Patients with Severe Depression Improve Using Guidelines
Results from a multiyear study of severely depressed patients treated according to guidelines established by researchers at UT Southwestern Medical Center at Dallas showed a significant improvement in patients’ symptoms and medical outcomes.
Called the Texas Medication Algorithm Project (TMAP), the guidelines, or algorithms, are a set of comprehensive management tools for doctors treating severely mentally ill patients within Texas’ publicly funded mental health care system. They are the result of an innovative collaboration between UT Southwestern and the Texas Department of Mental Health and Mental Retardation (TDMHMR) initiated in fall 1997 to provide more uniform treatment for Texas’ mentally ill patients.
Findings, which showed two to three times greater improvement in patients with major depressive disorder (MDD) who were treated according to TMAP guidelines, are published today in the Archives of General Psychiatry.
MDD is a debilitating illness affecting 7 percent to 12 percent of men and 20 percent to 25 percent of women. It usually recurs, with 10 percent to 30 percent of patients having major depressive episodes that last more than two years. It accounts for up to 60 percent of psychiatric hospitalizations, with 8 percent to 15 percent of those patients committing suicide.
“TMAP is a disease-management program that includes algorithms and other support systems that help the physician make treatment decisions based on a patient’s clinical status, history, symptoms and results up to a specific point,” said Dr. Madhukar Trivedi, head of the depression and anxiety disorders program at UT Southwestern, associate professor of psychiatry and the study’s lead author. “This study, which is the first to show the effectiveness of the TMAP project on depression, is quite powerful and compelling.”
The study compared 547 patients with MDD at 14 clinics. Patients at four clinics received algorithm-based treatment, while others received treatment methods regularly administered by the clinics’ doctors.
“Both groups of patients received treatment from qualified physicians who had access to the same treatments and medications,” Dr. Trivedi said. “Therefore all patients improved.
“But the level of improvement in the disease-management group was twice as much better when measured by a clinician and three times as much better when the patient described his or her own level of improvement. The outcomes for symptomatic improvement, as well as functional improvement, were dramatically better among patients who followed the algorithm-based program. These results should encourage physicians and health-care systems to design management programs based on these easy-to-use algorithms.”
Patients’ outcomes were measured by three standardized tests regularly used to determine levels of depression.
When TMAP began seven years ago, it was the first program in the nation aimed at establishing and implementing medication guidelines for treating psychiatric illness in the public sector. Besides mapping out algorithms for depression, TMAP also offers parallel guidelines for treating bipolar disorder and schizophrenia. Its organizers hoped the effort could lead to substantial improvements in quality of care and clinical outcomes, along with cost predictability for patients.
The effort was prompted by research findings pointing to significant variations nationally in medical treatments administered to the mentally ill. When patients moved from clinic to clinic, they often received different treatments.
Other researchers from UT Southwestern’s Department of Psychiatry involved in the study were Drs. John Rush, professor; Michael Kashner, professor; Trisha Suppes, associate professor; assistant professors Thomas Carmody, Melanie Biggs and Kathy Shores-Wilson; and Kenneth Altshuler, clinical professor. Also contributing to the study were researchers from the College of Pharmacy, the University of Texas at Austin; Health Services Research and Development Service Research Career Scientist Program, Department of Veterans Affairs; TDMHMR; and the University of Texas Health Science Center at San Antonio.
The research was supported by the National Institute of Mental Health, the Robert Wood Johnson Foundation, the Meadows Foundation, the Lightner-Sams Foundation, the Nanny Hogan Boyd Charitable Trust, TDMHMR, the Center for Mental Health Services, the Department of Veterans Affairs, the Health Services Research and Development Research Career Scientist Award, the United States Pharmacopoeia Convention Inc. and Mental Health Connections.