Med. 1999;14(suppl 2):125.

    Google Scholar 

  22. Karson A, Kuperman G, Horsky J, Fairchild D, Fiskio J, Bates D, Patient-specific computerized outpatient reminders to improve physician compliance with computerized guidelines. J Gen Intern Med. 2000;15(suppl 1):126.

    Google Scholar 

  23. Cannon DS, Allen SN. A comparison of the effects of computer and manual reminders on compliance with a mental health clinical practice guideline. J Am Med Inform Assoc. 2000;7:196–203.

    PubMed  CAS  Google Scholar 

  24. Rollman BL, Hanusa BH, Gilbert T, Lowe HJ, Kapoor WN, Schulberg HC. The electronic medical record: a randomized trial of its impact on primary care physicians’ initial management of major depression. Arch Intern Med. 2001;161:189–97.

    Article  PubMed  CAS  Google Scholar 

  25. Burger M. Logician, ver 4.2. JAMA. 1997;278:1380–2.

    Google Scholar 

  26. Agency for Health Care Policy and Research. Depression in Primary Care, Vol. 1. Detection and Diagnosis; Vol. 2. Treatment of Major Depression. Rockville, Md: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1993.

    Google Scholar 

  27. Spitzer RL, Williams JBW, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study. JAMA. 1994;272:1749–56.

    Article  PubMed  CAS  Google Scholar 

  28. Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA. 1984;252:1905–7.

    Article  PubMed  CAS  Google Scholar 

  29. Potts MK, Daniels M, Burnam MA, Wells KB. A structured interview version of the Hamilton Depression Rating Scale: evidence of reliability and versatility of administration. J Psychiatr Res. 1990;24:335–50.

    Article  PubMed  CAS  Google Scholar 

  30. Rollman BL, Gilbert T, Lowe HJ, Kapoor WN, Schulberg HC. The electronic medical record: its role in disseminating depression guidelines in primary care practice. Int J Psychiatry Med. 1999;29:267–86.

    Article  PubMed  CAS  Google Scholar 

  31. Ware JE Jr, Kosinski M, Keller SD. A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34:220–33.

    Article  PubMed  Google Scholar 

  32. Simon GE, VonKorff M, Rutter C, Wagner E. Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care. BMJ. 2000;320:550–4.

    Article  PubMed  CAS  Google Scholar 

  33. Wells KB, Sherbourne C, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA. 2000;283:212–20.

    Article  PubMed  CAS  Google Scholar 

  34. Donner A, Birkett N, Buck C. Randomization by cluster: sample size requirements and analysis. Am J Epidemiol. 1981;114:906–14.

    PubMed  CAS  Google Scholar 

  35. Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA. 1995;273:1026–31.

    Article  PubMed  CAS  Google Scholar 

  36. Linn LS, Yager J. The effect of screening, sensitization and feedback on notation of depression. J Med Educ. 1980;55:942–9.

    PubMed  CAS  Google Scholar 

  37. Shapiro S, German PS, Skinner EA, et al. An experiment to change detection and management of mental morbidity in primary care. Med Care. 1987;25:327–39.

    Article  PubMed  CAS  Google Scholar 

  38. Magruder-Habib K, Zung WW, Feussner JR. Improving physicians’ recognition and treatment of depression in general medical care. Results from a randomized clinical trial. Med Care. 1990;28:239–50.

    Article  PubMed  CAS  Google Scholar 

  39. Balas E, Weingarten S, Garb C, Blumenthal D, Boren S, Brown G. Improving preventive care by prompting physicians. Arch Intern Med. 2000;160:301–8.

    Article  PubMed  CAS  Google Scholar 

  40. Litzelman DK, Dittus RS, Miller ME, Tierney WM. Requiring physicians to respond to computerized reminders improves their compliance with preventive care protocols. J Gen Intern Med. 1993;8:311–7.

    Article  PubMed  CAS  Google Scholar 

  41. Hunt DL, Haynes RB, Hanna SE, Smith K. Effects of computer-based clinical decision support systems on physician performance and patient outcomes. JAMA. 1998;280:1339–46.

    Article  PubMed  CAS  Google Scholar 

  42. Rost K, Nutting P, Smith J, Coyne JC, Cooper-Patrick L, Rubenstein L. The role of competing demands in the treatment provided primary care patients with major depression. Arch Fam Med. 2000;9:150–4.

    Article  PubMed  CAS  Google Scholar 

  43. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q. 1996;74:511–44.

    Article  PubMed  CAS  Google Scholar 

  44. Lin EH, Von Korff M, Katon W, et al. The role of the primary care physician in patients’ adherence to antidepressant therapy. Med Care. 1995;33:67–74.

    Article  PubMed  CAS  Google Scholar 

  45. Tierney WM, Overhage JM, Takesue BY, et al. Computerizing guidelines to improve care and patient outcomes: the example of heart failure. J Am Med Inform Assoc. 1995;2:316–22.

    PubMed  CAS  Google Scholar 

  46. Rost K, Smith R, Matthews DB, Guise B. The deliberate misdiagnosis of major depression in primary care. Arch Fam Med. 1994;3:333–7.

    Article  PubMed  CAS  Google Scholar 

  47. Schulberg HC, Block MR, Madonia MJ, et al. Treating major depression in primary care practice. Eight-month clinical outcomes. Arch Gen Psychiatry. 1996;53:913–9.

    PubMed  CAS  Google Scholar 

  48. Spitzer R, Kroenke K, Williams J. Validation and utility of a self-report version of the PRIME-MD. The PHQ Primary Care Study. JAMA. 1999;282:1737–44.

    Article  PubMed  CAS  Google Scholar 

  49. Kobak KA, Taylor LH, Dottl SL, et al. A computer-administered telephone interview to identify mental disorders. JAMA. 1997;278:905–10.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Bruce L. Rollman MD, MPH.

Additional information

This work was supported by AHCPR Grant R01 HS09421.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Rollman, B.L., Hanusa, B.H., Lowe, H.J. et al. A randomized trial using computerized decision support to improve treatment of major depression in primary care. J GEN INTERN MED 17, 493–503 (2002). https://doi.org/10.1046/j.1525-1497.2002.10421.x

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1046/j.1525-1497.2002.10421.x

Key words

Navigation