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Depression Outcomes Module

  1. Overview
  2. Background
  3. Development
    1. Goals
    2. Development Team
    3. Domains
  4. Components
    1. Target Population
    2. Patient Screener
    3. Patient Baseline Assessment
      1. Diagnosis at Baseline
      2. Outcomes of Care
      3. Prognostic Characteristics
    4. Clinician Baseline Assessment
      1. Eligibility
      2. Diagnosis
      3. Prognostic Characteristics
      4. Treatment
    5. Patient Follow-up Assessment
      1. Treatment
      2. Outcomes
  5. Reliability & Validity
    1. Primary Care Setting
    2. Specialty Care Population
    3. Clinical Utility
  6. Potential Uses
    1. Strengths
    2. Limitations
  7. Data Analysis and Presentation
    1. Individual Patient Reports
    2. Aggregate Patient Reports
    3. Scoring
    4. Usage
  8. Summary
  9. Bibliography






Overview  Top

Depression, in its mild and transient form, is a common life experience. However, major depressive disorder (MDD), a debilitating illness, afflicts more than nine million people in the United States in any six-month period. The Depression Outcomes Module (DOM) measures the types of care received by patients with major depression, the outcomes of that care, and the patient characteristics that influence either the types or the outcomes of care. Data generated by this module may be used to understand how specific treatments or processes of care affect outcomes in patients during and following treatment for depression. This data may also be used to develop new treatment and service delivery plans that improve the quality and cost-effectiveness of that care.


Background  Top

    Major Depression Disorder (MDD) in patients age 18 years and older is an episodic disorder, with each episode lasting six months or longer if untreated.(1) The disorder can occur once or recur many times; and in severe cases, recurrences may be as often as one per year. Depressive disorders are among the most common psychiatric problems seen in medical care settings and are about as prevalent as most types of physical disorders such as high blood pressure. However, with MDD there is often a delay in diagnosis, misdiagnosis, or under-treatment.(2)

    A study of primary care physicians showed that depression is recognized twice as often in women as in men and that patients are 24% more likely to be correctly diagnosed with depression for each additional year of education they have.(3)

    Depression is also among the most poorly managed illnesses in America, especially in primary care practices.(4-7) Although very effective treatments are available for depression, which is often disabling, the disorder is only recognized 50% of the time. When it is recognized, only 50% of the patients receive appropriate treatment.(8)

    Although several studies have shown that primary care physicians are unlikely to detect depression in their patients,(9-11) another study has shown that more than 50% of primary care providers deliberately substituted another diagnostic code for major depression.(12) Of patients who were depressed, 31% received an alternative diagnosis. The most common reasons for the diagnostic substitution were uncertainty about the diagnosis, problems with reimbursement for services for MDD, and stigma associated with mental disorders.(12-13) Using a telephone screening of 98 adults with MDD who had visited a primary care physician during the six months following baseline, researchers found that 32% of the patients with current MDD remained undiagnosed for up to one year, with almost half of those patients developing suicidal ideation. Of the patients whose depression was detected, only 27% received guideline-concordant treatment, and 61% of those reported five or more current symptoms one year later.(11)

    When compared with patients who are not depressed, patients with depressive disorders incur greater than average charges for diagnostic tests. The reason for these higher charges is the latter patient's greater burden of coexisting medical illnesses, as shown in a study of primary care patients.(13) Katon & Schulberg found that 40% of high users of health care had a currently diagnosed affective disorder and two-thirds had a lifetime history of MDD.(15)

    Depression, however, can be effectively treated in 70% of patients once it is diagnosed.(16) Thus, both quality improvement efforts for detection and improvement of management are needed to improve patient outcomes.

Development  Top

The high prevalence of MDD and impairment of patient recovery due to lack of clinical detection and/or proper treatment led a multidisciplinary, nationally recognized team to develop an outcomes module for depression. The DOM seeks to provide information that can be used to improve the quality of care given, provide accountability for those who purchase care, and control the costs for treating patients with depression.

Goal

The DOM identifies patients with MDD and assesses their symptom severity and functioning over time. The DOM assesses patient characteristics and the process and outcomes of care for patients with MDD, as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)(17) criteria, by assessing disease-specific and generic outcomes, prognostic variables, and relevant process of care elements. It is designed to assess depression as a tracer condition in routine clinical care settings as part of an outcomes management system for continuous quality improvement efforts.

Development Team

A multi-institutional, multidisciplinary panel advised UAMS on the development of relevant clinical and methodological assessments for issues that surround the treatment and outcomes of MDD. The module was developed by G. Richard Smith, Jr., MD; M. Audrey Burnam, Ph.D.; Barbara J. Burns, Ph.D.; Paul Cleary, Ph.D.; and Kathryn M. Rost, Ph.D.

Domains

The DOM verifies diagnostic criteria to identify a relatively homogeneous group of patients and determine whether patients meet the DSM-IV criteria of MDD. The patient self-report scale, referred to as the Depression Arkansas Scale (D-ARK), consists of 11 items and assesses the DSM-IV criteria of MDD. The symptoms include feeling blue, depressed, or low in spirits; anhedonia; appetite and sleep change; psychomotor retardation; reduced energy; feelings of worthlessness or guilt; difficulties in concentration, and suicidality. There is also a clinician symptom checklist, which has been shown to have at least a 76% concordance rate with the patient self-report. General functioning of the patient is measured using the SF-36.(18) The patient's changes in symptoms, disease-specific functioning, and general functioning over time comprise the outcomes domains. Prognostic variables allow comparison of outcomes across patient groups. Treatment components included in the domain are type, extent, and setting.

Components  Top

The DOM consists of five components: Patient Screener, Patient Baseline Assessment, Clinician Baseline Assessment, Patient Follow-up Assessment, and Medical Record Review. The Patient Screener and Medical Record Review are optional.

Target Population

Patients are entered into NetOutcomesTM DOM primarily after receiving a diagnosis of a new episode of MDD. In some instances, they enter the DOM if they screen positive on the Patient Screener or have some other trigger, such as a prescription for an anti-depressant medication. Enrollment in the DOM should begin as soon as possible after the diagnosis of an MDD episode. To be eligible for enrollment, the patient must be 18 years of age or older, able to read and write English, and able to cognitively understand the assessment.

Patient Screener

The Patient Screener, which consists of three questions, takes about one minute to complete. Often administered to all patients in a practice or particular health care plan, this screener has been shown to identify 83-94% of general medical patients and 89-93% of mental health care patients who are at risk for having experienced an episode of a depressive disorder within the previous year.(19) Because some patients may screen positive without actually having a depressive disorder, the actual diagnosis of major depression requires further evaluation. This can be accomplished clinically or by using the Patient and Clinician Baseline Assessments.

Patient Baseline Assessment

The Patient Baseline Assessment, comprised of 80 questions, is self-administered to all patients who are diagnosed by a clinician as having a new episode of major depression and who screen positive on the Patient Screener. It provides the information necessary to establish a diagnosis, determine the severity of illness, and measure prognostic characteristics that may affect the outcomes of treatment received. The assessment also includes the SF-36 and several questions to evaluate the patient's level of productivity, including number of bed days and number of reduced activity days. This questionnaire takes approximately 20 minutes to complete.

Diagnosis at Baseline

Using DSM-IV criteria, a diagnosis of major depression can be established using the Patient Baseline Assessment. Using DSM-IV criteria maximizes the usefulness of DOM data for clinicians and researchers. DSM-IV criteria are also accepted by the Health Care Financing Administration (HCFA) and most third-party payers in their reimbursement classification systems.

Outcomes of Care

The severity of a patient's depression and the outcomes of treatment can be measured by examining how symptom levels and patient functioning change over time. The Patient Baseline Assessment measures initial symptom severity, social functioning, and bed days. Baseline responses are compared with follow-up responses to determine the outcome of specific treatments.

Prognostic Characteristics

The DOM measures several variables that influence treatment effectiveness, including those on the following page.

  • Severity of depression
    		•
  • Previous psychiatric
        hospitalization
  • Co-occurring psychiatric conditions
        (alcoholism, substance abuse, dysthymia) that complicate
        management of MDD
    		•
  • Number of lifetime
        depressive episodes
  • Co-occurring physical problems
    		•
  • Age at onset
  • Family history of depression or alcoholism
    		•
  • Social support

      • Clinician Baseline Assessment

      Information on eligibility, diagnosis, prognostic characteristics, outcomes, and treatment is detailed by the clinician making the diagnosis of major depression immediately after seeing the patient. The assessment quickly provides baseline information using a 20-item questionnaire. It takes less than 1.5 minutes to complete because all of the required information is part of a clinical assessment.

      Eligibility

      Patients who should not be participating in the DOM are identified through the Clinician Baseline Assessment. Patients who have recently suffered the loss of a loved one (bereavement), who have a history of mania, or who are currently taking medication for which depression is a known side effect do not meet DSM-IV criteria for major depression. Patients who do not meet eligibility criteria after completion of the Patient and Clinician Baseline Assessments are dropped from the DOM. Only eligible patients complete the Patient Follow-up Assessment.

      Diagnosis At Baseline

      The depressive diagnosis and the symptoms that the clinician considers in making the diagnosis are recorded.

      Prognostic Characteristics

      Assessment of co-occurring medical and psychiatric conditions, such as dysthymia and alcohol- or drug-related disorders, are included in the assessment for use as case-mix variables.

      Treatment

      Information is collected on psychotropic medication prescribed or adjusted at the initial visit.

      Patient Follow-up Assessment

      Similar to the Patient Baseline Assessment, an 83-item, self-administered patient follow-up questionnaire is completed every three months after baseline until the diagnosis of major depression is resolved. Designed to be completed in approximately 20 minutes, the questionnaire provides information on treatment and outcomes of care. The follow-up assessment should be completed at least twice from baseline or until the patient's symptoms remit. Follow-up assessment can be conducted by mail or telephone. If patients are only followed through their clinic visits, then a significant proportion of those who do not seek additional treatment will be omitted from the DOM.

      Treatment

      By completing the assessment, the patient reports on anti-depressant medication, medication compliance, psychotherapy, electroconvulsive therapy, hospitalization, day treatment, and emergency room visits. Responses reflect the care that patients have received from sources other than their major provider.

      Outcomes of Care

      Disease-specific outcome information that is gathered includes data on symptom severity and symptom remission. This information enhances the data on functional outcomes provided by the SF-36. 

      Medical Record Review (Optional)

      The 11-item, optional Medical Record Review offers details about the processes of care that are provided by the major provider or covered by a third-party payer. If used, this review is completed at the same time as the follow-up assessment. Treatment information includes data on psychotropic medications, frequency of care in the general medical setting, referral to any mental health care setting, frequency of care in the mental health setting, type of psychotherapy, extent of inpatient care, emergency room visits, partial hospitalization, and electroconvulsive therapy. The only outcome measured by the Medical Record Review is patient death, including cause of death. The review may take 25 minutes to complete when records are reviewed manually, but requires substantially less time if patient records are computerized.

      Reliability & Validity  Top

      Data analysis and reporting are probably the most important aspects of the outcomes management systems. Without an accurate and effective feedback loop, information is erroneously communicated to the various stakeholders, resulting in poor decisions in patient care.

      Individual Patient Reports

      Individual reports are created from the DOM to provide information about the patient's specific depressive symptoms, symptom severity, and aspects of disease-specific and general functioning. These individual patient reports can be used to track a patient's progress and alert the clinician to changes in symptomatology, including the severity of critical items such as suicidality. Individual patient reports may be obtained from www.NetOutcomes.net.

      Aggregate Patient Reports

      The NetOutcomesTM outcomes management systems have three types of aggregate reports-provider, program, and facility reports. Provider reports present individual providers with quarterly summaries of baseline and follow-up information as well as derived data such as the percentage of patients who receive guideline-concordant care. The provider's data is also compared to the provider's program data and to national benchmarks.

      Program reports present data on each provider within a program as well as the aggregate data for the entire programmed national benchmark. Each provider is distinguished by a code known only to the provider and the clinical director.

      Facility reports are used in situations where similar programs are to be compared within a facility or system of care. National benchmarks are also presented. As mentioned previously, statistics can either be descriptive or inferential. Probably, in the initial stages of using the outcomes management systems, organizations will be interested in baseline descriptive statistics. These statistics characterize depressed patients by demographics, prior mental health status, comorbid physical and psychiatric conditions, and level of disease-specific and generic symptoms. This information, which allows organizations to profile the types of patients who present for treatment of depressive symptoms, can be used for treatment planning and potential system remediation. For example, one site may be more likely to treat young, fairly well-educated depressed women with few prior episodes of depression. Another site, such as a Veterans Administration hospital, may be more likely to treat older depressed men with multiple chronic ailments, a history of substance abuse, and prior psychiatric hospitalizations. The initial interventions would certainly be different in these two populations, and outcomes would be expected to be poorer in the latter group.

      Inferential statistics should be conducted whenever there is a large enough group to conduct more complex data analyses. These analyses may indicate differences between groups, such as patients presenting with moderate vs. severe depression or patients being treated by different providers. The analyses could also highlight prognostic variables that predict treatment failure. If an organization is interested in pursuing this level of data analysis, it is recommended that a statistical consultant be included in the project's developmental stages to advise the organization on power calculations, software purchases, and appropriate statistical tests.

      Table 6.1 Psychometric Properties of the DOM

      Component

      Reliability

      Depressive Symptom Severity

      0.85-0.92(a), (b)

      Suicidality

      0.56-0.70 (a)

      Classification of Remission of MDD at Follow-up

      (0.51) (a)

      Inter-rater Agreement between Research Assistants

      100%

      Repeated Follow-up Assessment (one week later)

      good agreement in use reports

      (a) Intraclass correlation r or a
      (b) Rost, K., Smith, G.R., Burnam, M.A. & Burns, B. J. (1992). Measuring the outcomes of care for mental health problems: The case of depressive disorders. Medical Care, 30(5), MS266-MS273.

      Primary Care Setting

      When used in rural primary care settings, the DOM's measure of severity of depressive symptoms was shown to have a test-retest reliability of 0.85 (p<0.001) and a Pearson correlation of 0.63 when compared with the Diagnostic Interview Schedule (DIS)(20) (p<0.001). The suicidality question yielded a test-retest of 0.70 (p<0.001) and validity of =0.42 (p=0.03) compared with the DIS.(4) Specialty Care Population The DOM has been tested with specialty care patients. In this patient population, the test-retest reliability for severity of depression symptoms had a strong correlation (r=0.87, p<0.0001). The suicidality measure had a retest value of r=0.56. The depression severity scale had high internal consistency with a coefficient of 0.87. An inter-rater concordance of 100% was found for two research assistants on the Medical Record Review.(21)

      Table 6.2 Correlation between D-ARK and Other Measures of Depression (22)

      Measure & Correlation

      r

      p

       Depression Severity
         Clinician Ratings (Hamilton-D) (a)

      0.41

      <0.01

         Number of Depression Symptoms (DIS Interview) (a)

      0.56

      <0.01

         Severity of Depression Symptoms (IDD)

      0.89-0.94

      <0.001

       Changes in Depression Symptoms (a)
         Change in Bed Days

      0.56

      <0.005

         Change in Social Functioning

      -0.52

      <0.01

         Change in Emotional Functioning

      -0.47

      <0.01

      (a) Smith, G.R., Ross, R.L., Rost, K.M. Psychiatric outcomes module: Depression (DOM). In: L.I. Sederer and B. Dickey (eds.) Outcomes Assessment in Clinical Practice. Baltimore: Williams and Wilkins: 82-84, 1995.

      Clinical Utility

      The DOM is able to diagnosis MDD with very high sensitivity and high specificity. The instrument has shown a 93% sensitivity and 96% specificity when compared to the SCID. In practice, there may be very few false negatives and some false positives. In mental health clinics or other settings with a high prevalence of MDD, the D-ARK's predictive value for MDD will be high. Conversely, in settings with fewer cases of MDD such as primary care clinics, the predictive value is somewhat lower.  

       

      Potential Uses  Top

      Strengths

      The DOM can be used to explore patterns in the relationships between patient characteristics, treatment, and outcomes without the need for specific training to administer the instrument. Relatively homogeneous groups of patients can be identified in specialty care settings. Key constructs are measured with sufficient reliability and validity to detect clinical improvements resulting from different treatments. These strengths of the DOM allow clinicians to use outcomes data to maximize the effectiveness of treatment. Clinicians can also make informed treatment decisions based on the data collected in a particular setting. Additionally, the outcomes of similar treatments delivered in different settings can be evaluated to explore the cost-effectiveness of services delivered to patients.(19)

      Limitations

      Data is not yet available describing special populations and national age- and sex-adjusted norms. Additional studies are needed to increase the reliability of the measure of suicidality.(19) The DOM is only available in English.

      Data Analysis and Presentation  Top

      Data analysis and reporting are probably the most important aspects of the outcomes management systems. Without an accurate and effective feedback loop, information is erroneously communicated to the various stakeholders, resulting in poor decisions in patient care.

      Individual Patient Reports

      Individual reports are created from the DOM to provide information about the patient's specific depressive symptoms, symptom severity, and aspects of disease-specific and general functioning. These individual patient reports can be used to track a patient's progress and alert the clinician to changes in symptomatology, including the severity of critical items such as suicidality. Individual patient reports may be obtained from www.NetOutcomes.net .

      Aggregate Patient Reports

      The NetOutcomesTM outcomes management systems have three types of aggregate reports-provider, program, and facility reports. Provider reports present individual providers with quarterly summaries of baseline and follow-up information as well as derived data such as the percentage of patients who receive guideline-concordant care. The provider's data is also compared to the provider's program data and to national benchmarks.

      Program reports present data on each provider within a program as well as the aggregate data for the entire programmed national benchmark. Each provider is distinguished by a code known only to the provider and the clinical director.

      Facility reports are used in situations where similar programs are to be compared within a facility or system of care. National benchmarks are also presented.

      As mentioned previously, statistics can either be descriptive or inferential. Probably, in the initial stages of using the outcomes management systems, organizations will be interested in baseline descriptive statistics. These statistics characterize depressed patients by demographics, prior mental health status, comorbid physical and psychiatric conditions, and level of disease-specific and generic symptoms. This information, which allows organizations to profile the types of patients who present for treatment of depressive symptoms, can be used for treatment planning and potential system remediation.

      For example, one site may be more likely to treat young, fairly well-educated depressed women with few prior episodes of depression. Another site, such as a Veterans Administration hospital, may be more likely to treat older depressed men with multiple chronic ailments, a history of substance abuse, and prior psychiatric hospitalizations. The initial interventions would certainly be different in these two populations, and outcomes would be expected to be poorer in the latter group.

      Inferential statistics should be conducted whenever there is a large enough group to conduct more complex data analyses. These analyses may indicate differences between groups, such as patients presenting with moderate vs. severe depression or patients being treated by different providers. The analyses could also highlight prognostic variables that predict treatment failure. If an organization is interested in pursuing this level of data analysis, it is recommended that a statistical consultant be included in the project's developmental stages to advise the organization on power calculations, software purchases, and appropriate statistical tests.

      Scoring

      Providers can gain access to the module's user's manual through the NetOutcomesTM website at www.NetOutcomes.net and have individual patient reports scored automatically without a charge. Scoring for programming and facility reports is available from the website for a modest fee .

      Usage

       The DOM is protected under copyright and is available for unlimited free use, provided that there is no charge associated with its administration. To that end, UAMS permits unlimited reproduction and distribution of the module by the public for nonprofit, educational, or research purposes. However, any commercial use of our work, including the creation of electronic versions or other derivative works of the module for sale, constitutes a violation of the copyright of the university unless prior authorization has been granted in writing.

      Summary  Top

      Background

      The Depression Outcomes Module (DOM) seeks to improve care for major depressive disorder (MDD), which affects more than nine million people in the US in any six-month period. Although very effective treatments are available for depressive disorders, which are among the most common psychiatric problems, there is often a delay in diagnosis or a misdiagnosis of the disorder. This disease is also one of the most poorly managed illnesses in American primary care practices.

      Development

      The DOM is designed to assess depression in routine clinical care settings by measuring types of care, outcomes of care, and patient characteristics. It is part of a continuous quality improvement effort to systematically improve the quality of care, provide accountability, and control treatment costs. A multi-institutional, multidisciplinary panel advised the University of Arkansas for Medical Sciences professionals who developed the DOM's clinical and methodological assessments. This module identifies patients with MDD and assesses general functioning, outcomes, prognostic variables, and treatment components.

      Components

      Patients may be entered into the DOM protocol after a positive screening, a new clinician diagnosis of MDD, or prescription of an anti-depressant medication. They must be at least 18 years old, be able to read and write English and cognitively understand the assessment, and consent to participate. Patients who have recently suffered the loss of a loved one, have a history of mania, or are currently taking medication that could cause depression are excluded. The module consists of a Patient Screener, Patient and Clinician Baseline Assessments, a Patient Follow-up Assessment, a Medical Record Review, and a User's Manual. Individual and aggregate provider reports are available.

      Although the optional three-item Patient Screener can identify approximately 80-90% of patients at risk for depressive disorder, the diagnosis of major depression is established with the Patient Baseline Assessment. Co-occurring medical and psychiatric conditions are assessed as case-mix variables along with information on psychotropic medications. The follow-up assessment and optional medical record review are completed every four months after baseline or at customized intervals until the diagnosis of major depression is resolved. In keeping with the DOM's emphasis on use in routine clinical settings, its basic components are relatively quick to complete. Both self-report patient assessments can be completed in about 20 minutes, and the Clinician's Baseline Assessment and Patient Screener take just minutes to complete.

      DOM individual reports can provide information about a patient's specific depressive symptoms, symptom severity, or general functioning. They can also be used to track a patient's progress and alert the clinician to changes in symptomatology, including the severity of critical items such as suicidality. Aggregate patient reports can provide both descriptive and inferential statistics, although the more complex data analyses for inferential statistics require data from large groups of patients. Descriptive statistics allow an organization to profile the types of patients who present for treatment of depressive symptoms. This information can be used in treatment planning and potential system remediation.

      Reliability and Validity

      The Patient Screener had a 91% sensitivity and 91% specificity when tested in the community and in patient samples for its ability to detect depression or dysthymia within the last year. The positive predictive value was 43%; the negative predictive value was 99%. The depressive symptom severity scale showed good internal consistency. Studies showed that the module's method for MDD diagnosis had 93-100% sensitivity and 78-96% specificity compared with the Structured Clinical Interview for DSM III-R (SCID) depression section and had high agreement with the Inventory to Diagnose Depression (IDD). Remission at follow-up, determined by patient reports, had a 67% sensitivity and 73% specificity when compared to SCID analysis. This is accurate enough to discriminate between those who did and did not receive effective pharmacologic treatment. Two research assistants achieved 100% concordance on five items from the Medical Record Review, and patients showed good agreement between the first and second follow-up assessments.

      In rural primary care settings, the DOM's measure of severity of depressive symptoms had a test-retest reliability of 0.85 (p<0.001) and a Pearson correlation of 0.63 when compared with the Diagnostic Interview Schedule (DIS) (p<0.001). The suicidality question yielded a test-retest reliability of 0.70 (p<0.001) and validity of =0.42 (p=0.03) compared with the DIS. Among specialty care patients, the test-retest reliability for severity of depression symptoms had a strong correlation, and the depression severity scale had high internal consistency.

      Potential Uses

      The DOM can explore patterns in relationships between patient characteristics, treatment, and outcomes. Key constructs are measured with sufficient reliability and validity to detect clinical improvements resulting from different treatments. These strengths allow clinicians to maximize treatment effectiveness, make informed treatment decisions, and evaluate treatment outcomes to explore service cost-effectiveness. Specific components of the DOM can be used to screen patients for depressive disorders, assess the diagnosis according to DSM-IV criteria and prognostic features, and monitor beneficial and adverse outcomes of treatment. Although the module's diagnostic component is not a specific test for confirming MDD diagnosis in individual patients, it is useful for selecting groups of patients to analyze cohort outcomes of care or to initially screen patients for the diagnosis of depression and severity of symptoms. Data are not yet available describing special populations, the burden in clinical populations, and national age- and sex-adjusted norms. Additional studies are needed to increase the suicidality measure's reliability, and the DOM is only available in English.



      Bibliography  Top

        

      1. Smith GR, Mosley CL, and Booth BM. Measuring health care quality: Major depressive disorder. (AHCPR Publication No. 96-N023), 1-41. 1996. Rockville, MD, Agency for Health Care Policy and Research. Discussion Papers.

      2. Katon W. Depression: Somatic symptoms and medical disorders in primary care. Compr Psychiatry. 1982;23(3):274-287.

      3. AHCPR Depression Guideline Panel. Clinical Practice Guideline Number 5. Depression in Primary Care: Volume 1. Detection and Diagnosis. AHCPR Pub. No. 93-0550. Rockville, MD: Agency for Health Care Policy and Research. Public Health Services,U S Department of Health and Human Services. 1993;AHCPR No. 93-0550.

      4. Rost K, Williams C, Wherry J, Smith GR, Jr. The process and outcomes of care for major depression in rural family practice settings. J Rural Health. 1995;11(2):114-121.

      5. Katon W, Von Korff M, Lin E, Bush T, Ormel J. Adequacy and duration of antidepressant treatment in primary care. Med Care. 1992;30(1):67-76.

      6. Rogers WH, Wells KB, Meredith LS, Sturm R, Burnam MA. Outcomes for adult outpatients with depression under prepaid or fee-for-service financing. Arch Gen Psychiatry. 1993;50:517-525.

      7. Ross R, Smith GR, Booth BM. Treatment outcomes in depressed patients. Psychiatr Annals. 1997;27(2):119-123.

      8. Smith GR. Developing an outcomes management strategy for the treatment of depression. Kaohsiung J Med Sci. 1989;5(11):590-592.

      9. Perez-Stable EJ, Miranda J, Munoz RF, Ying Y. Depression in medical outpatients: Underrecognition and misdiagnosis. Arch Intern Med. 1990;150:1083-1088.

      10. Von Korff M, Shapiro S, Burke JD, Teitlebaum M, Skinner EA, German P, Turner RW, Klein L, Burns B. Anxiety and depression in a primary care clinic: Comparison of Diagnostic Interview Schedule, General Health Questionnaire, and practitioner assessments. Arch Gen Psychiatry. 1987;44:152-156.

      11. Rost KM, Zhang M, Fortney J, Smith J, Coyne J, Smith GR, Jr. Persistently poor outcomes of undetected major depression in primary care. Gen Hosp Psychiatry. 1998;20(1):12-20.

      12. Rost K, Smith GR, Guise B, Matthews DB. The deliberate misdiagnosis of major depression in primary care. Arch Fam Med. 1994;3:333-337.

      13. Williams JW, Jr., Rost K, Dietrich AJ, Ciotti MC, Zyzanski SJ, Cornell J. Primary care physicians' approach to depressive disorders: Effects of physician specialty and practice structure. Arch Fam Med. 1999;8(1):58-67.

      14. Callahan MC, Kesterson JG, Tierney WM. Depression and coexisting illnesses should be treated together to reduce costs and improve outcomes. Ann Intern Med. 1997;26:426-432.

      15. Katon W. The epidemiology of depression in medical care. Int J Psychiatr Med. 1987;17(1):93-112.

      16. Wells KB. Depression as a Tracer Condition for the National Study of Medical Care Outcomes - Background Review . Santa Monica: RAND; 1985.

      17. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV. Fourth ed. Washington, DC: American Psychiatric Association; 1994.

      18. Ware JE, Jr., Snow KK, Kosinski M, Gandek B. SF-36 health survey manual and interpretation guide. Boston: Health Institute, New England Medical Center; 1993.

      19. Rost K, Burnam MA, Smith GR. Development of screeners for depressive disorders and substance disorder history. Med Care. 1993;31(3):189-200.

      20. Smith GR, Jr. Toward more effective recognition and management of somatization disorder. J Fam Pract 1987; 25(6): 551-552.

      21. Smith GR, Jr., Ross RL, Rost KM. Psychiatric outcomes module: Depression (DOM). In: Sederer LI, Dickey B, eds. Outcomes Assessment in Clinical Practice. Baltimore, MD: Williams & Wilkins; 1996:82-84.

      22. Routh DK, Enst AR. Somatization disorder in relatives of children and adolescents with functional abdominal pain. J Pediatr Psychol 1984; 9 (4): 427-437.

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