Achieving effective antidepressant pharmacotherapy in primary care: the role of depression care management in treating late-life depression.

OBJECTIVES To estimate the effect of an evidence-based depression care management (DCM) intervention on the initiation and appropriate use of antidepressant in primary care patients with late-life depression. DESIGN Secondary analysis of data from a randomized trial. SETTING Community, primary care. PARTICIPANTS Randomly selected individuals aged 60 and older with routine appointments at 20 primary care clinics randomized to provide a systematic DCM intervention or care as usual. METHODS Rates of antidepressant use and dose adequacy of patients in the two study arms were compared at each patient assessment (baseline, 4, 8, and 12 months). For patients without any antidepressant treatment at baseline, a longitudinal analysis was conducted using multilevel logistic models to compare the rate of antidepressant treatment initiation, dose adequacy when initiation was first recorded, and continued therapy for at least 4 months after initiation between study arms. All analyses were conducted for the entire sample and then repeated for the subsample with major or clinically significant minor depression at baseline. RESULTS Rates of antidepressant use and dose adequacy increased over the first year in patients assigned to the DCM intervention, whereas the same rates held constant in usual care patients. In longitudinal analyses, the DCM intervention had a significant effect on initiation of antidepressant treatment (adjusted odds ratio (OR)=5.63, P<.001) and continuation of antidepressant medication for at least 4 months (OR=6.57, P=.04) for patients who were depressed at baseline. CONCLUSIONS Evidence-based DCM models are highly effective at improving antidepressant treatment in older primary care patients.