OBJECTIVE:

To explore reasons for clinical inertia in the management of persistent depression symptoms.

RESEARCH DESIGN:

We characterized patterns of treatment adjustment in primary care and their relation to the patient's clinical condition by modeling transition to a given treatment "state" conditional on the current state of treatment. We assessed associations of patient, clinician, and practice barriers with adjustment decisions.

SUBJECTS:

Survey data on patients in active care for major depression were collected at 6-month intervals over a 2-year period for the quality improvement for depression (QID) studies.

MEASURES:

Patient and clinician characteristics were collected at baseline. Depression severity and treatment were measured at each interval.

RESULTS:

Approximately, one-third of the observation periods ending with less than a full response resulted in an adjustment recommendation. Clinicians often respond correctly to the combination of severe depression symptoms and less than maximal treatment by changing the treatment. Appropriate adjustment is less common, however, in management of less severely depressed patients who do not improve after starting treatment, particularly if their care already meets minimal treatment intensity guidelines.

CONCLUSIONS:

Our findings suggest that quality improvement efforts should focus on promoting appropriate adjustments for patients with persistent depression symptoms, particularly those with less severe depression.