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Improving depression care in a psychiatry resident psychopharmacology clinic: measurement, monitoring, feedback and education
  1. B Shiner1,2,3,
  2. R L Green1,4,
  3. K Homa3,
  4. B V Watts1,5,
  5. A Groft1,
  6. W C Torrey1,
  7. T E Oxman1,2
  1. 1Department of Psychiatry, Dartmouth Medical School, Lebanon, New Hampshire, USA
  2. 2Department of Community and Family Medicine, Dartmouth Medical School, Hanover, New Hampshire, USA
  3. 3Dartmouth Hitchcock Leadership Preventive Medicine Residency Program, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire, USA
  4. 4Department of Psychology, Dartmouth College, Hanover, New Hampshire, USA
  5. 5VA National Center for Patient Safety Field Office, White River Junction, Vermont, USA
  1. Correspondence to Dr Brian Shiner, VA New England Health Care Engineering Resource Center, 215 North Main Street, 11Q White River Junction VT 05009 brian.r.shiner{at}


Objective Better outcomes for major depressive disorder (MDD) are associated with proactive treatment, including timely follow-up, systematic assessment and treatment changes for inadequate improvement. The effectiveness of an intervention to facilitate proactive treatment for MDD in a resident psychopharmacology clinic was studied.

Methods A quality improvement program with administrative process changes to improve flow and a 40-week pre/post study to evaluate the effect of education and feedback was conducted. A systematic assessment and reengineered scheduling system were implemented. During the first 20 weeks, baseline data were collected; during the second 20 weeks, feedback to residents and attending psychiatrists about adherence to evidence-based treatment recommendations was added.

Results Reengineering our system to improve flow was successful. By linking outcomes collection to completion of billing sheets, outcomes at 90% of visits for MDD throughout the 40-week study was assessed. By centralising our scheduling system, the percentage of active-phase patients with MDD seen for follow-up within 6 weeks was improved from 19% to 59%. In response to feedback, residents did not make significant changes to their overall practice patterns. Patient outcomes did not improve as a result of feedback to residents. Residents did improve their practice patterns for a subset of patients including those without comorbid psychiatric disorders and those whose depressive episodes had lasted <1 year.

Conclusions Improving administrative processes for the treatment of patients with MDD resulted in rapid changes that were associated with improvements in the delivery of evidence-based care. Feedback to residents was more difficult and less successful.

  • Major depressive disorder
  • quality assurance
  • guidelines
  • feedback
  • internship and residency
  • clinical practice guidelines
  • evidence-based medicine
  • graduate medical education
  • statistical process control
  • patient outcomes

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  • Funding Financial support for this work was provided by a grant from the Dartmouth-Hitchcock Quality Research Grant Program.

  • Competing interests TEO is a partner in 3CM, LLC, a company that provides consultation and training to healthcare organisations on management of mental health disorders in primary care settings. BW is a consultant for Pfizer, Janssen and Forrest Pharmaceuticals.

    BS had full access to all data in the study and takes responsibility for the integrity of the data and the accuracy of its data analysis.

  • Ethics approval The Dartmouth College Committee for the Protection of Human Subjects determined that this project does not meet the definition of human subjects research. This project has been classified as quality improvement (CPHS #20142).

  • Provenance and peer review Not commissioned; externally peer-reviewed.

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