Despite substantial empirical evidence supporting the efficacy of psychotherapy for depression in older adults, our study showed that only a minority of depressed elderly patients received psychotherapy. This finding is consistent with findings in previous studies (28
). Overall, psychotherapy use remained stable at this low level between 1992 and 1999, although antidepressant use in this population increased during this period (29
Although education and income are indicators of socioeconomic status, in the multiple logistic regression only education was related to psychotherapy use. College-educated older adults were more likely to use psychotherapy than were those with no college. Previous research with groups of nonelderly subjects has found that acceptance of psychotherapy is directly related to level of education (30
). Psychiatrists initiating treatment of depression for older patients should bear in mind that their patients who have not attended college may tend to be less accepting of psychotherapy than those with higher educational attainment. The selection of treatment modality should be influenced by the patient’s preferences as well as clinical considerations such as symptom severity, the presence of interpersonal difficulties, or a comorbid axis II disorder (31
). With older patients who have less formal education, it may be especially important for psychiatrists to discuss how psychotherapy works and remain responsive to patients’ concerns or misconceptions regarding this treatment.
In our study, environmental factors significantly affected use and consistency of psychotherapy. Our findings suggest that older Americans face significant barriers in access to psychotherapy because of limited local availability of qualified providers (21
Provider discipline played an important role in affecting the likelihood of receiving consistent psychotherapy. Patients who received psychotherapy only from psychiatrists were less likely to receive psychotherapy for the period of time recommended by Agency for Health Care Policy and Research guidelines. Because a great majority of the medication management visits were provided by psychiatrists, psychotherapy may be used by psychiatrists to supplement pharmacotherapy, rather than as a primary treatment. Costs may also contribute to the observed psychotherapy utilization pattern. Given that a majority of the patients had prescription drug coverage and that Medicare covers 80% of medication management visit payments (32
), patients who are treated with antidepressant medications incur lower copayments than those who receive psychotherapy. Psychologists and social workers also have substantially lower fee schedules than psychiatrists (33
The risk of early termination may be greater for patients under the care of psychiatrists in solo practice than for patients treated by psychiatrists in mental health centers or multidisciplinary groups. Psychiatrists who have institutionalized referral relationships with nonpsychiatrist psychotherapists may have an advantage in maintaining their older patients through the continuation and maintenance phases of psychotherapy for depression. Therefore, higher financial barriers to treatment, differences in rates of antidepressant treatment, and variation in psychotherapy orientations may help to explain the low rates of consistent psychotherapy among patients who received psychotherapy only from psychiatrists.
The study has some important limitations. Coding biases are likely to affect the sensitivity, more than the specificity, of diagnosis (34
). Therefore, our study may have underestimated the overall number of depressive episodes. The sample includes only non-HMO and non-institution-dwelling Medicare beneficiaries, and so the findings cannot be generalized to HMO and institution-dwelling populations. The Medicare Current Beneficiary Survey data provide only event-level information on prescription drug use, and thus we were unable to determine precise dates of antidepressant use. Most important, Medicare Current Beneficiary Survey data provide no information on the types of psychotherapy being provided (e.g., cognitive behavior, interpersonal, nonspecific supportive) or on their clinical effectiveness.
Despite these limitations, our study provides important information on use of psychotherapy among elderly patients with a diagnosis of depression. The findings confirm that use of psychotherapy is influenced by a host of factors at the patient, provider, and health care system levels.