“Usual Care” for Major Depression in the 1990s: Characteristics and Expert-Estimated Outcomes

OBJECTIVE: Motivated by the public health importance of major depression and calls to study the effectiveness of treatments frequently used in routine practice, the authors characterized the usual outpatient care of acute-phase major depression in a privately insured population as well as the effectiveness of this care. METHOD: Upon identifying frequent antidepressant interventions from a large administrative database spanning the years 1991–1996, and after completing an exhaustive review of published efficacy evidence, the authors undertook a two-stage elicitation process. A panel of 10 experts estimated probabilities of symptom-based outcomes for 120 combinations of treatment, provider type, and patient characteristics seen in 9,054 depressive episodes. The 10 most frequent treatments, utilized in 90% of the episodes, are reported here. RESULTS: A short course of psychotherapy delivered by specialists to healthy premenopausal women was the most frequent pattern of care. Only two prevalent treatments had adequate evidence. On the basis of expert-estimated rates of remission (Hamilton Depression Rating Scale score <8), response (score <13), and no change (score ≥18), three of the 10 most frequent treatments were highly effective, two were moderately effective, and five were minimally effective. CONCLUSIONS: Although experts gave high marks to three commonly used treatments, the expert-estimated effectiveness for this particular system of care was quite modest. More research is needed on the outcomes associated with specific usual care practices as well as the contributors to ineffective care.