Significant Clinician-Level Differences Exist in Antidepressant Prescribing Patterns, Outcomes

“Our findings have implications for efforts to develop precision medicine methods for the treatment of depression, highlighting the importance of considering treatment setting in such approaches in addition to patient-level features,” the authors wrote.

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There are significant differences in prescribing patterns and patient outcomes among groups of clinicians treating major depressive disorder (MDD), according to the results from a new study published in JAMA Psychiatry.¹ Despite extensive research into patient-level differences in antidepressant treatment outcomes, the variability among clinicians themselves hasn’t been thoroughly evaluated.

Understanding these clinician-level differences is crucial for developing risk models, precision treatment strategies, and improving health care efficiency, according to the study.

Prescribing Among PCPs

Last year, research published in Administration and Policy in Mental Health Services Research investigating the University of California, Irvine (UCI) School of Medicine's Train New Trainers Primary Care Psychiatry (TNT PCP) Fellowship, a 12-month evidence and mentorship-based training program, found that this program significantly impacted primary care providers (PCPs).² Results showed that patients treated by TNT-trained PCPs received 0.154 more antidepressant prescriptions per quarter-year than expected (P < .01). Although precision decreased when clustering standard errors by provider characteristics (P < .10), the results' direction and magnitude remained consistent suggesting that the TNT PCP Fellowship effectively enhances PCPs' antidepressant prescribing behavior.

Investigating Prescribing Patterns Across Clinician Groups

In this investigation, however, the authors aimed to characterize the differences between outpatient clinicians in terms of treatment selection and outcomes for patients diagnosed with MDD across various medical settings, including academic medical centers, community hospitals, and affiliated clinics.¹

The longitudinal cohort study utilized electronic health record data from 2 large academic medical centers and 6 community hospitals, along with their outpatient networks, in eastern Massachusetts. The participants included de-identified clinicians who had billed at least 10 International Classification of Diseases, Ninth Edition, (ICD-9) or ICD-10 diagnoses of MDD per year between 2008 and 2022. Data analysis occurred from September 2023 to January 2024.

Main Outcomes and Measures

The study focused on 3 primary outcomes. First, it examined the heterogeneity of prescribing, measured by the number of distinct antidepressants that accounted for 75% of prescriptions by a given clinician. Second, it looked at the proportion of patients who did not return for follow-up after receiving an initial prescription. Third, it assessed the proportion of patients who received stable, ongoing antidepressant treatment.

Data from 11,934 clinicians treating MDD were analyzed and used unsupervised learning to identify 10 distinct clusters based on ICD codes, encompassing outpatient psychiatry, oncology, obstetrics, and primary care. A total of 381,623 unique patients were associated with the data. Key findings revealed substantial variability in the types of antidepressants prescribed, particularly among selective serotonin reuptake inhibitors (SSRIs), selective norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants.

There were significant differences in the number of distinct antidepressants prescribed by clinicians. Additionally, there was variability in patient follow-up rates, which ranged from 27% to 69%, and in achieving stable treatment, which ranged from 22% to 42%. The study found that clinician clusters were significantly associated with treatment outcomes.

“​​While most investigations of antidepressant prescribing focus on individual clinics or general psychiatry, clinicians in the cancer and kidney disease clusters had the highest rate of antidepressant prescribing, similar to that of outpatient psychiatry after excluding nonprescribing clinicians,” the authors wrote. “Rates of MDD are known to be high in these populations, and many patients in these settings may not receive adequate mental health treatment. Furthermore, antidepressant medications such as TCAs, SSRIs, or SNRIs may also be prescribed to treat chronic pain comorbid with depressive symptoms in this context.”

Based on the results, the authors noted the importance of considering clinician-level factors and treatment context in risk stratification and precision treatment strategies. Incorporating group identifiers into predictive models provided similar accuracy to more complex models using individual codes, emphasizing the potential benefits of a broader, context-aware approach in clinical settings.

“Our findings have implications for efforts to develop precision medicine methods for the treatment of depression, highlighting the importance of considering treatment setting in such approaches in addition to patient-level features,” the study stated. “In aggregate, the heterogeneity we identified underscores the need to consider aspects specific to the clinician alongside patient-level features in efforts to develop precision medicine strategies in psychiatry.”

References

1. Rathnam S, Hart KL, Sharma A, et al. Heterogeneity in antidepressant treatment and major depressive disorder outcomes among clinicians. JAMA Psychiatry. Published online July 10, 2024. doi:10.1001/jamapsychiatry.2024.1778

2. Huo S, Bruckner TA, Xiong GL, et al. Antidepressant prescription behavior among primary care clinician providers after an inter professional primary care psychiatric training program. Adm Policy Ment Health. 2023;50(6):926-935. doi:10.1007/s10488-023-01290-x