Funds are requested for the second 6 months of Year 04 and for all of Year 05 so as to extend our 42 month study of whether treatments for major depression validated with psychiatric patients are equally effective with primary medical care patients experiencing this disorder. The question of whether treatments can be transferred across service delivery settings arises since ambulatory medical patients experience depressions of possibly differing etiology, severity, symptomatology, and duration. This issue has clinical and policy significance in light of repeated assertions that primary care physicians improperly treat their depressed patients, and pending AHCPR clinical guidelines for treatment of depression in ambulatory medical patients provided """"""""usual care"""""""" by their primary care physicians with the clinical course of similar patients treated with standardized pharmacotherapy (nortriptyline) alone of time-limited psychotherapy (interpersonal psychotherapy) alone. Patients at three Pittsburgh, PA primary health centers are screened with the Center for Epidemiologic Studies-Depression Scale, and the Diagnostic Interview Schedule. Patients meeting DIS criteria for a current major depression are assessed by a psychiatrist to confirm the diagnosis of affective disorder and to ascertain severity of greater than or equal to 13 on the Hamilton Rating Scale - Depression. Such patients also are give laboratory tests to rule out medical contraindications to psychiatric treatment. 270 patients meeting all inclusionary and exclusionary criteria will be randomized to the three treatment conditions. Study patients are followed for 18 months after treatment assignment. It is hypothesized that significantly more patients treated with pharmacotherapy or psychotherapy than patients receiving usual care will no longer meet DIS criteria for a major depression and have HRS-D scores less than or equal to 7 four months after starting treatment. Outcome on the diagnosis-severity criterion and other psychiatric, medical, and social indices also is assessed at three prior and three subsequent time points so as to compare each treatment cohort's course of illness. The study will generate findings about the validity of transferring depression treatment standards across service delivery and will be completed with cost-effectiveness data produced through Dr. Lave's economic analyses.
