Texas Medication Algorithm Project, Phase 3 (TMAP-3): Rationale and Study Design
J Clin Psychiatry 2003;64:357-369
© Copyright 2014 Physicians Postgraduate Press, Inc.
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Background: Medication treatment algorithms may
improve clinical outcomes, uniformity of treatment, quality of
care, and efficiency. However, such benefits have never been
evaluated for patients with severe, persistent mental illnesses.
This study compared clinical and economic outcomes of an
algorithm-driven disease management program (ALGO) with
treatment-as-usual (TAU) for adults with DSM-IV schizophrenia
(SCZ), bipolar disorder (BD), and major depressive disorder (MDD)
treated in public mental health outpatient clinics in Texas.
Discussion: The disorder-specific intervention
ALGO included a consensually derived and feasibility-tested
medication algorithm, a patient/family educational program,
ongoing physician training and consultation, a uniform medical
documentation system with routine assessment of symptoms and side
effects at each clinic visit to guide ALGO implementation, and
prompting by on-site clinical coordinators. A total of 19 clinics
from 7 local authorities were matched by authority and urban
status, such that 4 clinics each offered ALGO for only 1 disorder
(SCZ, BD, or MDD). The remaining 7 TAU clinics offered no ALGO
and thus served as controls (TAUnonALGO). To determine if ALGO
for one disorder impacted care for another disorder within the
same clinic ("culture effect"), additional TAU subjects
were selected from 4 of the ALGO clinics offering ALGO for
another disorder (TAUinALGO). Patient entry occurred over 13
months, beginning March 1998 and concluding with the final active
patient visit in April 2000. Research outcomes assessed at
baseline and periodically for at least 1 year included (1)
symptoms, (2) functioning, (3) cognitive functioning (for SCZ),
(4) medication side effects, (5) patient satisfaction, (6)
physician satisfaction, (7) quality of life, (8) frequency of
contacts with criminal justice and state welfare system, (9)
mental health and medical service utilization and cost, and (10)
alcohol and substance abuse and supplemental substance use
information. Analyses were based on hierarchical linear models
designed to test for initial changes and growth in differences
between ALGO and TAU patients over time in this matched clinic