Treatment Initiation for New Episodes of Depression in Primary Care Settings
Depression is prevalent and costly, but despite effective treatments, is often untreated. Recent efforts to improve depression care have focused on primary care settings. Disparities in treatment initiation for depression have been reported, with fewer minority and older individuals starting treatment.
To describe patient characteristics associated with depression treatment initiation and treatment choice (antidepressant medications or psychotherapy) among patients newly diagnosed with depression in primary care settings.
A retrospective observational design was used to analyze electronic health record data.
A total of 241,251 adults newly diagnosed with depression in primary care settings among five health care systems from 2010 to 2013.
ICD-9 codes for depression, following a 365-day period with no depression diagnosis or treatment, were used to identify new depression episodes. Treatment initiation was defined as a completed psychotherapy visit or a filled prescription for antidepressant medication within 90 days of diagnosis. Depression severity was measured with Patient Health Questionnaire (PHQ-9) scores on the day of diagnosis.
Overall, 35.7% of patients with newly diagnosed depression initiated treatment. The odds of treatment initiation among Asians, non-Hispanic blacks, and Hispanics were at least 30% lower than among non-Hispanic whites, controlling for all other variables. The odds of patients aged ≥ 60 years starting treatment were half those of patients age 44 years and under. Treatment initiation increased with depression severity, but was only 53% among patients with a PHQ-9 score of ≥ 10. Among minority patients, psychotherapy was initiated significantly more often than medication.
Screening for depression in primary care is a positive step towards improving detection, treatment, and outcomes for depression. However, study results indicate that treatment initiation remains suboptimal, and disparities persist. A better understanding of patient factors, and particularly system-level factors, that influence treatment initiation is needed to inform efforts by heath care systems to improve depression treatment engagement and to reduce disparities.
KEY WORDSdepression primary care race and ethnicity disparities
This study was supported by NIMH Cooperative Agreement U19MH092201.
Compliance with Ethical Standards
Conflict of Interest
Dr. Simon receives royalties from Wolters Kluwer for editing chapters of the UpToDate decision support system. In the last 3 years, he has received research grant support from Novartis Pharmaceuticals for research regarding suicidal behavior in psoriasis.
Dr. Daida receives research grant support from Gilead Sciences and Intercept Pharmaceuticals for research regarding hepatitis and fibrotic liver diseases, respectively. Research funds are received through the Henry Ford Health System (prime site for both studies).
All other authors declare that they do not have a conflict of interest.
- 1.National Institute of Mental Health: Major Depression Among Adults. https://www.nimh.nih.gov/health/statistics/prevalence/major-depression-among-adults.shtml. Accessed 21 Dec 2017.
- 2.National Network of Depression Centers: Facts. http://www.nndc.org/the-facts/. Accessed 21 Dec 2017.
- 14.U.S. Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med. 2002;136(10):760-764.Google Scholar
- 15.NCQA HEDIS Depression Measures Specified for Electronic Clinical Data Systems. http://www.ncqa.org/hedis-quality-measurement/hedis-learning-collaborative/hedis-depression-measures. Accessed 21 Dec 2017.
- 24.Mental Health Research Network. http://hcsrn.org/mhrn/en/. Accessed 21 Dec 2017.
- 25.Ross TR, Ng D, Brown JS, et al. The HMO Research Network Virtual Data Warehouse: A Public Data Model to Support Collaboration. EGEMS (Washington, DC). 2014;2(1):1049.Google Scholar
- 27.SAS Institute Inc., SAS Software 9.4, Cary, N.C.Google Scholar
- 28.Thornicroft G, Chatterji S, Evans-Lacko S, et al. Undertreatment of people with major depressive disorder in 21 countries. Br J Psychiatry 2016.Google Scholar
- 44.Coventry P, Lovell K, Dickens C, et al. Integrated primary care for patients with mental and physical multimorbidity: cluster randomised controlled trial of collaborative care for patients with depression comorbid with diabetes or cardiovascular disease. BMJ (Clin Res ed). 2015;350:h638.Google Scholar
- 47.Suicide among adults aged 35-64 years--United States, 1999-2010. MMWR. 2013;62(17):321-325.Google Scholar