Quality of Antidepressant Treatment: What’s Improved and What Hasn’t

Beginning in the early 1990s mental health services researchers began studying the quality of antidepressant treatment in community practice. That research identified several specific gaps in care. First, many people with significant depression were not recognized or treated . Second, prescribed antidepressant doses were often too low to be effective. Third, many patients starting antidepressants discontinued them before they might have provided benefit. Fourth, many patients did not return for follow-up care. While some of the earliest research in this area focused on antidepressant treatment in primary care, subsequent research found similar gaps in treatment provided by community psychiatrists. Now, 25 years later, we can examine our progress in closing each of those gaps.

Regarding underrecognition of depression, we can point to fairly dramatic changes since the 1990s. Recognition and treatment of depression have increased dramatically, so that the proportion of US adults using antidepressant medications is now approximately 10%. This dramatic increase has raised the opposite concern of possible overprescription or unnecessary drug treatment for people with mild depression. The recent article by my colleagues and me in The Journal of Clinical Psychiatry suggests that concerns about overtreatment are probably overstated. Most antidepressant prescribing for depression falls reassuringly within what evidence-based guidelines recommend.

Regarding underdosing of depression, we can also point to significant progress, but physicians cannot take much credit. Underdosing was really a problem of the tricyclic antidepressant medication era. The greater tolerability of SSRIs and other newer antidepressants made gradual dose escalation less necessary than with tricyclics, leading to much simpler dosing schedules. Newer medications may not be more effective, but they are certainly easier to use (and harder to use ineffectively).

Unfortunately, the other two gaps in care have not shown much improvement. Early discontinuation of antidepressants remains common. The National Committee for Quality Assurance (NCQA) developed the Health Plan Employer Data and Information Set (HEDIS) in the 1990s to track health care quality, and the antidepressant medication management measures have shown very little progress in antidepressant adherence over the last decade. Frequency of follow-up visits typically falls far short of any recommended minimum. We should be a bit embarrassed that the original NCQA/HEDIS measure for depression follow-up visits was removed from our national “report card” because no health system could even approach a passing grade!

Financial disclosure:Dr Simon has received grant/research support from Novartis. ​