Our data provide unique findings about depression treatment in a large, nationally representative sample of veterans. Overall, 75% of veterans received some form of acute phase depression treatment. We found that approximately 53% of veterans with depression received antidepressant medications; a rate substantially high than the rate of 30% of depressed individuals in employer-provided health-care plans that has been reported previously.23
Further, of those starting on antidepressants, about 61% received adequate acute phase medication coverage, a rate similar to private sector healthcare systems.10
Receipt of any PT was slightly lower than receipt of MT (~50% total had any PT contacts), with relatively few (~5% of the sample) receiving guideline concordant number of PT sessions. The rates of overall PT seem similar to other studies. For example, Kniesner et al23
found that approximately 55% of those diagnosed with depression and enrolled in employer-provided healthcare plans received some PT. However, rates of CT in our sample (~26% had at least 1 antidepressant prescription and one or more PT visits) were slightly higher than rates (20%) observed by Kniesner et al23
Overall, the VA seems similar (if not somewhat better) than the private sector in initial acute phase treatment for depressed patients. However, rates of guideline concordant PT and CT were relatively low in our sample. It is difficult to benchmark the adequacy of acute phase PT and CT within the VA against other samples, given that some samples have used relatively low thresholds for guideline concordant PT (“4 or more visits” during a calendar year), and/or did not examine acute phase care specifically.9,25
Patients with comorbid psychiatric diagnoses had variable experiences of treatment for depression. Overall, patients in all the comorbidity groups (SUD, PTSD, SUD-PTSD) were more likely to receive guideline concordant care, with such comorbidities much more strongly related to GC PT and GC CT care. However, depressed patients with SUDs (without PTSD) were no more likely to receive GC MT. It is possible that providers may be more reluctant to initiate antidepressant treatment for this subgroup until substance use problems are in remission and/or because of concerns that mood symptoms may be substance induced, or because some patients with a history of substance use problems may be reluctant to take antidepressants. Future research is needed to obtain a better understanding of factors related to lower antidepressant use among this comorbidity group. Nevertheless, although the depressed patients with SUDs were more likely to receive PT and CT, rates of such care for this group were relatively low. This suggests a potential need for PT approaches targeting those veterans with comorbid depressive and SUD symptoms.
Although the VA has a much lower proportion of women than the general population, consistent with a number of studies women were more likely to receive GC MT
but did not differ from men in receipt of GC PT
or GC CT
. Overall, older age groups were less likely to receive both low level
and guideline concordant
care. These findings could reflect cohort differences in views on mental health problems (higher perceived stigma among older veterans), increased difficulty/barriers for older depressed veterans to attend appointments, and/or associated treatment preferences of older adults.28
For example, there is evidence that older adults with depression are more likely to be treated in general medical settings (and prefer to receive care in such settings)28
where MT is the most common intervention for depression. The findings that married veterans were more likely to receive MT is consistent with a prior large study of depressed veterans,26
and other studies also have reported that married individuals were less likely to receive PT.29
The observed relationship between race and type of care revealed some interesting differences. African Americans were less likely to receive GC MT
and GC CT
, but were more likely to receive GC PT
. This is consistent with previous studies indicating that minorities are less likely to receive antidepressant treatment, to fill prescriptions for antidepressant medications, and some minority groups are more likely to prefer PT over medications compared with whites.26,30,31
Further, those whose race was unknown were less likely to receive low level
care, as well as GC PT
and GC CT
. It should be noted that some caution should be used in interpreting findings on race based on such VA data, given the high rates of those with “unknown” and “other” race. Nevertheless, the findings raise a number of issues in terms of providing optimal care for the veteran patient population. Overall, there is greater availability of MT given that such care can be provided by ambulatory care medical providers as well as mental health specialty settings. Thus, relatively lower availability of PT may particularly effect care provision to African American veterans. Further, the findings may suggest additional efforts may be needed to engage participants in certain care types when clinically indicated (culturally informed approaches to address concerns about MT among African Americans, and concerns about PT for some other groups). Clearly, research is needed to better understand reasons for differences (patient preferences; barriers to care, etc) in care type by race.
The present findings suggest that additional research could examine reasons for potential under-utilization of PT and CT among depressed veterans. Such factors could include patient level factors (low problem recognition/motivation, concerns about stigma, treatment preferences), and factors related to treatment access (availability of services, insufficient PT and CT resources, acceptability of services to patients and referring clinicians). Treatment access may be particularly challenging when specialty services are not available in all treatment locations (eg, lack of PT services in primary care, low availability of PT even within mental health specialty settings, lack of depression specific PT in SUD and PTSD treatment settings). Further, both patients and clinicians may struggle with whether (or when) specialty services may be indicated given issues such as the patient’s primary and secondary diagnoses and treatment preferences. Research examining such factors could guide the development or application of interventions at both the clinical level (eg, motivational interviewing targeting treatment engagement for those with depression and psychiatric comorbidities, case management, provider training, patient and provider education), and at the systems level (guideline concordant treatment for depression, increased availability of PT, broader availability of integrated care approaches in primary care settings), and/or may help identify potential treatment system and staffing resource needs.
Although the VA is the largest US health system, it is likely that the prevalence of MT, PT, and CT approaches differ from those seen in other health systems, and it is possible that the pattern of findings regarding patient level predictors (demographics, comorbidity) of care receipt may differ in non-VA healthcare. Further, a major strength of the VA is the ability to provide medical, general mental health and specialty care services within single medical center settings, which suggests non-VA systems may have additional (or different) barriers for providing PT and CT. The results of this and other studies24
suggest the VA provides MT at somewhat higher rates than other health care systems, but it remains unknown how the VA compares to other large health systems regarding PT and CT treatment for depression (it was difficult to benchmark the PT and CT rates compared with non-VA systems given that prior studies of healthcare systems focus primarily on MT). Finally, since the data acquisition period of this study, the VA has funded numerous enhancements for VA mental health care. Future studies should examine the impact of such enhancements on care quality.
An additional limitation is the reliance on administrative data to identify the cohort of depressed veterans. There is evidence from studies of private sector managed care organizations that administrative data may yield high false positive rates, and that higher false positive rates are related to poorer performance on quality indicators.32
This makes sense in that those without a true depression diagnosis may not need or seek specialty care. Although we used methods to identify our cohort and assess care quality that allow for some comparisons with other studies, similar to such studies it is likely that a proportion our cohort were not in need of specialty care, and this could negatively impact rates of care receipt. Our supplemental analyses examining a more specific depression qualifying diagnosis did suggest some modest improvement in performance on our quality indicators, and it is likely that identification of patients with more structured and validated assessment approaches could similarly impact assessment of care quality. Clearly, further research is needed at both macro and more micro levels to better understand quality of depression care.
Additionally, our PT outcome measures also had a number of limitations; we collapsed and summed across a number of different therapy codes and provider types (eg, individual and group codes; psychologists, psychiatrists, social workers); it was not possible to examine the type of PT (supportive listening, cognitive-behavioral therapy, interpersonal PT), the degree to which depressive symptoms actually were addressed during sessions, or whether providers were using empirically supported PT approaches. Thus, our approach may overestimate provision of any or guideline concordant PT (and CT) targeting depression. Finally, we defined guideline concordant PT as receiving 12 or more sessions during the 114 days after initial diagnosis; a higher number than some prior studies. This was selected to allow time to arrange a referral for PT, and to approximate the standard guidelines for acute phase provision of therapy for depression (eg, once per week sessions). However, an alternative less stringent definition of GC PT (“8 or more” visits) yielded only modest increases in the percent of veterans receiving such care. Overall, given our requirements for MT, PT, and CT in our study, the data suggest substantial under-provision of PT and CT in the VA population.
In summary, it seems the VA performs as well or better than other health settings in providing MT treatment to depressed patients. However, like other health systems, PT and CT treatment for depression are likely suboptimal. Future research is needed to further delineate potential patient and system level moderators that could improve access to and receipt of PT and CT for depression, thereby improving overall quality of care and quality of life for these depression sufferers.