Continuity of Outpatient Treatment After Discharge ofPatients With Major Depressive Disorder

Hee Ryung Wang, MD,* Hoo-Rim Song, MD,* Young-Eun Jung, MD,Þ Young Sup Woo, MD, PhD,*Tae-Youn Jun, MD, PhD,* Kwang-Soo Kim, MD, PhD,* and Won-Myong Bahk, MD, PhD*

Purpose: This study aimed to identify the predictors associated with the conti-nuity of outpatient treatment after discharge for patients with major depression.Methods: The medical records of patients discharged with diagnosis of majordepression were analyzed. The subjects were divided into two groups based onwhether they regularly visited the outpatient clinic for more than 4 months afterdischarge.Results: The 4-month follow-up group was older, had a lower employmentrate, and had a lower rate of being divorced or separated. The 4-month follow-upgroup had a longer duration of illness, a higher rate of recurrent major depres-sive disorder, older age at onset, and a longer duration of index hospitalization.Longer duration of index hospitalization and combination therapy were signif-icantly related to an increased likelihood of 4-month follow-up visits.Conclusions: Duration of hospitalization and prescription pattern of psy-chotropic medication appeared to have an influence on the continuity of out-patient treatment after discharge.

Key Words: Major depressive disorder, continuity of care,outpatient treatment.

(J Nerv Ment Dis 2013;201: 519Y524)

Depression is one of the most common psychiatric disorders withfrequent recurrence of symptoms (Kessler et al., 1994). Approx-

imately 60% to 80% of patients will eventually experience recurrence(Judd, 1997; Keller and Boland, 1998; Keller et al., 1992), and 5% to10% of patients commit suicide (Bostwick and Pankratz, 2000). An-tidepressant drugs have been known to effectively reduce depressivesymptoms and reduce relapse (Geddes et al., 2003). Although anti-depressants have played a significant role in the pharmacotherapy formajor depressive disorder (MDD), existing evidence has shown thatpremature discontinuation of antidepressant therapy is a big challengefor psychiatrists and primary care physicians (Akincigil et al., 2007;Cantrell et al., 2006; Melartin et al., 2005).

Premature discontinuation of antidepressants has been asso-ciated with symptoms relapse, decline in social functioning, and in-crease in socioeconomic burdens (Melfi et al., 1998; Sheehan et al.,2004; Sood et al., 2000; Thase, 2001). Treatment guidelines gener-ally recommend continuing antidepressant treatment for 4 months orlonger after symptoms remission (American Psychiatric Association,2000; Geddes et al., 2003; Olfson et al., 2006). Nonadherence toantidepressant therapy is estimated to range from 30% to 83%,depending on the population (Bultman and Svarstad, 2002; Lin et al.,1995; Melfi et al., 1998; Peveler et al., 1999; Sirey et al., 2001).

The period after discharge from inpatient treatment is veryimportant because it is during this period when many patients face anincreased risk for suicide or symptoms aggravation (Zivin et al.,2009). However, so far, there are few studies investigating the adher-ence rate of outpatient treatment during this risk period, whereas therehave been many studies on treatment adherence after the initiationof antidepressant therapy. In addition, there were few previous studieson continuity of outpatient treatment after discharge from psychiatrichospitalization in patients with MDD in Korea (Lee et al., 2010).We conducted a retrospective chart review and investigated the pre-dictors of continuity of outpatient treatment in patients with MDD whowere discharged from psychiatric hospitalization in a university hos-pital in Korea.

METHODS

Study Population and Selection CriteriaThis study included the patients who were discharged after

psychiatric hospitalization with the diagnosis of MDD from the De-partment of Psychiatry, Yeouido St. Mary’s Hospital, from January 1,2007, to December 31, 2010. The diagnosis was based on the Diag-nostic and Statistical Manual of Mental Disorders, Fourth Edition(DSM-IV). Subjects were excluded if they met any of the followingexclusion criteria: having other DSM-IVaxis I diagnoses, younger than18 years, being referred to another hospital during the 1-year periodafter discharge, participating in clinical trials during the 1-year periodafter discharge, and being readmitted during the 1-year period afterdischarge. This study was approved by the institutional review boardof Yeouido St. Mary’s Hospital, Seoul, Korea. The institutional reviewboard approved the exemption from informed consent because thiswas retrospective chart review study.

MethodsWe reviewed the medical records of the study population who

met the selection criteria (previously mentioned in the Study Popula-tion and Selection Criteria section) and divided the subjects into the‘‘4-month follow-up group’’ and the ‘‘4-month nonYfollow-up group.’’The 4-month follow-up group included the subjects who regularly vis-ited the outpatient clinic according to the scheduled appointments(at least bimonthly) for more than 4 months after discharge. The4-month nonYfollow-up group included the subjects who prematurelydiscontinued the scheduled outpatient treatment within 4 months afterdischarge.

Data on sociodemographic and disease-related variables werecollected from retrospective chart review. The sociodemographic var-iables investigated included age, sex, occupation, years of formal ed-ucation, marital status, and socioeconomic status. The disease-relatedvariables included family history of psychiatric diseases, durationof illness, age at onset, duration of index hospitalization, whetherthe patient received previous psychiatric outpatient treatment within3 months before index admission, type of admission (involuntaryversus voluntary admission), number of previous psychiatric hospi-talizations, psychotropic medication prescribed at discharge, andseverity of symptoms at admission.

ORIGINAL ARTICLE

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*Department of Psychiatry, Yeouido St. Mary’s Hospital, The Catholic Universityof Korea, Seoul, South Korea; and †Department of Psychiatry, Saint CarolloHospital, Sooncheon, South Korea.

Send reprint requests to Won-Myong Bahk, MD, PhD, Department of Psychiatry,Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University ofKorea, 62 Yeouido-Dong, Youngdeungpo-Gu, Seoul, 150-713, South Korea.E-mail: wmbahk@catholic.ac.kr.

Copyright * 2013 by Lippincott Williams & WilkinsISSN: 0022-3018/13/20106Y0519DOI: 10.1097/NMD.0b013e318294a238

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Data AnalysisWe compared the sociodemographic and disease-related variables

between the 4-month follow-up group and the 4-month nonYfollow-upgroup. Chi-square statistics for categorical variables and independentt-test for continuous variables were used to analyze for differencesin between groups. Logistic regression analysis was used to examinethe predictors of continuity of outpatient treatment. A p-value lowerthan 0.05 was considered statistically significant. All tests used weretwo tailed.

RESULTS

Comparison of Sociodemographic Variables Betweenthe 4-Month NonYfollow-up Group and the 4-MonthFollow-up Group

Data from a total of 204 patients were included. Among them,128 patients (62.7%) continuously received outpatient treatment formore than 4 months after discharge and 76 patients (37.3%) prema-turely discontinued their outpatient treatment. The 4-month follow-up

group was more likely to be older than the 4-month nonYfollow-upgroup (55.7 T 15.4 vs. 48.7 T 18.7, p = 0.006). The 4-month follow-up group was less likely to be employed than the 4-month nonYfollow-up group (26.6% vs. 43.4%, p = 0.013). For marital status, the 4-monthnonYfollow-up group was more likely to be single or divorced/sepa-rated than the 4-month follow-up group (single, 19.7% vs. 12.5%;divorced/separated, 13.2% vs. 4.7%; p = 0.006; Table 1).

Comparison of Disease-Related Variables Betweenthe 4-Month NonYfollow-up Group and the 4-MonthFollow-up Group

A higher percentage of the patients among the 4-month follow-upgroup were more likely to be diagnosed with MDD, recurrent (ratherthan single-episode MDD), than among the 4-month nonYfollow-upgroup (57.0% vs. 42.1%, p = 0.039). The 4-month follow-up groupwas more likely to have longer duration of illness (6.1 T 9.1 years vs.3.9 T 6.7 years, p = 0.048) and older at age at onset (49.6 T 16.1 yearsvs. 44.8 T 17.9 years, p = 0.049) than the 4-month nonYfollow-upgroup. The 4-month follow-up group showed longer duration of

TABLE 1. Comparison of Sociodemographic Variables Between the 4-Month NonYfollow-up Group and the 4-Month Follow-upGroup

4-Month NonYfollow-up Group 4-Month Follow-up Group

F or W2 p(n = 76) (n = 128)

Age, mean T SD 48.7 T 18.7 55.7 T 15.4 5.41 0.006Sex (male), % 27.60 28.90 0.04 0.845Occupation, % 43.40 26.60 6.15 0.013Education, mean T SD, yrs 10.8 T 3.8 10.8 T 4.4 3.93 0.989Family history, % 26.30 18.80 1.61 0.204Marital status, % 12.36 0.006

Single 19.70 12.50Married 61.80 64.10Divorced or separated 13.20 4.70Bereaved 5.3 18.80

Socioeconomic status, % 1.76 0.414High 8.00 14.10Middle 66.70 64.10Low 25.30 21.90

TABLE 2. Comparison of Disease-Related Variables Between the 4-Month NonYfollow-up Group and the 4-MonthFollow-up Group

4-Month NonYfollow-upGroup

4-Month Follow-upGroup

For W2 p(n = 76) (n = 128)

Diagnosis, % 4.25 0.039Single episode 57.90 43.00Recurrent 42.10 57.00

Duration of illness, mean T SD, yrs 3.9 T 6.7 6.1 T 9.1 8.33 0.048Age at onset, mean T SD, yrs 44.8 T 17.9 49.6 T 16.1 1.204 0.049Duration of index hospitalization, mean T SD, days 22.4 T 13.3 29.4 T 19.8 2.46 0.007Previous psychiatric outpatient treatment within 3 mos before admission, % 63.20 73.40 2.38 0.123Involuntary admission, % 25.00 35.90 2.63 0.105No. previous hospitalizations, mean T SD 3.9 T 6.7 6.1 T 9.1 5.81 0.217Symptoms severity at admission, % 0.05 0.819

Mild to moderate 7.90 7.00Severe 92.10 93.00

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hospitalization (29.4 T 19.8 days vs. 22.4 T 13.3 days, p = 0.006)than the 4-month nonYfollow-up group; Table 2).

Comparison of Psychotropic Medication Prescribedat Discharge Between the 4-Month NonYfollow-upGroup and the 4-Month Follow-up Group

Among the 204 patients, antidepressant or antipsychoticmonotherapy was prescribed for 81 patients (39.7%) and combinationtherapy was prescribed for 123 patients (60.3%). Among the 81 pa-tients prescribed with monotherapy, 5 patients (6.2%) were diagnosedwith MDD most recent episode mild or moderate; 69 patients (85.2%),with MDD most recent episode severe without psychotic features;and 7 patients (8.6%), with MDD most recent episode severe withpsychotic features. Among the 123 patients who were prescribed withcombination therapy, 9 patients (7.3%) were diagnosed with MDDmost recent episode mild or moderate, 97 patients (78.9%) were di-agnosed with MDD most recent episode severe without psychoticfeatures, and the remaining 17 patients (13.8%) were diagnosed withMDD most recent episode severe with psychotic features.

In the 4-month nonYfollow-up group, antidepressant mono-therapy was the most frequently prescribed regimen (52.0%), followedby combination of antidepressant and antipsychotic medication (26.7%).In the 4-month follow-up group, combination of antidepressant andantipsychotic medication was the most frequently prescribed regimen(44.5%), followed by antidepressant monotherapy (29.7%; Table 3).

The Effects of Sociodemographic andDisease-Related Variables on the Likelihood ofa Continuous 4-Month Follow-up

The logistic regression analysis showed that the continuity of4-month outpatient treatment after discharge was significantly pre-dicted by longer duration of index hospitalization (odds ratio, 1.02;p = 0.048), combination therapy (use of antidepressant in combina-tion with either a mood stabilizer or an antipsychotic agent; oddsratio, 2.16; p = 0.025) rather than antidepressant monotherapy(Table 4).

DISCUSSIONAmong the patients who were discharged from psychiatric

hospitalization with a diagnosis of MDD, 62.7% regularly followed upwith their outpatient treatment. A direct comparison of the variousrates of continuity of outpatient treatment cannot be made because noprevious study used the same definition of continuity of outpatienttreatment (defined as regularly visiting the outpatient clinic in accor-dance to their scheduled appointments, at least on a bimonthly basis,for more than 4 months after discharge) that we used in this study.

The results of this study indicated that the 4-month follow-upgroup were older and had older age at onset than the 4-monthnonYfollow-up group. This finding is similar to that of other studies.

Older age is consistently reported to be associated with or is a pre-dictor of good treatment adherence. Young et al. (2001) investigatedthe rate of appropriate treatment among American population withdepressive and anxiety disorders. The data in this study were basedon a cross-sectional telephone survey among 1636 adults with de-pressive or anxiety disorder. Appropriate treatment was defined asprescription of medication or receiving counseling consistent withpractice guidelines. They found that guideline-consistent care wasmore common among older-aged patients. Zivin et al. (2009), usingthe Veterans Affairs database, investigated the predictors of treatmentadherence after psychiatric hospitalization among veterans with de-pression. They examined 3- and 6- month medication adherence usingmedication possession ratios among veterans who were dischargedafter psychiatric hospitalization between 1999 and 2003. In this study,younger age was found to be significantly associated with poor treat-ment adherence at 3 and 6 months. Sawada et al. (2009) investigatedpatient persistence and compliance rate in 367 outpatients with majordepression who started to receive antidepressant treatment. They foundthat patients older than 60 years were associated with higher persis-tence rates at month 6. They interpreted this finding as being in linewith more favorable attitudes toward antidepressant treatment in olderpeople.

TABLE 3. Comparison of Psychotropic Medication Prescribed at Discharge Between the 4-Month NonYfollow-up Group and the4-Month Follow-up Group

4-Month NonYfollow-up Group 4-Month Follow-up Group

F or W2 p(n = 76) (n = 128)

AD monotherapy 52.0% 29.7%Combination therapy 46.7% 68.0%MS or AP monotherapy 1.3% 2.3%Total 100% 100% 10.02 0.007

Combination therapy included antidepressant + mood stabilizer, antidepressant + antipsychotic agent, antidepressant + mood stabilizer + antipsychotic agent, and antipsychoticagent + mood stabilizer.

AD indicates antidepressant; AP, antipsychotic agent; MS, mood stabilizer.

TABLE 4. Logistic Regression Analysis of the Effects ofSociodemographic and Disease-Related Variables on theLikelihood of 4-Month Follow-up

Odds Ratio p

Age 1463067454824.36 0.999Occupation 0.83 0.598Marital statusSingle 1Married 1.21 0.746Divorced or separated 0.47 0.311Bereaved 2.76 0.258

DiagnosisSingle episode 1Recurrent 1.46 0.323

Age at onset 0.00 0.999Duration of illness 0.00 0.999Duration of hospitalization 1.02 0.048Psychotropics prescribed at discharge, %AD monotherapy 1Combination therapy 2.16 0.025AP or MS monotherapy 2.01 0.579

AD indicates antidepressant; AP, antipsychotic agent; MS, mood stabilizer.

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For employment status, the rate of being unemployed is higheramong the 4-month follow-up group than the 4-month nonYfollow-up group. Bull et al. (2002) investigated the association betweenseveral demographic/clinical variables and the discontinuation of an-tidepressants for 3 months among patients with depression who startedwith selective serotonin reuptake inhibitor within 6 months beforestudy enrollment. In this study, the employment status was not sig-nificantly related to early antidepressant discontinuation (Bull et al.,2002). Lin et al. (1995) examined the predictors of antidepressantadherence among patients who were newly given antidepressants fordepression. This study also showed that employment status was not apredictor of early discontinuation of antidepressants. These previousstudy findings were not in line with our results. In our study, com-parison of sociodemographic and disease-related variables betweenthe unemployed group and the employed group showed that thosewho were employed at admission were younger, had shorter inpatientstay, and had shorter duration of illness (Table 5). On the basis ofthese findings, we thought that those who were younger and in theearlier phase of the illness were less likely to experience functionaldeterioration due to the illness, and, thus, they were more likely to beemployed. In addition, it is possible that the patients who wereemployed just before index hospitalization may have been terminatedearlier because of their better functional outcome or earlier symptomresolution, or it can be interpreted in another way. Those who wereemployed were more likely to discontinue outpatient treatment earlierbecause of their lack of time to visit outpatient clinic due to their work.

This study showed that those who were single or divorced/separated were less likely to continuously follow up with their outpa-tient treatment. This finding can be interpreted in the context of socialsupport, even though marital status does not directly reflect the socialsupport structure of each patient. The association between treatmentadherence and social support has been the key subject in many studies.Lee et al. (2010) evaluated variables predicting antidepressant medi-cation adherence among outpatients with depressive disorders in auniversity hospital in Korea. In this study, using the MultidimensionalScale of Perceived Social Support, they examined the relationshipbetween social support and antidepressant treatment adherence. Theyfound that a simple direct relationship was not apparent in stable pa-tients with depression. Lam and Rosenheck (1999) investigated therelationship between social support and psychiatric service use amonghomeless persons who had serious mental disorders. In this study,they found that those who had better social support were more likelyto avail of psychiatric services and that social support groups had

important roles in encouraging patients to do so (Lam and Rosenheck,1999). These findings are in line with other studies that showed apositive correlation between treatment adherence and social supportin other psychiatric or medical disorders (Connelly et al., 1982;Kreyenbuhl et al., 2009; Rubenstein et al., 2007; Smith et al., 1997).Putting these together, those who had lower level of social supportsuch as being single or divorced/separated showed a higher rate ofdiscontinuity of outpatient treatment, possibly because they lack thesocial support groups’ additional encouragement for them to regularlyvisit the outpatient clinic or help with the patients’ economic or emo-tional condition.

The relationship between length of inpatient stay and com-pliance with outpatient treatment after discharge is controversial.Axelrod and Wetzler (1989) examined treatment compliance among134 patients who were discharged from a New York City municipalhospital after psychiatric emergency hospitalization. They found thatthose who received psychiatric inpatient treatment for a longer periodwere more likely to have better compliance with psychiatric aftercarein the 6 months after discharge (Axelrod and Wetzler, 1989). Boyeret al. (2000) investigated the risk factors for not completing outpa-tient psychiatric care after inpatient treatment among 229 patientswith a primary psychiatric diagnosis who were discharged from twogeneral hospitals. They reported that patients with shorter inpatientstay were more likely to keep their scheduled appointments. Theyexplained that the longer duration of hospitalization might reflect thepresence of persistent mental disorders or might be due to difficultyin shifting the management of inpatients to outpatient programs. Inour study, the 4-month follow-up group had longer duration of indexhospitalization than the 4-month nonYfollow-up group. There is apossibility that, for those who stayed for a shorter period, incompleteand inadequate discharge plans were given because of lack of time,which resulted in lower compliance with outpatient treatment. Thisfinding can be interpreted in another way. The patients who hadshorter hospital stays may have responded better to treatment or havemore benign prognoses than those who stayed longer. This morebenign clinical course might result in the lower rate of continuousoutpatient follow-up.

The 4-month follow-up group was diagnosed more often withMDD, recurrent, rather than MDD, single episode, compared with the4-month nonYfollow-up group. In addition, the 4-month follow-upgroup showed longer illness duration than the 4-month nonYfollow-upgroup. These findings can be understood in view of history of previouspsychiatric treatment. Those who had previous major depressive episodes

TABLE 5. Comparison of Sociodemographic and Disease-Related Variables Between the Unemployed Group and theEmployed Group

Unemployed Group Employed Group

F or W2 p(n = 137) (n = 67)

Sex (male), % 19.0 47.8 18.32 G0.001Diagnosis, % 1.79 0.233

Single episode 45.3 55.2Recurrent 54.7 44.8

Medication at discharge, % 1.54 0.464AD monotherapy 35.0 43.9Combination therapy 62.8 54.5MS or AP monotherapy 2.2 1.5

Age, mean T SD, yrs 57.6 43.9 5.86 G0.001Duration of index hospitalization, mean T SD, days 28.6 23.1 2.07 0.040Education, mean T SD, yrs 9.9 12.6 j4.50 G0.001Duration of illness, mean T SD, yrs 6.1 3.6 2.41 0.017Age at onset, mean T SD, yrs 51.5 40.2 4.67 G0.001

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before the index episode or who had longer illness duration weremore likely to receive previous psychiatric treatment. Previousstudies that investigated the relationship between treatment compli-ance and history of previous psychiatric treatment showed that thosewho received previous psychiatric treatment were more compliantwith their current psychiatric treatment than those who did not. Boyeret al. (2000) investigated the risk factors of unsuccessful linkage withoutpatient psychiatric care after discharge from psychiatric inpatienttreatment. In this study, approximately two thirds of the 229 studyparticipants did not show up at the scheduled outpatient programswithin 4 weeks from discharge. The psychiatric inpatients who hadprevious psychiatric hospitalization showed a higher rate of keepingtheir outpatient appointments. Stein et al. (2007) investigated therelationship between various variables and timely aftercare afterdischarge from psychiatric hospitalization among 6730 Medicaid-enrolled adults. They examined the rate of timely aftercare follow-up within 7 days and 30 days after discharge. They found thatthose who had previous psychiatric clinical treatment, especially inthe month before the index hospitalization, were more likely to re-ceive timely psychiatric aftercare after discharge. Individuals whowere receiving clinical treatment before the psychiatric hospitaliza-tion were three to four times more likely to receive timely aftercarethan those who were not. In addition, the difference was found to beconsiderably greater for the other sociodemographic or disease-related factors examined in this study (Stein et al., 2007). The pa-tients who had longer duration of illness or previous depressiveepisodes were more likely to have received psychiatric treatmentbefore the index episode, and these previous experiences may resultin better compliance in this population.

The two most commonly used treatment regimens at dischargewere antidepressant monotherapy and combination of antipsychoticsand antidepressants. The regression analysis showed that combina-tion therapy (including combination of antipsychotic agent and an-tidepressant; combination of antipsychotic agent and mood stabilizer;combination of mood stabilizer and antidepressant; and combinationof antipsychotic agent, mood stabilizer, and antidepressant) was as-sociated with a higher rate of continuous follow-up at month 4 (oddsratio, 2.16, in comparison with antidepressant or antipsychotic agentmonotherapy). This finding can be interpreted in view of diseaseseverity. One reason why those who took combination therapy hadbetter treatment compliance might be that this population had moresevere depressive symptoms and thus were more likely to continuouslyfollow up with outpatient treatments because their symptoms didnot improve. In a previous study (by Wu et al., 2011), patients withdepression with comorbid anxiety disorder were found to be moreadherent to their outpatient treatment because of their unresolvedsymptoms than patients without anxiety.

This study was done to investigate the predictors of continuityof outpatient treatment as defined by the patients’ degree of compli-ance with their scheduled outpatient follow-up visits. This study hasseveral limitations. First, because this study was done by retrospec-tive chart review, the subjects’ clinical information used for analysiswas limited by what was available in the electronic medical charts.Second, generalizing our result to the whole population with MDDmay not be appropriate because our study population involved pa-tients with depression who had psychiatric hospitalization at auniversity hospital. Third, certain clinical information that havebeen associated with treatment compliance in previous studiessuch as the character of the doctor-patient relationship, symptomsseverity measured by validated scales, the presence and type ofmedication-induced side effects, and insight level of each patientwere not considered in this study because of the retrospectivechart review method used. We hope that future research will pro-spectively and systematically evaluate the relationship betweencontinuity of outpatient treatment after discharge and the various

characteristics of the patient with depression and find out the riskfactors of poor treatment compliance.

CONCLUSIONSThis study investigated the predictors of continuity of outpa-

tient treatment after psychiatric hospitalization among patients withMDD. A total of 62.7% of the study population continuouslyfollowed up with their outpatient treatment for more than 4 months.In this study, duration of index hospitalization and combinationtherapy were found to be significantly associated with continuity ofoutpatient treatment. MDD is a recurrent and chronic disease, andthus, maintenance pharmacotherapy is very important to prevent re-currences. Screening for patients with high likelihood of poor com-pliance with continuity of outpatient care during the hospitalizationperiod, making appropriate discharge plans, and making efforts inproper linkage of inpatient and outpatient programs will be veryimportant in clinical practice. In addition, we hope that prospectivestudies to investigate the risk factors or predictors of poor treatmentcompliance among patients recently discharged from psychiatrichospitalization will be done.

DISCLOSURESThe authors declare no conflict of interest.

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