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The impact of evidence-based guideline dissemination for the assessment and treatment of major depression in a managed behavioral health care organization


This study tests whether a managed behavioral health care organization can influence adherence to practice guidelines for the treatment of major depression in a randomized trial of guideline dissemination. Guidelines were disseminated to mental health clinicians (N=443) under one of three conditions: (1) a general mailing of guidelines to clinicians, (2) a mailing in which guidelines were targeted to a patient starting treatment with the clinician, and (3) no mailing of guidelines. The results showed no effects of guideline dissemination as measured by self-report of patients and clinicians and through episode characteristics derived from claims data, despite sentinel effects. Results also showed high rates of clinician-reported guideline adherence that were not detected in the claims data, indicating significant undertreatment of depression. Results suggest that mental health systems must look to other dissemination strategies to improve adherence to standards of care and raise the performance of independent practicing clinicians

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  1. 1.

    American Psychological Association Task Force on Psychological Intervention Guidelines.Template for Developing Guidelines: Interventions for Mental Disorders and Psychological Aspects of Physical Disorders. Washington, DC: American Psychological Association; 1995.

    Google Scholar 

  2. 2.

    American Psychiatric Association. Practice guidelines for the treatment of patients with major depressive disorder (revision).American Journal of Psychiatry. 2000;157(suppl):1–45.

    Google Scholar 

  3. 3.

    Rush AJ, Rago WV, Crismon ML, et al. Medication treatment for the severely and persistently mentally ill: the Texas Medication Algorithm Project.Journal of Clinical Psychiatry. 1999;60(5):284–291.

    Google Scholar 

  4. 4.

    West JC, Leaf PJ, Zarin DA. Health plan characteristics and conformance with key practice guideline psychopharmacologic treatment recommendations for major depression.Mental Health Services Research. 2000;2(4):223–237.

    Google Scholar 

  5. 5.

    Wolfe J. Overcoming barriers to evidence-based practice: lessons from medical practitioners.Clinical Psychology: Science & Practice. 1999;6:445–448.

    Google Scholar 

  6. 6.

    Wennberg JE. Understanding geographic variations in health care delivery.New England Journal of Medicine. 1999;340(1):52–53.

    Google Scholar 

  7. 7.

    National Committee for Quality Assurance.Standards and Surveyor Guidelines for the Accreditation of Managed Behavioral Healthcare Organizations (MBHOs). Washington, DC: NCQA; 2001.

    Google Scholar 

  8. 8.

    Savitz A, Fuess WN, Carli T, et al. NCQA requirements: friend or foe?Behavioral Healthcare Tomorrow. 1999;8(3):34–39.

    Google Scholar 

  9. 9.

    Smith WR. Evidence for the effectiveness of techniques to change physician behavior.Chest. 2000;118(2, suppl):8S-17S.

    Google Scholar 

  10. 10.

    Grol R, Grimshaw J. Evidence-based implementation of evidence-based medicine.Joint Commission Journal for Quality Improvement. 1999;25(10):503–513.

    Google Scholar 

  11. 11.

    Bero LA, Grilli R, Grimshaw JM, et al. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings.British Medical Journal. 1998;317:465–468.

    Google Scholar 

  12. 12.

    Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations.Lancet. 1993;342:1317–1322.

    Google Scholar 

  13. 13.

    Worrall G, Chaulk P, Freake D. The effects of clinical practice guidelines on patient outcomes in primary care: a systematic review.Canadian Medical Association Journal. 1997;156(12):1705–1712.

    Google Scholar 

  14. 14.

    Davis D, O'Brien MA, Freemantle N, et al. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes?Journal of the American Medical Association. 1999;282:867–874.

    Google Scholar 

  15. 15.

    Lomas JL. Do guidelines guide practice? The effect of a consensus statement on the practice of physicians.New England Journal of Medicine. 1989;321:1306–1311.

    Google Scholar 

  16. 16.

    Simon GE, VonKorff M, Rutter C, et al. Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care.British Medical Journal. 2000;320:550–554.

    Google Scholar 

  17. 17.

    Rubenstein LV, Jackson-Triche M, Unutzer J, et al. Evidence-based care for depression in managed primary care practices.Health Affairs. 1999;18:89–105.

    Google Scholar 

  18. 18.

    Goldberg HI, Wagner EH, Fihn SD, et al. A randomized controlled trial of CQI teams and academic detailing: can they alter compliance with guidelines?Journal on Quality Improvement. 1998;24:130–142.

    Google Scholar 

  19. 19.

    Wells KB, Sherbourne C, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial.Journal of the American Medical Association. 2000;283(2):212–220.

    Google Scholar 

  20. 20.

    Katzelnick DJ, Simon GE, Pearson SD, et al. Randomized trial of a depression management program in high utilizers of medical care.Archives of Family Medicine. 2000;9(4):345–351.

    Google Scholar 

  21. 21.

    Katon W, Von Korff M, Lin E, Simon G, et al. Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial.Archives of General Psychiatry. 1999;56(12):1109–1115.

    Google Scholar 

  22. 22.

    McFarland BH, George RA, Goldman W, et al. Population-based guidelines for performance measurement: a preliminary report.Harvard Review of Psychiatry. 1998;6(1):23–37.

    Google Scholar 

  23. 23.

    Sturm R, Goldman W, McCulloch J. Mental health and substance abuse parity: a case study of Ohio's state employee program.The Journal of Mental Health Policy and Economics. 1998;1:1–6.

    Google Scholar 

  24. 24.

    Goldman W, McCulloch J, Sturm R. Costs and use of mental health services before and after managed care.Health Affairs. 1998;17(2):40–52.

    Google Scholar 

  25. 25.

    Goldman W, McCulloch J, Cuffel BJ, et al. More evidence for the insurability of managed behavioral health care.Health Affairs. 1999;18(5):172–181.

    Google Scholar 

  26. 26.

    Ma CA, McGuire TG. Costs and incentives in a behavioral health carve-out.Health Affairs. 1998;17(2):53–69.

    Google Scholar 

  27. 27.

    Findlay S. Trends: managed behavioral health care in 1999: an industry at a crossroads.Health Affairs. 1999;18(5):116–124.

    Google Scholar 

  28. 28.

    Agency for Health Care Policy and Research.Depression Guideline Panel: Clinical Practice Guideline 5: Depression in Primary Care, Volume 2. Treatment of Major Depression. Rockville, MD: AHCPR; 1993; AHCPR publication 93-551.

    Google Scholar 

  29. 29.

    Wells KB, Sturm R, Sherbourne CD, et al.Caring for Depression. London, England: Harvard University Press; 1996.

    Google Scholar 

  30. 30.

    Wang PS, Berglund P, Kessler RC. Recent care of common mental disorders in the United States: prevalence and conformance with evidence-based recommendations.Journal of General Internal Medicine. 2000;15(5):284–292.

    Google Scholar 

  31. 31.

    Azocar F, Cuffel BJ, Goldman W, et al. Dissemination of guidelines for the treatment of major depression in a managed behavioral healthcare network.Psychiatric Services. 2001;52(8):1014–1016.

    Google Scholar 

  32. 32.

    Mittman BS, Tonesk X, Jacobson PD. Implementing clinical practice guidelines: social influence strategies and practitioner behavior change.Quality Review Bulletin. 1992;18(12):413–422.

    Google Scholar 

  33. 33.

    Addis ME, Wade WA, Hatgis C. Barriers to dissemination of evidence-based practices: addressing practitioners' concerns about manual-based psychotherapies.Clinical Psychology: Science & Practice. 1999;6:430–441.

    Google Scholar 

  34. 34.

    Adams AS, Soumerai SB, Lomas J, et al. Evidence of self-report bias in assessing adherence to guidelines.International Journal of Quality Health Care. 1999;11(3):187–192.

    Google Scholar 

  35. 35.

    Pincus HA, Tanielian TL, Marcus SC, et al. Prescribing trends in psychotropic medications.Journal of the American Medical Association. 1998;279:526–531.

    Google Scholar 

  36. 36.

    Freudenheim M. Minnesota health plans to standardize treatments.New York Times, March 13, 2001, 9.

  37. 37.

    Rosser WW. The place of guidelines and their means of dissemination.Canadian Journal of Clinical Pharmacology. 2001;8(suppl A):34A-38A.

    Google Scholar 

  38. 38.

    Cuffel BJ, McCulloch J, Wade R, et al. Patients' and providers' perceptions of outpatient treatment termination in a managed behavioral health organization.Psychiatric Services. 2000;51(4):469–473.

    Google Scholar 

  39. 39.

    Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement.Journal of the American Medical Association. 1999;282:1458–1465.

    Google Scholar 

  40. 40.

    American Medical Association. AMA collaborative work with JCAHO and NCQA. (2001). Accessed February 15, 2002.

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Correspondence to Francisca Azocar PhD.

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Azocar, F., Cuffel, B., Goldman, W. et al. The impact of evidence-based guideline dissemination for the assessment and treatment of major depression in a managed behavioral health care organization. The Journal of Behavioral Health Services & Research 30, 109–118 (2003).

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  • Mental Health
  • Practice Clinician
  • Health System
  • Health Promotion
  • Health Psychology