Depression is a common chronic episodic disorder with substantial associated disability and economic costs. The Agency for Health Care and Policy Research recognized the societal burden of depression and developed clinical practice guidelines to improve primary care physician's ability to manage patients with depression. The proposed study will evaluate whether introduction of these practice guidelines will lead to changes in practice and improvement in patient outcomes. Ninety primary care physicians will be randomized to either 1) attention control (mailing the guidelines to them) 2) physician intervention (participatory review of guidelines and academic detailing) and patient intervention (mailing patient guide to the guidelines) and 3) physician intervention, patient intervention and the addition of a treatment facilitator who contacts patients starting depression treatment at their home 4 weeks later to assist in achieving treatment goals. The study will take place with primary care physicians who practice in the HealthPlus Independent Physician Associate (IPA) style health maintenance organization located in the Maryland suburbs of Washington, D.C. The major hypothesis is that patients with depression treated by primary care physicians in the intervention groups will have higher remission rates from depression, lower levels of depressive symptoms and better functional status at one year than patients treated by physicians in the control group. We will also measure changes in recognition, assessment, pharmacological treatment, psychotherapeutic treatment, and referral of the depressed patient presenting in primary care. Study outcomes will be assessed with a cohort of patients found through screening to meet criteria for major depression and through routinely collected pharmaceutical and specialty mental health referral data on the entire panel of the study physicians. A cost-effectiveness analysis will be performed to determine if the improved outcomes are achieved with reasonable costs. Several process outcomes concerning changes in patient's and physician's knowledge of depression and its treatment, their attitudes toward treatment, and their opinions of the AHCPR Depression Guidelines will also be measured. The results of this study will add to our knowledge of how to translate complicated practice guidelines into changes in practice, particularly for physicians who practice in IPA HMO models.
