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