This research was funded by NIMH (K01-MH63780)
Depression in the U.S.
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
Disparities in Treatment
• Studies have shown that some populations
especially vulnerable to under- rt eatment
– 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
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
• 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
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
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
- digit ICD
3
- 9code by coders
• All individuals with ICD
- 9codes of 296 or 311
were included in the analysis
– N = 1,347
1
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)
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)
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
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”
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
Any Antidepressant or
Psychotherapy/Counseling
Caucasian
African
- American
Hispanic
Other
Under 18
18 to 34
35 to 64
65+
OR
0.44
0.46
0.35
0.90
0.49
1.23
-P value
<.001
<.001
.051
.761
<.001
.522
95% CI
0.29
- 0.67
0.30
- 0.69
0.12
- 1.00
0.44
- 1.81
0.33
- 0.72
0.65
- 2.35
2
Any Antidepressant or
Psychotherapy/Counseling
OR
Private Insurance
Medicaid
Medicare
Medicaid+Medicare
Uninsured
0.98
1.27
1.82
0.57
-P value
.936
.479
.145
.032
95% CI
0.52
- 1.82
0.65
- 2.50
0.81
- 4.11
0.34
- 0.95
Adequate Depression Care
If Some Treatment Received
Private Insurance
Medicaid
Medicare
Medicaid+Medicare
Uninsured
Psychotherapy Tx
Antidepressant Tx
Combination Tx
OR -P value
1.21
.592
1.13
.687
2.34
.018
0.99
.957
0.98
.952
2.87
.002
95% CI
0.61
- 2.40
0.62
- 2.07
1.16
- 4.74
0.57
- 1.71
0.54
- 1.79
1.49
- 5.51
Adequate Depression Care
If Some Treatment Received
Caucasian
African
- American
Hispanic
Other
Under 18
18 to 34
35 to 64
65+
OR
1.26
0.67
0.72
0.82
0.56
0.72
-P value
.474
.099
.508
.580
.022
.217
95% CI
0.67
- 2.35
0.42
- 1.08
0.27
- 1.93
0.41
- 1.66
0.34
- 0.92
0.43
- 1.21
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
3
Any Antidepressant
Caucasian
African
- American
Hispanic
Other
Under 18
18 to 34
35 to 64
65+
OR
0.47
0.47
0.39
0.76
0.40
1.35
-P value
.001
.001
.082
.371
<.001
.340
95% CI
0.30
- 0.73
0.31
- 0.73
0.14
- 1.13
0.41
- 1.40
0.27
- 0.58
0.73
- 2.49
Adequate Antidepressant Care If
Filled At Least 1 Antidepressant Rx
Caucasian
African
- American
Hispanic
Other
Under 18
18 to 34
35 to 64
65+
OR
0.74
0.90
0.73
0.69
0.50
0.68
-P value
.472
.680
.519
.308
.016
.155
95% CI
0.33
- 1.67
0.54
- 1.50
0.28
- 1.89
0.34
- 1.41
0.29
- 0.88
0.40
- 1.16
Any Psychotherapy/Counseling
Caucasian
African
- American
Hispanic
Other
Under 18
18 to 34
35 to 64
65+
OR
0.70
1.12
0.64
1.40
1.00
0.58
-P value
.287
.631
.324
.328
.984
.075
95% CI
0.36
- 1.35
0.71
- 1.76
0.26
- 1.57
0.71
- 2.75
0.67
- 1.51
0.32
- 1.06
Any Antidepressant
OR
Private Insurance
Medicaid
Medicare
Medicaid+Medicare
Uninsured
0.84
1.38
1.57
0.73
-P value
.589
.288
.249
.215
95% CI
0.44
- 1.60
0.76
- 2.51
0.73
- 3.40
0.45
- 1.20
Adequate Antidepressant Care If
Filled At Least 1 Antidepressant Rx
Private Insurance
Medicaid
Medicare
Medicaid+Medicare
Uninsured
OR -P value
1.22
.549
1.17
.596
1.87
.068
1.15
.634
95% CI
0.64
- 2.31
0.65
- 2.14
0.96
- 3.64
0.64
- 2.08
Any
Psychotherapy/Counseling
Private Insurance
Medicaid
Medicare
Medicaid+Medicare
Uninsured
OR -P value
1.40
.230
1.08
.812
2.01
.041
0.41
.004
95% CI
0.81
- 2.44
0.57
- 2.06
1.03
- 3.94
0.22
- 0.75
4
Adequate Course of Psychotherapy
If Started Psychotherapy
Caucasian
African
- American
Hispanic
Other
Under 18
18 to 34
35 to 64
65+
OR
2.47
0.37
0.27
0.33
0.35
0.19
-P value
.053
.007
.332
.041
.017
.024
95% CI
0.99
- 6.16
0.18
- 0.76
0.02
- 3.86
0.11
- 0.95
0.15
- 0.83
0.48
- 0.80
Adequate Course of Psychotherapy
If Started Psychotherapy
Private Insurance
Medicaid
Medicare
Medicaid+Medicare
Uninsured
OR -P value
1.37
.572
2.25
.179
3.26
.072
0.58
.460
95% CI
0.46
- 4.09
0.69
- 7.39
0.90
- 11.84
0.14
- 2.47
5