We used a unique longitudinal VA dataset with comprehensive diagnosis, utilization and pharmacy data to examine rates of clinical monitoring during the two highest-risk treatment periods (12 weeks after inpatient stay and after new antidepressant start) in a comprehensive sample of VA patients in depression treatment. Characteristics associated with significantly lower rates of monitoring include older age, white race, and living in the South or Northeast. Of concern, older age has been associated with higher risks of suicide following psychiatric hospitalization.5
The results indicating significantly less depression monitoring for older patients are troubling, but perhaps not surprising. In terms of new antidepressant starts, most older adults with depression are identified by their primary care physicians and treated as part of their overall medical care.12
Multiple prior studies in the 1990’s indicated that depression was underdiagnosed and undertreated in the elderly.13,14,15
Although there is ample evidence that antidepressant therapy can effectively ameliorate symptoms of later-life depression16,17,18
, a number of factors or confounds create complexity in its overall management.19
Patient factors, such as medical illness and neuropsychiatric comorbidity, may interact with provider factors to make treatment more complex. Even among the inpatient cohort in our study, most of whom would be expected to have psychiatric outpatient followup after hospitalization, the rates of monitoring were significantly lower than in younger adult patients. Factors such as comorbidity and functional impairment as well as provider scheduling decisions, patient preferences, and transportation issues may have played a role in preventing older patients from returning to clinic as often as their younger counterparts.
Although the FDA meta-analysis did not
show increased risks when older adults were randomized to an antidepressant rather than a placebo, the monitoring recommendation did not appear to be amended for older adults (e.g. no new recommendation was made by the FDA regarding a lower visit frequency for this population). However, providers may have noted the FDA meta-analysis results and not felt as much need to follow older adults as closely. This would perhaps stem from concern over the risks of suicide ensuing from depression medication itself rather than absolute suicide rates. In prior work5
, we found that in clinical settings, these periods are very high risk for older adults, likely because of illness severity which prompted the medication initiation or change rather than a medication effect per se.
During the period of this study, the VA had mandated depression screening on an annual basis. In its depression guidelines, it recommended regular follow-up for new depression episodes. It also emphasized following HEDIS guidelines for follow-up after psychiatric hospitalization, documenting outpatient visits in the first 7 days after discharge and in the first month after discharge. Aside from mandated annual screening, the guideline recommendations and follow-up recommendations were similar to those used by other health systems—although they may have been more rigorously monitored and emphasized in the VA. More recently (after this study period), the work outlined in our prior study5
was widely disseminated in VA settings.
Subsequently, more intensive monitoring has been implemented for post-hospitalization periods, likely due in part to the documentation of high suicide risks during this period.
Given our results demonstrating that the elderly receive less intensive monitoring during high-risk periods, these patients may require adapted interventions to get the depression care follow-up that they require. The VA has recently initiated home-based primary care programs for medically ill and older veterans. Routinely including depression care as part of these programs could enhance monitoring efforts for patients that may find it difficult to return to clinic for more frequent outpatient visits. Health systems serving large numbers of elderly patients may need to consider guidelines and followup measures specific to older adults during high-risk treatment periods.
Somewhat less expected were the results for African-American patients indicating that they had significantly more
monitoring visits than white patients following new antidepressant starts. These findings could not be explained by increased care due to substance use comorbidities in the exploratory analyses stratified by substance abuse diagnosis. Prior studies have shown that minorities have significantly lower rates of mood disorder diagnoses20
, may be less likely to receive guideline-concordant antidepressant treatment21
or to fill prescriptions for antidepressant medications than whites22
, and may prefer counseling to medications.23
However, the results of the present study are similar to an earlier analysis where we found no racial differences in healthcare utilization for mood disorders in older patients diagnosed with depression in the VA system.24
Additionally, other studies have found that African Americans were actually more likely than whites to receive an adequate course of psychotherapy in VA25
settings. Our findings support the idea that the VA may be doing a good job reaching out to racial minority patient groups who have been traditionally underserved with depression care.
In this paper, we report significantly lower monitoring rates for older than for younger patients during high risk treatment periods (e.g, after antidepressant starts and post-hospitalization); we have previously reported higher suicide rates among older than younger patients in this cohort during the post-hospital period. However, in this paper, we did not use our observational data to directly assess the relationship between lower rates of monitoring and suicide risks among elders. To do so would require highly complex analyses, given the small number of completed suicides (suicide is a low base rate event) and salient issues of treatment selection in clinical settings. In clinical settings, treatments are not assigned at random, and patients with more severe mental health issues often have more frequent visits and are more likely to commit suicide, resulting in potentially spurious associations between high monitoring rates and suicide. Thus, we note, that even though the mental health literature, governmental organizations, and clinical practice guidelines routinely suggest higher levels of monitoring for higher risk populations, it may be that increased monitoring would not result in reduction in suicide risks among older patients.
The study has a number of other limitations. Consistent with the demographic characteristics of the VA patient population, the study cohort was primarily male and thus, the results may not be generalizable to other clinical populations. Additionally, we relied upon antidepressant fills and hospitalizations within the VA to characterize high-risk periods. Some patients may have used mental health services outside of the VA system. However, prior reports indicate that only a minority of VA mental health users receive care in other health systems.26 27
Older adults, in particular, may often exclusively use the VA because of generous drug benefits. It is also possible, given the VA’s monitoring efforts, that depressed older patients during the time of the study may have actually been followed somewhat more closely in VA than in other settings.