Dr. Rost and Colleagues Reply

To the Editor: In our article, we reported greater cost savings for patients treated by psychiatric specialists than for those treated in the general medical sector. One explanation for this is that 48% of the community residents treated for depression in the specialty care sector received guideline-concordant care in contrast to 21% of the community residents treated for depression in the primary care setting. In his letter, Dr. Muskin requested further information to identify where the deviations from guideline-concordant care occurred in both sectors. We are happy to provide a further breakdown without extensive statistical comparisons. Specialty care patients were more likely than primary care patients to get any antidepressant medication (64.3% and 53.0%, respectively). Among those who received antidepressant medication, specialty care patients were more likely than primary care patients to be prescribed a guideline-concordant dose (52.8% and 39.4%) and were somewhat more likely to take the medication for a minimum of 8 weeks (75.0% and 70.5%). The remaining difference in guideline-concordant treatment rates was explained by the greater likelihood for specialty care patients to report that they received eight or more counseling visits for depression. The 1992 medication patterns do not adequately represent current primary care medication prescribing patterns, particularly the greater use of newer-generation antidepressants whose limited side effects allow physicians to prescribe therapeutic doses more readily. However, if specialty care’s achievement of better outcomes is in part attributable to providing psychotherapy (in combination with medication or independently), we might continue to observe these outcome differences if the study were to be replicated in the current health care environment.