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This research was funded by NIMH (K01-MH63780). Disparities in the Adequacy of Depression Treatment in the United States. Jeffrey S. Harman, Ph.D. University of Florida Mark J. Edlund, M.D., Ph.D. John C. Fortney, Ph.D. Central Arkansas Veterans Healthcare System - PowerPoint PPT Presentation
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Disparities in the Adequacy of Depression Treatment in the
United States
Jeffrey S. Harman, Ph.D.
University of Florida
Mark J. Edlund, M.D., Ph.D.
John C. Fortney, Ph.D.
Central Arkansas Veterans Healthcare System
University of Arkansas for Medical Sciences
This research was funded by NIMH (K01-MH63780)
Depression in the U.S.
• Depression is common, costly, and impacts functioning, quality of life
• Effective treatments exist• National treatment guidelines have
been developed• Estimated that only 7% to 30% receive
adequate treatment
Disparities in Treatment
• Studies have shown that some populations especially vulnerable to under-treatment– African-Americans, ethnic minorities– Older persons, young adults– Medicaid beneficiaries, uninsured
• These studies were limited– Most are not nationally representative– Most do not distinguish between initiation vs.
persistence
Purpose of Study
• To use nationally representative data to examine disparities in depression treatment by age, race/ethnicity, insurance coverage– Compare rates of initiating treatment– Compare rates of adequate treatment
among those who initiated treatment
Data
• Data are from the 2000 Medical Expenditure Panel Survey (MEPS)– Nationally representative– Sponsored by the Agency for Healthcare
Research and Quality– Collects information on health care use
and expenses, health status, health insurance coverage, demographics, etc
Individuals with Depression
• Individuals with depression identified using 2000 MEPS Medical Condition File– Contains observation for each self-reported
medical condition during the year
• Self-reported conditions were mapped onto a 3-digit ICD-9 code by coders
• All individuals with ICD-9 codes of 296 or 311 were included in the analysis– N = 1,347
Antidepressant Treatment
• Identified using 2000 Prescribed Medicine Event File– Each event represents one prescription
• Antidepressants identified by drug name• Daily dosage calculated using pill dosage and
number of pills– Assumed 30 day supply unless < 30 pills
• Compared to minimally adequate daily dosage (Weilburg et al., 2003)
Psychotherapy/MH Counseling
• Psychotherapy or MH counseling identified using MEPS event files – 2000 Outpatient Visit File – 2000 Office-Based Medical Provider Visit File
• Respondent asked to identify which category best described care provided during visit– One category was “Psychotherapy or Mental
Health Counseling”
Adequacy of Treatment
• Adequate depression treatment over one-year period defined as:– At least 4 antidepressant prescriptions at the
minimum adequate daily dosage– At least 8 psychotherapy/MH counseling visits
• Definition based on treatment guidelines and similar to that used by Kessler et al. (2003)
Patient Characteristics
• Race/ethnicity consisted of 4 mutually exclusive categories– Caucasian, African-American, Hispanic, Other
• Age categorized into 4 groups– Under 18, 18-34, 35-64, and 65+
• Insurance categorized into 5 groups– Private, Medicaid only, Medicare only, Medicaid
and Medicare, uninsured
Statistical Analyses
• Goal is to assess whether disparities in care exist– Probability of any depression treatment– Probability of adequate treatment given some
depression treatment
• Used logit models (Stata survey commands)• Controlled for income, education, gender,
marital status, health status, MH status, ADL, IADL
Any Antidepressant or Psychotherapy/Counseling
OR P-value 95% CI
Caucasian - - -
African-American 0.44 <.001 0.29-0.67
Hispanic 0.46 <.001 0.30-0.69
Other 0.35 .051 0.12-1.00
Under 18 0.90 .761 0.44-1.81
18 to 34 0.49 <.001 0.33-0.72
35 to 64 - - -
65+ 1.23 .522 0.65-2.35
Any Antidepressant or Psychotherapy/Counseling
OR P-value 95% CI
Private Insurance - - -
Medicaid 0.98 .936 0.52-1.82
Medicare 1.27 .479 0.65-2.50
Medicaid+Medicare 1.82 .145 0.81-4.11
Uninsured 0.57 .032 0.34-0.95
Adequate Depression Care If Some Treatment Received
OR P-value 95% CI
Caucasian - - -
African-American 1.26 .474 0.67-2.35
Hispanic 0.67 .099 0.42-1.08
Other 0.72 .508 0.27-1.93
Under 18 0.82 .580 0.41-1.66
18 to 34 0.56 .022 0.34-0.92
35 to 64 - - -
65+ 0.72 .217 0.43-1.21
Adequate Depression Care If Some Treatment Received
OR P-value 95% CI
Private Insurance - - -
Medicaid 1.21 .592 0.61-2.40
Medicare 1.13 .687 0.62-2.07
Medicaid+Medicare 2.34 .018 1.16-4.74
Uninsured 0.99 .957 0.57-1.71
Psychotherapy Tx - - -
Antidepressant Tx 0.98 .952 0.54-1.79
Combination Tx 2.87 .002 1.49-5.51
Summary
• Overall, disparities appear to be due to initiating treatment, not continuing treatment
• Combination treatment associated with higher probability of adequate care
• Young adults less likely to initiate treatment and less likely to continue treatment
Implications
• Initiating depression treatment may be primary hurdle to overcome disparities
• Interventions should focus on getting racial/ethnic minorities, young adults, uninsured into treatment
• Still much room for improvement in overall rate of adequate depression care
Any Antidepressant
OR P-value 95% CI
Caucasian - - -
African-American 0.47 .001 0.30-0.73
Hispanic 0.47 .001 0.31-0.73
Other 0.39 .082 0.14-1.13
Under 18 0.76 .371 0.41-1.40
18 to 34 0.40 <.001 0.27-0.58
35 to 64 - - -
65+ 1.35 .340 0.73-2.49
Any Antidepressant
OR P-value 95% CI
Private Insurance - - -
Medicaid 0.84 .589 0.44-1.60
Medicare 1.38 .288 0.76-2.51
Medicaid+Medicare 1.57 .249 0.73-3.40
Uninsured 0.73 .215 0.45-1.20
Adequate Antidepressant Care If Filled At Least 1 Antidepressant Rx
OR P-value 95% CI
Caucasian - - -
African-American 0.74 .472 0.33-1.67
Hispanic 0.90 .680 0.54-1.50
Other 0.73 .519 0.28-1.89
Under 18 0.69 .308 0.34-1.41
18 to 34 0.50 .016 0.29-0.88
35 to 64 - - -
65+ 0.68 .155 0.40-1.16
Adequate Antidepressant Care If Filled At Least 1 Antidepressant Rx
OR P-value 95% CI
Private Insurance - - -
Medicaid 1.22 .549 0.64-2.31
Medicare 1.17 .596 0.65-2.14
Medicaid+Medicare 1.87 .068 0.96-3.64
Uninsured 1.15 .634 0.64-2.08
Any Psychotherapy/Counseling
OR P-value 95% CI
Caucasian - - -
African-American 0.70 .287 0.36-1.35
Hispanic 1.12 .631 0.71-1.76
Other 0.64 .324 0.26-1.57
Under 18 1.40 .328 0.71-2.75
18 to 34 1.00 .984 0.67-1.51
35 to 64 - - -
65+ 0.58 .075 0.32-1.06
Any Psychotherapy/Counseling
OR P-value 95% CI
Private Insurance - - -
Medicaid 1.40 .230 0.81-2.44
Medicare 1.08 .812 0.57-2.06
Medicaid+Medicare 2.01 .041 1.03-3.94
Uninsured 0.41 .004 0.22-0.75
Adequate Course of Psychotherapy If Started Psychotherapy
OR P-value 95% CI
Caucasian - - -
African-American 2.47 .053 0.99-6.16
Hispanic 0.37 .007 0.18-0.76
Other 0.27 .332 0.02-3.86
Under 18 0.33 .041 0.11-0.95
18 to 34 0.35 .017 0.15-0.83
35 to 64 - - -
65+ 0.19 .024 0.48-0.80
Adequate Course of Psychotherapy If Started Psychotherapy
OR P-value 95% CI
Private Insurance - - -
Medicaid 1.37 .572 0.46-4.09
Medicare 2.25 .179 0.69-7.39
Medicaid+Medicare 3.26 .072 0.90-11.84
Uninsured 0.58 .460 0.14-2.47
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