 r. Wayne J. Katon talks about his
highly cited paper, "Adequacy and duration of antidepressant
treatment in primary care," (Med.
Care 30 [1]: 67-76, January 1992) in this in-cites interview. This
paper has been cited 199 times to date, placing it among the top 20
papers of the past decade in the field of Social Sciences. Dr. Katon’s
work is featured in multiple areas of the ISI
Essential Science Indicators
Web product, including Psychiatry/Psychology and Clinical Medicine, as
well as Social Sciences. Dr. Katon is Professor and Vice Chair of
Psychiatry at the University of Washington in Seattle. He is also
Chief of the Division of Psychiatric Epidemiology and Health Services,
and Director of the National Research and Services Administration
fellowship at the University of Washington.
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What, in your view, is the
significance of this paper for the field?
This paper showed that few primary
care patients who were diagnosed with depression and started on
antidepressants received adequate dosage and duration of
antidepressant therapy. The data in this article showed that
approximately 40% of primary care patients started on antidepressants
dropped out of treatment within a one-month period. The article also
established that providing an accurate diagnosis of depression and an
algorithm of antidepressant treatment for the primary care doctor did
not lead to improved pharmacotherapy or clinical outcomes compared
with usual care.
This study was important because it
led to the idea of collaborative care interventions. These were
interventions that integrated a range of mental health professionals
and other care managers into primary care to help the primary care
doctor provide more education, more frequent patient follow-up,
careful monitoring of outcomes, and facilitation of referral to a
mental health specialist when adverse outcomes occurred. The 1992
study led us to the idea that improving outcomes for depression
couldn't be accomplished with brief, infrequent visits with the
primary care physician and would need to be accomplished with a health
care team.
What were the greatest challenges in
performing and presenting your work?
The greatest challenges in developing
this research were that we had to innovate in many ways. For instance,
patients were randomized to either an intervention to improve primary
care services or to usual care. Prior trials often randomized using a
placebo control of nonspecific intervention that controlled for time
in care. We had to convince reviewers and editors that this was a
health-service intervention designed to improve outcomes of usual care
so this was an apt control. Our outcomes were done with telephone
interviews, but reviewers and editors were accustomed to in-person
outcome monitoring and therefore doubted the reliability of our
methods. In this study, we also reported outcomes based on automated
databases, which was still a relatively new way of monitoring outcomes
in 1992, and reviewers were also skeptical of some of this data. A big
challenge was that the intervention in this high-utilizer study
essentially had a negative compared with usual care, and editors
appeared unfriendly to a randomized controlled trial with negative
findings.
How did you decide where to submit or
publish your paper?
We attempted to publish our findings
from this study in both medical journals and psychiatric journals
because the results were important for both fields. We were able to
publish many papers in some of the best journals from both fields but
ironically had the most trouble with the main randomized trial paper
because of negative findings.
If you performed your research again,
or published your paper again, what, if anything, would you do
differently and why?
We learned a great deal in this
study, including how to carry out a large trial in primary care, how
to recruit patients without interfering with patient flow in the
clinic, minimizing questionnaires for busy clinicians, how to train
research assistants to carry out phone follow-ups, and the limits of
the primary care system in improving disease management for
psychiatric disorders. It led to the development of collaborative care
aimed at improving patient education and activating them to become
full partners in their care, as well as the integration of mental
health professionals into primary care to help busy primary care
doctors improve depression management.
What would you like to convey to the
general public about your work?
We have worked as a research team for
over 15 years and have gradually learned how to improve outcomes of
patients with common mental illnesses within primary care systems. Our
work has been disseminated worldwide, and it has been a privilege to
work with the Group Health primary care system and the Center for
Health Studies at Group Health to develop systematic interventions to
improve outcomes of patients. It has been inspirational how quickly
these interventions have been adapted to other health care systems
throughout the world.
What are the implications of your
work for the future of your field or neighboring fields?
Although we have excellent treatments
for most chronic illnesses, few patients are receiving them or
adhering to them at the necessary levels to improve outcomes. We have
worked with other Center for Health studies research groups at Group
Health who are working to improve outcomes of patients with asthma,
diabetes, and CHF, and we have learned a great deal from each other.
We are now embarked on a study to improve depression outcomes of
patients with diabetes which has led us even further into
understanding commonalities in improving outcomes of other illnesses.
Wayne J. Katon, M.D.
University of Washington
School of Medicine
Psychiatry and Behavioral Sciences
Seattle, WA, USA
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cites
