We found that approximately 70 percent of Medicaid-enrolled adults initiating treatment for major depression in specialty mental health care settings received minimally adequate care. Rates of minimally adequate psychotherapy treatment appear to be reasonably high—almost two-thirds of depressed Medicaid-enrolled adults received four or more psychotherapy visits during the first 12 weeks of treatment. However, rates of minimally adequate pharmacotherapy are substantially lower with only 30 percent of individuals receiving adequate care. Our findings that 70 percent of individuals in a high risk, low SES Medicaid population are receiving minimally adequate depression care are consistent with other studies reporting that 60 percent of all individuals being treated for mood disorders in specialty mental health settings are receiving minimally adequate care (Wang et al. 2007
), and they are encouraging given more recent reports about modest rates of quality care across a range of disorders and settings (McGlynn et al. 2003
We found substantial racial disparities in the rates of minimally adequate depression care. African Americans consistently received lower rates of minimally adequate treatment than other individuals, even after controlling for other numerous factors that could explain these differences. This finding is consistent with other studies documenting racial/ethnic disparities in mental health treatment quality (DHHS 1999
; Wang et al. 2007
;). These disparities may be due to differences in access to care (IOM 2002
), patient preferences, including the use of individuals outside the health care system to address mental health issues (Young, Griffith, and Williams 2003
), stigma (Corrigan 2004
), or provider bias or discrimination (Atdjian and Vega 2005
). Policy-level interventions to improve the quality of mental health care overall and to improve access to care for racial minorities (McGuire and Miranda 2008
) and patient-level educational interventions to reduce stigma in minority populations may help to reduce these disparities in the quality of depression treatment.
We also found low rates of minimally adequate care for individuals initiating depression treatment with a psychiatric hospitalization, a concern since such individuals likely have more severe depression than those initiating treatment in outpatient settings. Hospitalized individuals were markedly less likely to receive minimally adequate psychotherapy or pharmacotherapy after discharge; only a third of individuals discharged from a hospital received any adequate treatment for depression. Low rates of clinical engagement following discharge from psychiatric hospitalization have been documented previously (Stein et al. 2007
), but given appropriate follow-up care's association with lower rates of readmission (Nelson, Maruish, and Axler 2000
), attention to improving the adequacy of outpatient depression treatment for this population is essential.
We found that individuals whose episode-initiating outpatient visits were with different providers were slightly more likely to receive adequate pharmacotherapy than those whose visits were with the same provider. Although this finding seems to conflict with research showing that continuity of care is an essential element of quality care (Teh et al. 2008
), we suspect that in this case, many individuals in this group had a first visit with a nonphysician mental health provider (e.g., clinical social worker) and were then appropriately referred to a psychiatrist for pharmacotherapy. We were unable to test this hypothesis, however, since our data did not allow identification of individual provider types.
Women are more likely to seek treatment for depression than men (Galbaud du Fort et al. 1999
). We found, however, that depressed women initiating treatment for major depression received lower rates of minimally adequate psychotherapy than men. Medicaid-enrolled women may face additional barriers to treatment than men, such as lack of adequate child care that could differentially reduce their ability to attend routine psychotherapy visits. Better understanding these barriers and implementing interventions to increase access to mental health care for Medicaid-enrolled women must be a goal of future public policy. Surprisingly, we also found that individuals living in rural counties received higher rates of minimally adequate psychotherapy than those in urban counties, despite the limited availability, accessibility, and acceptability of mental health care services common in rural areas (Sawyer, Gale, and Lambert 2006
). Further research exploring the causes and generalizability of this finding is needed.
Our findings are based on mental health specialty and pharmacy claims data from a Medicaid-enrolled population in a large mid-Atlantic state. A limitation of this analysis is lack of generalizability: we do not know to what extent our findings generalize to populations from other regions, or to populations in areas with different Medicaid mental health benefits. Because of the racial composition of our study state and limitations of the way race was recorded in the data, we were not able to report on differences in depression care quality by race and ethnicity beyond a simple comparison between white and black. We could not observe depression treatment services provided outside of the behavioral health system, such as pastoral counseling or psychotherapy services provided by a physical health provider. While such services may benefit individuals with depression, we note, however, that they are not commonly considered in assessing the adequacy of psychotherapy provided (Schoenbaum et al. 2002
; Teh et al. 2008
;). We are unable to assess the content or quality of psychotherapy visits, and given that most mental health visits do not contain evidence-based treatment, it is likely that the number of individuals receiving effective psychotherapy is low (Tai-Seale et al. 2007
). Our measure of minimally adequate acute-phase psychotherapy also provides for a very low level of treatment intensity; however, even such minimal depression treatment has been associated with improved depression outcomes (Schoenbaum et al. 2002
Better understanding of the factors associated with receipt of quality care for depression among Medicaid-enrolled individuals who initiate depression treatment will allow for more targeted efforts to improve treatment and outcomes for this population. Findings in the current study suggest that targeting efforts to increase the adequacy of antidepressant prescribing and adherence as a good place to start. Moreover, given that racial minorities and individuals discharged from inpatient treatment are at highest risk for receiving inadequate care for depression, specific interventions might target these individuals as well. Quality improvement efforts can build upon established models of depression care management (e.g., care coordination, communication, patient education) that have documented success in improving outcomes such as rates of appropriate use of antidepressant medication for individuals with depression (Williams et al. 2007
). System-level interventions might include efforts to increase payment rates for psychotherapy and medication management and to provide clinicians with information about their performance on key outcomes versus their peers. Medicaid enrollees face significant barriers to receiving quality behavioral health care. It is essential that systems and policy makers use available information about factors that are related to quality of care and respond in a manner that ensures high-quality depression treatment for this vulnerable population.