Health plan characteristics and conformance with key practice guideline psychopharmacologic treatment recommendations for major depression

Our objective was to assess whether specific health plan, patient, setting, and psychiatrist characteristics are associated with conformance with key evidence-based practice guideline psychopharmacologic treatment recommendations for major depressive disorder (MDD). Nationally generalizable data from the APA Practice Research Network 1997 Study of Psychiatric Patients and Treatments on 406 adult patients of psychiatrists with MDD were used. This observational study used logistic regression to assess factors associated with guideline conformance. Existing data from a psychiatric practice research network were analyzed. Ninety-one and seven-tenths percent of patients received treatment consistent with the recommendations. Conformance with specific recommendations was as follows: (1) an antidepressant or ECT for moderate, severe, or recurrent depression (92.3%); (2) an antidepressant and an antipsychotic or ECT for psychotic depression (80.9%); (3) an antidepressant and/or psychotherapy for mild depression (97.6%); and (4) no antianxiety medications alone without an antidepressant (96.0%). Variables most strongly associated with nonconformance were (1) lack of psychiatrist financial incentives (OR = 9.6; 95% CI = 1.2, 75.4), (2) psychiatrists with low proportions of public patients (OR = 7.8; 95% CI = 1.9, 32.1), (3) nonmanaged plans (OR = 3.8; 95% CI = 1.4, 10.4), and (4) psychiatrists 62 years or older (OR = 2.9; 95% CI = 1.2, 7.3). Although overall conformance was high, findings have implications for targeting quality improvement initiatives. Research is needed to distinguish clinically appropriate from inappropriate reasons for nonconformance and assess conformance with other recommendations.