Ensuring initial access and sustained treatment for depression is a challenging but important goal for health care providers and health systems. Psychotherapy and antidepressant pharmacotherapy are the most commonly used treatments for depression, and understanding the facilitators and barriers to receipt of these treatments may help individual treatment planning and allocation of health system resources. Using national VA health system data, we found distance to the nearest mental health treatment facility was a significant barrier to receiving any or adequate psychotherapy, whereas distance increased the likelihood of receipt of any or adequate pharmacotherapy. Interestingly, the decrease in psychotherapy (with or without antidepressant treatment) associated with greater distance from a mental health treatment facility was largely offset by an increase in pharmacotherapy, such that the predicted probabilities of receiving some form of depression treatment were similar.
Our finding regarding the negative association between distance and receipt of psychotherapy for depression is consistent with a prior study of guideline-based care for depression in which psychotherapy and pharmacotherapy were not considered separately (Fortney et al. 1999
). Our findings regarding distance to treatment facilities as a barrier to psychotherapy also complement studies that have shown increased distance to be associated with gaps in treatment for patients with serious mental illness and decreased services utilization after a psychiatric hospitalization (Druss and Rosenheck 1997
; McCarthy et al. 2007b
;). When nonpharmacologic treatments for depression are indicated for patients who live in outlying areas, alternatives to in-person psychotherapy that may be less sensitive to distance barriers should be considered. Telephone-administered psychotherapy has demonstrated efficacy for depression and deserves further investigation of its comparative effectiveness for patients with depression who live at remote distances (Mohr et al. 2008
). The VA has made recent efforts to increase the use of telemental health services; however, the impact of these initiatives on receipt of adequate psychotherapy is not yet known.
Beyond confirming the hypothesis that travel distance would negatively impact psychotherapy, we also investigated whether being initially diagnosed with depression at a smaller community-based clinic might impact subsequent receipt of psychotherapy, as these clinics may be closest to patients living in outlying areas and health systems may consider the addition of more community clinics to remote areas to improve access. We encouragingly found that receiving treatment at community clinics did not impact overall receipt of initial psychotherapy, and patients living farther than 30 miles from a mental health facility were actually more likely to receive any psychotherapy when diagnosed at a small community clinic. However, patients were less likely to receive an adequate number of psychotherapy sessions if they were initially diagnosed at a community clinic compared with a VA medical center. This finding could result if patients with more severe or complicated illness are more likely to be referred (or self-refer) to VA medical centers and adhere to an adequate course of psychotherapy. However, the possibility that patients diagnosed at CBOCs receive limited treatment at those facilities or do not transition to another facility to receive an adequate course of psychotherapy has important quality of care implications. This finding is particularly concerning among patients diagnosed at large CBOCs that are expected to provide more robust mental health services to their patients. The VA has made efforts to increase the use and availability of evidence-based psychotherapies at the largest CBOCs since the time of this study; however, the impact of these initiatives is yet unknown.
The finding that greater distance from a mental health treatment facility was associated with increased likelihood of receiving any or adequate pharmacotherapy is novel. Prior studies have found antidepressant treatment among patients living in remote or rural areas to either have similar or less antidepressant use than patients living in urban areas or areas with greater access to mental health treatment, although travel distance was not specifically examined in these studies (Goldney, Taylor, and Bain 2007
; Morrison et al. 2009
;). These findings suggest patients and/or providers may include travel barriers (i.e., burden of subsequent appointments) in the decision to start an antidepressant medication and to prescribe and obtain an adequate supply of medication. The extensive use and convenience of mailed prescriptions within the VA may also contribute to this finding.
We found diagnosis at a small CBOC to be negatively associated with prescription of any or adequate antidepressant pharmacotherapy after adjusting for all covariates. This finding is in contrast to a prior report which, in unadjusted analyses, found greater rates of adequate antidepressant coverage among patients treated at VA CBOCs compared with VA medical centers and suggested this may be due to more frequent initial prescriptions for a 90-day supply of medication (thereby automatically fulfilling the criteria for adequate antidepressant coverage) at the community clinics (McCarthy et al. 2007a
). Our findings demonstrate that distance and facility type have different, potentially opposing, effects on antidepressant prescribing and should be considered separately in future studies of antidepressant prescribing patterns.
The decreased likelihood of receiving an initial antidepressant at a small CBOC may be due to differences in preferences for depression treatment at these clinics compared with VA medical centers. In analyses comparing the predicted probability of receiving psychotherapy, pharmacotherapy, both treatment or neither, patients diagnosed at small CBOCs did have a greater predicted probability of receiving psychotherapy only compared with patients diagnosed at VA medical centers; however, this was not sufficient to offset the lower probabilities of receiving pharmacotherapy or combined treatment. Patients diagnosed at small CBOCs do not appear to be simply choosing between the two depression treatment modalities and instead were more likely to receive no treatment. Depression care management services within primary care clinics, which have established efficacy for improving antidepressant treatment (Gilbody et al. 2006
), have been developed specifically for VA clinical settings and are now required of all VA medical centers and large CBOCs (Post and Van Stone 2008
). Extending depression care management to smaller outpatient clinics may improve the disparity in antidepressant treatment initiation and adequacy, although such programs may be less cost-effective in rural versus urban settings (Fortney et al. 2007
; Pyne et al. 2010
Our finding that urban or rural location of the diagnosing facility was not related to receipt of adequate depression care is consistent with prior work which found similar quality of depression care between rural and urban residents despite rural residents receiving less specialty mental health care (Rost et al. 1998
Although the primary aim of this study was to determine the effect of distance and facility type on receipt of treatment for depression, other factors associated with receipt of care may inform efforts to improve treatment engagement and adherence. Patients younger than 35 years were generally more likely to initiate treatment than older patients, but as they were less likely to receive adequate psychotherapy compared with middle-aged patients or adequate pharmacotherapy compared with all older patients, services for younger patients might prioritize retaining them in care. On the other hand, older patients may benefit more from efforts to improve treatment initiation. Low utilization of psychotherapy among patients older than 65 years has been demonstrated in other populations, and these patients may need particular assistance in overcoming access barriers (Wei et al. 2005
). Consistent with prior studies, married patients were less likely to receive adequate psychotherapy and more likely to receive adequate pharmacotherapy, suggesting family responsibilities may be a barrier to attending psychotherapy sessions or that the social support provided by a spouse may affect patients' real or perceived need for psychotherapy (Olfson et al. 2002
; Busch, Leslie, and Rosenheck 2004
; Chermack et al. 2008
;). Although women in the general U.S. population receive psychotherapy at higher rates than men (Olfson et al. 2002
), female VA patients were less likely than male patients to receive adequate psychotherapy and men were less likely to receive adequate pharmacotherapy compared with women, an issue that deserves further study particularly because women comprise an increasing proportion of the veteran population. The greater likelihood of psychotherapy use by blacks compared with whites is contrary to U.S. national trends but consistent with previous finding within the VA and may better reflect differences in treatment preferences when patients have similar access and benefits to care (Olfson et al. 2002
; Chermack et al. 2008
Patients with comorbid substance use and posttraumatic stress disorders were more likely to receive psychotherapy than those without these comorbidities likely because the subspecialty services provided for these conditions within the VA generally include psychotherapy. Patients with general medical comorbidities had significantly decreased odds of receiving any or adequate psychotherapy and yet did not have increased odds of receiving pharmacotherapy. These patients may be more likely to receive their care exclusively in primary care or nonpsychiatric medical specialty settings and therefore have more limited access to psychotherapy. Integration of psychotherapy services into primary care and medical specialty settings or initiatives to bundle psychotherapy appointments with other medical appointments should be considered to improve adequacy of depression treatment for medically ill patients. We also note the relationship between receipt of psychotherapy and pharmacotherapy. While receiving one treatment increased the odds of receiving the other, neither treatment increased the likelihood of receiving adequate treatment of the other modality. This is consistent with clinical trial data which show combined treatment is more efficacious than monotherapy but does not result in improved treatment adherence (Pampallona et al. 2004
Because of limitations imposed by the available data, our study was not able to include several potentially important predictors of psychotherapy or pharmacotherapy utilization such as measures of depression severity (other than psychiatric hospitalization), employment, education, or patient treatment preferences. In a related study of mental health visits for depression which included some of these covariates, distance had the strongest marginal effect (Fortney et al. 1999
). The relationships between distance and facility type may be related to unmeasured differences in attitudes or preferences for treatment among patients who live in outlying areas or seek treatment in community settings. An Australian study found people living in remote or outlying areas to be less likely to consider psychologists to be helpful; however, the direction of causality is unclear and this finding may due to less exposure to psychological services due to distance barriers (Goldney, Taylor, and Bain 2007
). Our analyses only included VA services, and patients living remote distances from VA facilities could potentially receive more services (i.e., psychotherapy) through non-VA providers. As our study population consisted of veterans receiving care in the VA health system, our findings may not generalize to depression in individuals within general populations, which on average are younger, predominantly female, and have less comorbidity with posttraumatic stress disorder. Our findings may also not generalize to the uninsured or insured patients whose health plans place administrative or cost barriers to receiving depression treatment. Finally, our method for calculating distance is only a proxy for actual travel time.
In summary, distance to treating facility is a significant barrier to receiving any or adequate psychotherapy for depression yet is associated with greater likelihood of receiving any or adequate pharmacotherapy. Patients diagnosed at smaller community clinics are less likely to receive adequate psychotherapy and less likely to initiate antidepressant treatment. Implications for health systems include providing alternatives to in-person psychotherapy for patients living in remote areas, insuring small community clinics are capable of providing adequate psychotherapy to those who initiate treatment, and extending depression care management services to small community clinics to support antidepressant treatment.