Update in Psychiatry

In 1978, Regier (1) coined the term de facto mental health services system after finding that most patients with mental illness are treated in the general medical sector, not in psychiatric settings. Despite this, many patients with mental disorders treated in the medical sector do not have a diagnosis; they go untreated or are treated for a medical problem instead of their mental disorder. This first Update in Psychiatry reviews the pertinent psychiatric literature published in 1998. We polled journal editors from leading psychiatric and general medical journals and leaders in consultation liaison psychiatry to develop a list of important publications. We did not include substance abuse because the relevant literature is so extensive that this topic warrants a separate discussion. Our goal is to expand on and in some cases introduce information about psychiatry that may not be readily available to the general clinical internist. Affective Disorders Depressive disorders, dysthymia, bipolar disorders, and cyclothymia are the major affective disorders. Major depression is the most common mental disorder seen by internists. Because of this high prevalence, much research has recently been done on depression and its management in primary care. The publications summarized in this section are a review of recent data that updated the Agency for Health Care Policy and Research (AHCPR) Depression Guidelines, a report on the optimal length of the continuation phase of treatment (how long should therapy with an antidepressant agent be continued after a good response? ), and two reports examining the cost-effectiveness of different treatment models for depression in primary care settings. Recent Studies Support AHCPR Guidelines in the Primary Care Setting and Suggest a More Prominent Role for Mental Health Specialists in Severely Depressed Patients Schulberg HC, Katon W, Simon GE, et al. Treating major depression in primary care practice: an update of the Agency for Health Care Policy and Research Practice Guidelines. Arch Gen Psychiatry. 1998; 55:1121-7. Many of the studies that were used in developing the AHCPR Depression Guidelines were conducted among patients in specialty mental health settings and used older medications. Since the guidelines were published in 1993, more evidence about the treatment of depression in primary care practice and about the guidelines themselves has become available. Schulberg and colleagues reviewed studies published between 1992 and 1998 that provided further information on the treatment of depression. Using the Cochrane Collaboration Depression, Anxiety, and Neurosis Trials Register, they applied intention-to-treat analysis to the efficacy of pharmacologic and psychotherapeutic treatments of major depression, first-line treatment choices, cost-effectiveness of treatments, and experiences with guideline implementation. The evidence from the newer studies supported the efficacy of both antidepressant pharmacotherapy and time-limited depression-targeted psychotherapies in primary care settings, as already demonstrated in mental health care settings. Regardless of the treatment choice, the attrition rate in the treatment of depression is high. Given the data supporting either or both methods, the authors suggest using patient preference to guide treatment choice; the goal of this is to decrease the high attrition rate. Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants were found to have similar total treatment costs per depressive episode, despite the higher acquisition costs for SSRIs. This finding was attributed to a higher rate of switching antidepressants when tricyclic antidepressants were used, which resulted from the generally less acceptable side effect profile of these drugs. Other studies reviewed suggested that improving treatment of depression in primary care requires properly organized treatment programs; regular follow-up; active monitoring of treatment adherence; and a prominent role for the mental health specialist as educator, consultant, and clinician for more severely depressed patients. Treatment for Depression Should Continue at Least 26 Weeks after Full Remission of Symptoms Reimherr FW, Amsterdam JD, Quitkin FM, et al. Optimal length of continuation therapy in depression: a prospective assessment during long-term fluoxetine treatment. Am J Psychiatry. 1998; 155:1247-53. During acute-phase treatment of major depression, remission of symptoms is the goal. After this initial period, the goal of treatment becomes the prevention of relapse. This second period is called the continuation phase. Many patients want to stop antidepressant therapy shortly after a positive response. The AHCPR Depression Practice Guidelines state that the continuation phase should last for 4 to 9 months. This broad time span is derived from studies that had varying designs and a relatively small number of patients. Reimherr and colleagues prospectively assessed 395 of 839 outpatients with major depression for relapse. These patients had had a symptomatic remission after 12-week treatment with fluoxetine, 20 mg/d. Patients who achieved remission were randomly assigned to be switched to placebo after 12, 26, and 50 weeks of treatment, creating time intervals 1 (12 to 24 weeks), 2 (26 to 38 weeks), and 3 (50 to 62 weeks), respectively. Relapse rates were assessed in each time interval. Relapse rates significantly differed between the treatment and placebo groups at time interval 1 (26.4% compared with 48.6%) and interval 2 (9.0% compared with 23.2%). The difference between relapse rates continued into time interval 3 (10.7% compared with 16.2%) but did not reach statistical significance. These data suggest that treatment should continue for at least 26 weeks (6.5 months) after remission, for a total of 38 weeks of treatment (9 months) and possibly longer. Most prescriptions for antidepressants are filled for no more than 3 months (about 13 weeks). This suggests that many patients stop pharmacotherapy, presumably after a favorable response, and do not proceed with the continuation phase of treatment. The result is a high risk for relapse. Successful treatment of depression depends on a sustained course of antidepressant therapy. Even with continued fluoxetine treatment, the relapse rate in Reimherr and colleagues' study was 26.4% in time interval 1 (12 weeks of treatment) and 9.0% in time interval 2 (26 weeks of treatment). One limitation of this study is that patients who met criteria for depression were included without regard for whether the depressive episode was a first occurrence or a recurrence. This could have biased the sample and skewed the relapse rate (recurrent depression is associated with higher relapse rates, whereas single-episode depression is associated with lower relapse rates). In addition, only 395 of 839 patients (47%) had a full response after 12 weeks of treatment with 20 mg of fluoxetine. This could indicate a more severely depressed cohort or one with more episodes of recurrent depression. In practice, the depressive episode is often the first one treated. The physician may be uncertain about whether a previously untreated episode has recurred. Reimherr and coworkers argue that the study more closely resembles real clinical practice because no distinction was drawn. Despite this limitation, this study strongly demonstrates the need for continued antidepressant treatment for at least 26 weeks after remission of symptoms, making the total treatment period 38 weeks. Even with treatment, the potential for relapse remains a significant risk among patients with depression. Intensive Standardized Treatments for Depression Improve Outcomes but Do Not Produce a Cost Offset Lave JR, Frank RG, Schulberg HC, et al. Cost-effectiveness of treatments for major depression in primary care practice. Arch Gen Psychiatry. 1998; 55:645-51. Von Korff MV, Katon W, Bush T, et al. Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression. Psychosom Med. 1998; 60:143-9. Lave and colleagues conducted a randomized, controlled trial in which 276 primary care patients with current major depression were assigned to one of three treatments: standardized nortriptyline therapy (by primary physicians), standardized interpersonal psychotherapy (by psychiatrists and clinical psychologists), or primary physicians' usual care. Patients receiving either of the standardized therapies had better outcomes than did those in primary physicians' usual care, but they consumed more resources. Neither standardized treatment reduced medical care utilization for other conditions. Von Korff and colleagues performed two randomized trials of collaborative care for depression in primary care. In the first study (n=217), primary care physicians' usual treatment was compared with collaborative management by primary care physicians and consulting psychiatrists, who provided enhanced management of drug therapy and brief psychoeducational interventions to enhance adherence with treatment. In the second study (n=153), usual care was compared with collaborative care by primary care physicians and consulting psychologists, who provided brief psychotherapy supplemented by educational materials. In both trials, the collaborative care models improved the cost-effectiveness of treatment for major depression, although overall treatment costs were increased. No difference was found in health care utilization for other medical illnesses. In each of these studies, standardized, more intensive treatment or treatments of depression led to better outcomes than usual care, but they also cost more. The incremental cost of better outcomes in each study was similar to those of other widely accepted treatments in medicine. Neither study found evidence of a cost offset (the theory that more effective treatment of a mental illness will reduce general medical care costs). These studies unders