Depression Treatment in Older Adult Veterans

Depression Treatment in Older AdultVeterans

Inger Burnett-Zeigler, Ph.D., Kara Zivin, Ph.D., Mark Ilgen, Ph.D.,Benjamin Szymanski, M.A., Frederic C. Blow, Ph.D., Helen C. Kales, M.D.

Objectives: Older adults in the VA Healthcare System may have an increased risk fordepression than those in the general population. These factors may also be associatedwith the likelihood of receiving depression treatment. This study examined the as-sociations between sociodemographic characteristics, psychiatric comorbidities, andmedical comorbidities and the receipt of depression treatment among depressed olderadults in the VA. Design: Secondary analysis of data obtained from the VA’s NationalRegistry for Depression, a linkage of several administrative data sources with detailedservices and pharmacy data for all VA patients diagnosed with depression. Setting:VA healthcare system. Participants: The sample included 147,631 VA patients whowere at least 50 years old and received a new diagnosis of depression in FY08.Measurements: The associations between the depression treatment conditions (an-tidepressants, psychotherapy, both, and none) as outcome variables and sociode-mographic characteristics, psychiatric comorbidities, and medical comorbidities asindependent variables were assessed using χ2 tests and multinomial logistic regres-sion analysis. Results: Approximately one-third (35.9%) of the depressed older adultsdid not receive any treatment. The odds receiving depression treatment decreasedwith increasing age. Those who were white, female and married were more likelyto receive antidepressants, while those who were male of minority race/ethnicity,and unmarried were more likely to receive psychotherapy. Medical comorbiditiesand psychiatric comorbidities were also associated with the type of depression treat-ment received. Conclusions: Many depressed older adults may have limited or notreatment. Future outreach and intervention efforts should be targeted toward thisvulnerable population. (Am J Geriatr Psychiatry 2012; 20:228–238)

Key Words: Antidepressants, older adult Veterans, psychotherapy

OBJECTIVE

D epression is associated with poor functioningand quality of life. The 12-month prevalence

Received March 13, 2010; revised June 7, 2010; accepted July 9, 2010. From the VA Ann Arbor Healthcare System, VA Serious Mental IllnessTreatment Research and Evaluation Center (SMITREC)/Health Services Research and Development (HSR&D), Ann Arbor, MI; and Department ofPsychiatry, University of Michigan Medical School, Ann Arbor. Send correspondence and reprint requests to Inger Burnett-Zeigler, Ph.D., 2215Fuller Road (11H), Ann Arbor, MI 48105. e-mail: [email protected]

c© 2012 American Association for Geriatric PsychiatryDOI: 10.1097/JGP.0b013e3181ff6655

rate of major depressive disorder in the United Statesis approximately 7%;1 rates of diagnosed depres-sion are almost twice as high (12%) in individu-als treated by the VA Healthcare System.2 However,

Copyright © American Association for Geriatric Psychiatry. Unauthorized reproduction of thisarticle is prohibited.

228 Am J Geriatr Psychiatry 20:3, March 2012

Burnett-Zeigler et al.

many of those with a depression diagnosis do notreceive treatment. Past research has found that onlyabout half (56%) of those with major depressive dis-order used any mental health services in the past12 months, and of those who did, only 38% re-ceived minimally adequate care.3 Rates of depressiontreatment appear to be somewhat higher within theVA. A study of a nationally representative sampleof Veterans found that about 75% of depressed Vet-erans received some type of treatment (psychother-apy, antidepressants, or both); 40% received low-level care (any psychotherapy or antidepressants)and 35% received guideline concordant care (antide-pressants for at least 84 of the 114 days after the in-dex depression diagnoses and/or 12 or more outpa-tient psychotherapy visits during the 114 days afterthe index depression diagnosis).4 Several sociodemo-graphic factors were associated with a lower like-lihood of Veterans receiving treatment of depres-sion including being male, unmarried, and AfricanAmerican.4 This study also found that treatment ofdepression was significantly less common in olderVeterans.

Research has demonstrated that depression inolder adults is related to increased impairment in rolefunctioning, poorer quality of life, mortality due tophysical illness, and suicide.5–8 Depression is rela-tively common (6.6%) in older adults residing in thecommunity,9 and even more prevalent in clinical set-tings in association with medical comorbidity.10 No-tably, older adults seen in the VA system may havehigher rates of medical problems than their nonvet-eran counterparts.11 Given that less education andlower income have been found to be associated withincreased rates of depression,9 older Veterans may beat higher risk for depression than those in the generalpopulation.

The majority of depressed older adults do not re-ceive treatment of depression.4 When they do re-ceive treatment, depressed older adults are morelikely to receive antidepressants rather than psy-chotherapy or counseling; although the antidepres-sant and psychotherapy treatments they receive areoften inadequate.4,12 A study of community-dwellingolder adults found that only 25% of the depres-sion episodes had any use of psychotherapy andonly 33% of those psychotherapy treatment episodeswere consistent with guideline recommendations.13

Those who were the oldest (>75), less educated, low-

income, unmarried, and living in a rural area wereleast likely to receive psychotherapy.13

The VA is the nation’s largest integrated health-care system and serves a large aging veteran pop-ulation. Older adults in the VA represent a groupwith unique characteristics such as a history of dif-ficult life experiences, multiple psychosocial stres-sors, and comorbid medical and psychiatric condi-tions that may make them especially vulnerable tobecoming depressed and influence the likelihood ofthem receiving depression treatment. Although sev-eral factors are associated with the receipt of depres-sion treatment among depressed older adults in thegeneral community, it is not known whether thesesame factors apply to those already receiving carein the VA. To our knowledge, there have been nostudies that examine the receipt of antidepressantsand psychotherapy as depression treatments in theolder adult VA population. This information wouldinform future interventions designed to decrease de-pressive symptoms, and the secondary outcomes re-lated to depression, in depressed older adults in theVA. This study examined the likelihood that olderadults who were newly diagnosed with depressionreceived antidepressants, psychotherapy, or both astreatments of depression in a 12-month period. Weexamined factors that are likely associated with thereceipt of depression treatment including sociode-mographic characteristics, psychiatric comorbidities,and medical comorbidities. We also examined wheredepressed older adults received their index depres-sion diagnosis and the clinic providing their follow-up treatment.

METHODS

Data Source

Data on patient demographic characteristics, men-tal health diagnoses, inpatient and outpatient ser-vices, and antidepressant medications were obtainedfrom the VA’s National Registry for Depression(NARDEP), maintained by the Serious Mental Ill-ness Treatment, Research, and Evaluation Center(SMITREC) in Ann Arbor, Michigan.2 NARDEP isa linkage of several VA administrative data sourceswith detailed services and pharmacy data for all VApatients diagnosed with depression.


Am J Geriatr Psychiatry 20:3, March 2012 229

Depression Treatment in Older Adult Veterans

Participants

We identified depressed patients, using the follow-ing International Classification of Diseases, Ninth Edition(ICD-9) codes: 296.2x, 296.3x, 298.0, 300.4, 309.1, and311; diagnoses included both those consistent withmajor and minor depression to be inclusive. We se-lected patients with a depression diagnosis in FY08and used their first diagnosis of depression duringthis year as the index diagnosis (N = 769,585). Pa-tients who died during the 365-day period after theindex diagnosis date (N = 9,791) were excluded, aswere patients with a depression diagnosis during thedormant period 365 days before the index diagnosisdate (N = 427,523), and patients with antidepressantfills during dormant period 365 days before the in-dex diagnosis date (N = 91,219). Disqualifying diag-noses of depression during the dormant period in-cluded occurrence of one or more of the followingICD-9 codes in any setting: 311, 296.0, 296.1, 296.2,296.3, 296.4, 296.5, 296.6, 296.7, 296.8, 296.9, 298.0,300.4, 309.0, 309.1, or 309.28. In addition, patients whowere not at least 50 years of age at the index diagnosiswere excluded (93,421). Following these exclusions,the analysis included 147,631 individuals.

Measures

Our analyses focused on the rates and predictorsof depression treatment in the 12-month period fol-lowing the index diagnosis of depression. Receipt ofdepression treatment was coded into four categories(no psychotherapy or antidepressant, psychotherapyonly, antidepressant only, or psychotherapy and an-tidepressant). Any psychotherapy included individ-ual, group, or family psychotherapy provided byboth physicians and nonphysicians, identified us-ing Current Procedural Technology codes (90804–90815,90845, 90847, 90853, and 90857). Antidepressant usewas defined as the receipt of at least one qualifyingantidepressant (phenelzine, tranylcypromine, bupro-pion, citalopram, fluoxetine, paroxetine, sertraline,venlafaxine, escitalopram, fluvoxamine, and isocar-boxazid) in the 12-month period following the in-dex diagnosis of depression. Tricyclic antidepressantsand other cyclic antidepressants were not includedbecause they are frequently used to treat conditionsother than depression, and VA field validation ef-forts revealed that such medications resulted in unac-

ceptably high rates of “false positive” results for de-pression care (VA Office of Quality and Performance,2007). Measures of sociodemographic characteristicsincluded age (50–64, 65–79, 80+ years), race (black,white, other, unknown), ethnicity (Hispanic, non-Hispanic), and marital status (married, not married[separated/divorced/widowed], and unknown).

Comorbid general medical conditions were as-sessed using a modified version of the CharlsonComorbidity Index, based on the presence of 17 med-ical conditions in the 12-month period prior to theindex diagnosis. We used five categories of Charlsonscores: 0, 1, 2, 3, and 4 or greater.14,15

We also assessed those who had at least 90 inpa-tient days during the follow-up year as a possible pre-dictor of depression treatment.

Psychiatric comorbidities were identified by ICD-9-CM diagnoses codes and included past 12-monthdiagnoses of the following disorders: psychotic disor-ders (schizophrenic disorders, delusional disorders,other nonorganic psychoses), posttraumatic stressdisorder (PTSD), other anxiety disorders (generalizedanxiety disorder, panic disorder, phobias, obsessive–compulsive disorder, acute reactions to stress, andanxiety disorder not otherwise specified), dementias,drug, and alcohol use disorders.

Analyses

We used SAS version 9.2 for all statisticalanalyses.16 Simple descriptive summary statisticswere used to describe the characteristics of the to-tal sample. The associations between the location ofthe index diagnosis as an outcome variable and med-ical and psychiatric comorbidity as independent vari-ables were analyzed using χ2 tests. The associationsbetween the location of follow-up care as an out-come variable and medical and psychiatric comor-bidity as independent variables were also analyzedusing χ2 tests. The associations between the depres-sion treatment conditions (none, psychotherapy, an-tidepressant, or both psychotherapy and antidepres-sant) as an outcome variable and sociodemographiccharacteristics, psychiatric comorbidities, and medi-cal comorbidities as independent variables were firstanalyzed using χ2 tests. Multinomial logistic regres-sions were then used to calculate unadjusted and ad-justed odds ratios with 95% confidence intervals for




the depression treatment conditions for each of theindependent variables.

RESULTS

Subjects

The sample for this study included 147,631 VA pa-tients who were at least 50 years old and received anew diagnosis of depression in FY08. The majority ofthe study participants were 50–64 years old (65.5%),male (94.6%), white (68.3%), non-Hispanic (95.7%),and married (52.1%). Very few (0.2%) patients had90 or more inpatient days during the follow-up year.Slightly less than half (43.2%) had one or more med-ical comorbidities and the majority did not have co-morbid psychiatric conditions (69%). Additional de-scriptive information about the sample is provided inTable 1.

Receipt of Depression Treatment

The majority of depressed older adults receivedtheir index diagnosis of depression in primary care(57%), followed by specialty mental health (28%),and other outpatient clinics (11%). About equal num-bers of depressed older adults received follow-upcare associated with their index diagnosis of depres-sion in specialty mental health (47%) and primarycare (44%). In unadjusted analyses, those who hadat least 90 inpatient days during the follow-up yearwere more likely to receive their follow-up care in pri-mary care than specialty mental healthcare settings.Alternatively, those with comorbid psychiatric condi-tions were more likely to receive their follow-up carein specialty mental healthcare settings than primarycare. Tables 2 and 3 provide additional informationon the associations between medical and psychiatriccomorbidities on location of index diagnosis and lo-cation of follow-up care.

Receipt of Depression Treatment

More than one-third (35.9%) of the older adultswith a new diagnosis of depression in the sampledid not receive any treatment. Of those who did re-ceive treatment, most individuals received both an-tidepressants and psychotherapy (26.9%), followed

by 21.1% who received antidepressants only, and16.2% who received psychotherapy only.

When examining the associations between the re-ceipt of depression treatment and each of the inde-pendent variables in the unadjusted multinomial re-gression models, those who were aged 50–64 yearswere more likely to receive antidepressants, psy-chotherapy, and both than those in the older agegroups. Those who were female, white, Hispanic,and married, with no psychiatric comorbidities wereat increased odds of receiving antidepressants onlycompared to no treatment. However, those whowere male, of minority race/ethnicity, never mar-ried or not married, and had any of the comor-bid psychiatric conditions (except dementia) were atincreased odds of receiving psychotherapy only com-pared to no treatment. Dementia was not a sig-nificant predictor of psychotherapy receipt in theunadjusted regression model. Those who receivedboth antidepressants and psychotherapy had sim-ilar characteristics as those receiving psychother-apy only; however, those with no medical comor-bidity had increased odds of receiving combinedtherapy, and those with dementia had decreasedodds of receiving combined therapy compared tono treatment. Additional results from the unad-justed multinomial regression models are provided inTable 4.

Table 5 presents the results from the adjustedmultinomial regression models. Given the large sam-ple size, most of the independent variables werefound to be significantly associated with the depres-sion treatment outcomes. Although there are no ex-isting guidelines for what constitutes clinically sig-nificant change in depression treatment outcomes,most of our results showed an increase or decreaseof 20% or more in odds of receiving treatment, whichwe consider clinically significant. When examiningthe associations between the receipt of depressiontreatment and each of the independent variables inthese models, the odds of receiving any of the treat-ments decreased with increasing age. Compared withindividuals aged 50–64 years, those who were 65–79 years of age were 0.81 times less likely to re-ceive antidepressants only, 0.53 times less likely to re-ceive psychotherapy only, and 0.37 times less likelyto receive both antidepressants and psychotherapy ascompared to no treatment. Compared with individu-als aged 50–64 years, those who were 80+ were 0.75




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TABLE 3. Location of Follow-Up Care

Other Overall PC versus SMHNo Follow-Up SMH PC Outpatient (Pearson χ2) (Pearson χ2)

N % N % N % N % χ2 df p value χ2 df p value

Overall 4,200 3 68,996 47 65,137 44 9,298 6Charlson in prior year 3,296 12 <0.001 95 4 <0.001

0 1,338 2 39,725 47 38,752 46 4,045 51 929 3 14,111 47 13,017 43 1,902 62 627 4 6,422 45 5,967 42 1,236 93 468 5 4,202 45 3,838 41 817 94+ 838 8 4,536 44 3,563 35 1,298 13

At least 90 inpatient daysduring follow-up year

397 14 227 8 1,756 61 514 18 2,846 3 <0.001 1,110 1 <0.001

Diagnoses in the prior yearPsychotic disorders 407 11 2,107 57 677 18 534 14 1,931 3 <0.001 669 1 <0.001Posttraumatic stress

disorder359 3 9,248 71 2,873 22 602 5 3,426 3 <0.001 3,296 1 <0.001

Other anxiety 325 3 5,806 62 2749 29 528 6 1,009 3 <0.001 987 1 <0.001Drug use (excluding

tobacco)752 7 6,845 65 2,182 21 806 8 2,971 3 <0.001 2,305 1 <0.001

Alcohol use 703 9 5,071 64 1,608 20 556 7 2,683 3 <0.001 1,687 1 <0.001Cognitive impairment 91 10 352 38 235 26 239 26 820 3 <0.001 17 1 <0.001

times less likely to receive antidepressants only, 0.45times less likely to receive psychotherapy only, and0.24 times less likely to receive both antidepressantsand psychotherapy compared to no treatment. Thosewho were female, white, Hispanic, and married, withno psychiatric comorbidities were more likely to re-ceive antidepressants only compared to no treatment.In particular, the presence of comorbid psychotic dis-orders and PTSD resulted in large decreases in theodds of receiving antidepressants only compared tono treatment; those with psychotic disorders were0.60 times less likely to receive antidepressants onlyand those with PTSD were 0.69 times less likely toreceive antidepressants only. In addition, those withdementia were 0.81 times less likely to receive antide-pressants only compared to no treatment.

The results for psychotherapy were consistent withthose in the unadjusted multinomial regression mod-els. The presence of all of the comorbid psychiatricconditions resulted in large increases in the oddsof receiving psychotherapy only compared to notreatment. Those with PTSD were 3.99 times morelikely to receive psychotherapy only, those with psy-chotic disorders were 2.92 times more likely to re-ceive psychotherapy only, and those with other anxi-ety disorders were 2.14 times more likely to receivepsychotherapy only than those who did not havethese disorders. Those with dementia were also more

likely to receive psychotherapy only compared to notreatment.

The results for combined antidepressant and psy-chotherapy were also similar to those in the un-adjusted multinomial regression models; however,those who were married were most likely to receiveboth antidepressants and psychotherapy. Again, thepresence of most comorbid psychiatric conditionsresulted in large increases in the odds of receiv-ing combined antidepressants and psychotherapy.Specifically, those with PTSD were 2.24 times morelikely to receive both antidepressants and psy-chotherapy and those with other anxiety disorderswere 1.66 times more likely to receive both an-tidepressants and psychotherapy compared to notreatment.

CONCLUSIONS

To date, this is the largest study of depression treat-ment service use to be conducted using a nationallyrepresentative sample of depressed older adults inthe VA. We found that 64% of Veterans with a newdiagnosis of depression received some form of treat-ment within 12 months. Of those who did receivetreatment, most received both antidepressants andpsychotherapy (26.9%). The odds of receiving any




TABLE 4. Unadjusted Odds Ratios

Meds Only PT only Meds and PT

OR LCL UCL OR LCL UCL OR LCL UCL

Age, y50–64 REF REF REF65–79 0.85 0.82 0.88 b 0.44 0.42 0.46 b 0.34 0.33 0.35 b

80+ 0.79 0.76 0.82 b 0.37 0.35 0.39 b 0.22 0.21 0.23 b

GenderFemale 1.12 1.05 1.19 b 0.94 0.88 1.01 0.97 0.92 1.03Male REF REF REF

RaceWhite REF REF REFAfrican American 0.87 0.83 0.91 b 1.85 1.78 1.93 b 1.47 1.42 1.53 b

Other race 0.80 0.72 0.89 b 1.50 1.36 1.65 b 1.25 1.15 1.36 b

Unknown 0.90 0.87 0.94 b 0.76 0.72 0.80 b 0.78 0.75 0.81 b

EthnicityHispanic 1.19 1.10 1.28 b 1.43 1.33 1.54 b 1.53 1.44 1.63 b

Not Hispanic REF REF REFMarital status

Married REF REF REFNot married 0.95 0.92 0.98 b 1.31 1.27 1.36 b 1.13 1.10 1.16 b

Never married 0.78 0.75 0.82 b 1.71 1.63 1.79 b 1.28 1.23 1.34 b

Unknown marital status 0.45 0.37 0.56 b 0.80 0.65 0.98 a 0.54 0.45 0.65 b

Charlson in prior year0 REF REF REF1 0.98 0.94 1.01 1.12 1.08 1.16 b 0.91 0.88 0.94 b

2 0.96 0.91 1.00 1.04 0.98 1.09 0.83 0.79 0.87 b

3 0.95 0.90 1.01 1.02 0.96 1.09 0.80 0.76 0.85 b

4+ 0.96 0.91 1.01 1.04 0.98 1.10 0.74 0.70 0.78 b

At least 90 inpatient days duringfollow-up year

0.62 0.54 0.71 b 2.23 2.01 2.47 b 2.19 1.99 2.40 b

Diagnoses in the prior yearPsychotic disorders 0.55 0.48 0.62 b 3.76 3.47 4.08 b 1.09 1.00 1.20Posttraumatic stress disorder 0.72 0.67 0.77 b 4.87 4.63 5.13 b 2.77 2.63 2.91 b

Other anxiety 0.94 0.88 1.01 2.33 2.20 2.47 b 1.63 1.54 1.72 b

Drug use (excluding tobacco) 0.85 0.79 0.91 b 3.49 3.31 3.69 b 2.24 2.12 2.36 b

Alcohol use 0.90 0.83 0.98 a 3.31 3.10 3.52 b 2.25 2.12 2.39 b

Dementia 0.68 0.57 0.81 b 0.99 0.83 1.18 0.46 0.39 0.56 b

Notes: LCL: lower confidence limit; OR: odds ratio; UCL: upper confidence limit. p values are based on Wald χ2 test on 1 df. b = p < .001.a p < 0.05.bp < 0.001.

kind of treatment (antidepressants only, psychother-apy only, and both antidepressants and psychother-apy) decreased notably with the increasing age. Olderadults who were female, white, Hispanic, and mar-ried had increased odds of receiving medication onlycompared to no treatment, while those who weremale, of minority race/ethnicity, and unmarried wereat increased odds of receiving psychotherapy onlycompared to no treatment. The sociodemographiccharacteristics of those who received combinedtreatment were similar to that of those who receivedpsychotherapy only.

These results indicate that a significant number ofdepressed older adults in the VA are not receivingdepression treatment, which is consistent with a re-cent report that found that depressed older adults inthe VA were less likely to receive consistent outpa-tient monitoring during periods that are the highestrisk for suicide (following new antidepressant startsand inpatient stays).17 This study also found that fol-lowing a new antidepressant start, only 24% of pa-tients met the suggested NCQA recommendationsfor three or more visits during the 84-day period.17

The finding that patients of minority racial/ethnic




TABLE 5. Adjusted Odds Ratios

Meds Only PT Only Meds and PT

OR LCL UCL OR LCL UCL OR LCL UCL

Age, y50–64 REF REF REF65–79 0.81 0.78 0.84 b 0.53 0.51 0.56 b 0.37 0.36 0.38 b

80+ 0.75 0.72 0.78 b 0.45 0.43 0.48 b 0.24 0.23 0.25 b

GenderFemale 1.08 1.02 1.15 a 0.95 0.88 1.02 0.86 0.81 0.92 b

Male REF REF REFRace

White REF REF REFAfrican American 0.88 0.84 0.92 b 1.37 1.31 1.43 b 1.17 1.13 1.22 b

Other race 0.79 0.71 0.88 b 1.26 1.14 1.39 b 1.08 0.99 1.18Unknown 0.90 0.87 0.94 b 0.86 0.82 0.90 b 0.83 0.80 0.87 b

EthnicityHispanic 1.15 1.07 1.24 b 1.40 1.29 1.51 b 1.47 1.37 1.57 b

Not Hispanic REF REF REFMarital status

Married REF REF REFNot married 0.94 0.91 0.97 b 1.14 1.10 1.18 b 0.99 0.96 1.02Never married 0.76 0.73 0.80 b 1.20 1.15 1.26 b 0.93 0.89 0.97 b

Unknown marital status 0.45 0.37 0.56 b 0.87 0.71 1.08 0.53 0.44 0.64 b

Charlson in prior year0 REF REF REF1 1.01 0.97 1.05 1.02 0.97 1.06 0.92 0.89 0.95 b

2 1.02 0.97 1.07 1.03 0.97 1.09 0.95 0.91 1.00 a

3 1.01 0.95 1.07 1.03 0.97 1.11 0.93 0.87 0.98 a

4+ 1.05 0.99 1.11 0.97 0.91 1.03 0.84 0.79 0.89 b

At least 90 inpatient days duringfollow-up year

0.69 0.60 0.80 b 1.60 1.43 1.78 b 2.08 1.89 2.30 b

Diagnoses in the prior yearPsychotic disorders 0.60 0.53 0.68 b 2.92 2.68 3.18 b 1.00 0.91 1.10Posttraumatic stress disorder 0.69 0.64 0.74 b 3.99 3.78 4.21 b 2.24 2.13 2.36 b

Other anxiety 0.96 0.90 1.03 2.14 2.02 2.28 b 1.66 1.56 1.75 b

Drug use (excluding tobacco) 0.88 0.81 0.95 b 1.76 1.65 1.88 b 1.34 1.27 1.43 b

Alcohol use 0.97 0.89 1.05 1.65 1.53 1.77 b 1.39 1.30 1.49 b

Cognitive impairment 0.81 0.67 0.97 a 1.24 1.03 1.50 a 0.95 0.78 1.15

Notes: LCL: lower confidence limit; OR: odds ratio; UCL: upper confidence limit. p values are based on Wald χ2 test on 1 df. b = p < .001.a p < 0.05.bp < 0.001.

groups are less likely to use antidepressants thanwhites is also consistent with past studies that havereported similar results in community populationsgenerally, and older adult community populationsspecifically.18–20 This may be an indication that mi-norities prefer psychotherapy over antidepressants astreatment of depression;21 however since we do nothave information on the refusal depression of treat-ments, this is speculative. Although the mechanismby which sociodemographic characteristics operate tomake some individuals more likely to receive one de-pression treatment and other individuals more likely

to receive another depression treatment is unknown,understanding these patterns of service use is usefulin targeting outreach efforts toward populations thathave historically been underserved.

The results of our study indicate that depressedolder adults with psychiatric comorbidities are morelikely to receive psychotherapy only or both antide-pressants and psychotherapy, and less likely to re-ceive antidepressants only as compared to no treat-ment. We found that although more depressed olderadults are diagnosed in primary care than spe-cialty mental health (57% versus 28%), those with




comorbid psychiatric conditions are more likely toreceive their care in specialty mental health thanprimary care. The differences in the settings pro-viding care, in addition to the specialized needsof those with comorbid psychiatric conditions, mayhave some influence on the treatments that are be-ing provided. Depressed older adults with no med-ical comorbidity were more likely to receive bothantidepressants and psychotherapy compared to notreatment. Although medical comorbidity was signif-icantly associated with the location of index diagno-sis in the unadjusted analysis, it was not significantlyassociated with the location of follow-up care. Moreresearch is needed to better understand how medicalcomorbidity influences the provision of mental healthservices.

Our study found rates of depression treatmentamong older adults in the VA that were lower thanthe rates of depression treatment among the gen-eral population in the VA, but higher than the ratesof depression treatment among older adults in thegeneral community.4,13,22 Several studies have linkeduntreated depression with poorer physical function-ing, mortality due to physical illness, and poorerquality of life.5,8 This study highlights the impor-tance of continued outreach and intervention ef-forts for depressed older adult Veterans who arevulnerable to being undertreated. Many of the inter-ventions that have been designed to treat depressionin older adults in the general community are based inprimary care. In 2007, recognizing that primary careappeared to be the optimal location to target effortsto improve access to depression treatment for manyVeterans (including older adults), the VA adopted aninitiative to integrate mental health into primary careto improve access and quality of care using co-locatedcollaborative care and care management integratedcare models.23 Over time, it will be important to ex-amine whether these changes in the structure of de-livery of mental healthcare improve the rates of de-pression treatment utilization in older adults.

Several limitations of the study should be consid-ered. This study relied primarily on administrative

data to identify depressed patients. As a result,depressed older adults without a diagnosis ofdepression in their medical record were not in-cluded in the study. In this case, our estimates ofdepressed older adults not receiving depressiontreatment would be conservative. In addition, itis possible that some individuals received treat-ment for their depression outside the VA. Theremay have also been some Veterans included in thesample for which antidepressant treatment wascontraindicated. In both cases, our estimates ofthose in need of depression treatment who did notreceive it would be somewhat inflated. Finally, thedesign of the study allowed for examination ofthe associations between sociodemographic char-acteristics, psychiatric comorbidities, and medicalcomorbidities and depression treatment. Otherpotentially important factors (e.g., availabilityof transportation to appointments and patients’attitudes and beliefs about depression anddepression treatment) were not available in thedata and, consequently, not included in the analyses.

Despite these limitations, our data suggest that in-creasing age is associated with a decreased likeli-hood of receiving depression treatment and contin-ued efforts are needed to ensure that older adults inneed of depression treatment are able to receive care.Efforts to improve utilization of depression treat-ment for older depressed Veterans should ensure thatboth psychotherapy and antidepressant treatment areavailable and accessible. Improving the treatmentof depression in older Veterans has the potential tolessen the burden of depression on the functioningand quality of life of depressed Veterans and theirfamilies.

This work was supported by the Department of Veter-ans Affairs, Office of Academic Affiliations, Advanced Fel-lowship Program in Mental Illness Research and Treat-ment; VA Health Services Research and Development(HSR&D) Service (CD2 07-206-1, KZ; IAC 08–099,MAI) and the National Institute on Drug Abuse (NIDA)(1R21DA026925, MAI).

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Depression Treatment in Older Adult Veterans