Anxiety/Depression Diagnoses and
Antidepressant Prescribing Patterns by Primary
Care and Psychiatric Specialties, NAMCS 19952003
Coauthors: Isabel Lagomasino, M.D., Jeanne Miranda, Ph.D.
Supported by a grant from the MacArthur Foundation
Background
• Rates of diagnosis and treatment for
depression/anxiety low among ethnic minorities
(Skaer et al. 2000; Olfson et al. 2002).
• Improvements in depression care for minorities
may be due to national efforts in primary care
settings.
• Kessler et al. 2005 - 2.6 fold increase in MH
treatment in the general medical sector, 2.2 fold
in psychiatric settings.
• Pincus et al. 1998; Olfson et al 2002 - much of
the increase in antidepressant prescriptions has
been among psychiatrists.
Research Questions and Hypotheses
• No previous studies have simultaneously
examined the roles of physician specialty and
patient race/ethnicity in diagnoses and
treatment.
• Examine trends in diagnoses and treatment for
depressive and anxiety, by psychiatrists and
primary care physicians, for white, Hispanic, and
African-American patients.
• Hypotheses: 1) depression/anxiety diagnoses
and treatment will increase over time and 2)
ethnic differences in diagnoses and treatment
will persist but be reduced over time, especially
in the primary care sector.
NAMCS 1995-2003
• Office-based outpatient visits for psychiatric specialties
(n=10747) and primary care (n=61516).
• Outcomes: depression/anxiety diagnoses,
antidepressant prescriptions
• Predictors: race/ethnicity (white, black, Hispanic),
gender, age, source of payment (private insurance,
Medicare, Medicaid/workers’ compensation, selfpay/charity care), time period (1995-1997, 1998-2000,
2001-2003), depression/anxiety reason for visit.
• Analysis: Multivariate logistic regression, main effects
and interactions, standardized predictions.
ORs for predictors of depression/anxiety diagnosis
OR (95% CI)
Psychiatry
Primary care
Black
0.62 (0.45, 0.86)**
0.55 (0.43, 0.70)***
Hispanic
0.81 (0.59, 1.11)
0.57 (0.44, 0.75)***
Race/ethnicity (vs white)
Age
1.01 (1.01, 1.02)*** 1.00 (1.00, 1.01)
Female
1.36 (1.16, 1.59)*** 1.19 (1.08, 1.31)***
Expected payment (vs priv. ins.)
Medicare
0.48 (0.39, 0.60)*** 0.96 (0.80, 1.16)
Medicaid/Worker’s comp.
0.45 (0.34, 0.58)*** 1.20 (0.94, 1.54)
Self pay/charity care
0.66 (0.51, .84)***
1.34 (1.09, 1.64)**
1998-2000
1.20 (0.87, 1.65)
0.99 (0.84, 1.17)
2001-2003
1.36 (0.98, 1.88)~
1.29 (1.10, 1.52)**
Time period (vs 1995-97)
Depression/anxiety visit
4.31 (3.48, 5.34)*** 24.6 (21.9,27.7)***
ORs for predictors of antidepressant prescriptions
OR (95% CI)
Psychiatry
Primary care
Race/ethnicity (vs white)
Black
0.78 (0.57, 1.07)
0.57 (0.47, 0.68)***
Hispanic
0.98 (0.71, 1.34)
0.57 (0.41, 0.80)**
Age
1.00 (1.00, 1.01)*
1.01 (1.00, 1.01)**
Female
1.15 (0.95, 1.39)
1.30 (1.18, 1.43)***
Expected payment (vs priv. ins.)
Medicare
0.73 (0.62, 0.87)*** 1.08 (0.94, 1.23)
Medicaid/Worker’s comp.
0.73 (0.58, 0.94)*
Self pay/charity care
0.47 (0.38, 0.59)*** 0.85 (0.68, 1.05)
1.19 (0.97, 1.46)~
Time period (vs 1995-97)
1998-2000
1.59 (1.18, 2.15)**
1.30 (1.09, 1.54)**
2001-2003
1.49 (1.12, 1.98)**
1.59 (1.38, 1.84)***
Depression/anxiety visit
1.90 (1.55, 2.32)*** 9.30 (8.25,10.5)***
Predicted Diagnoses of Anxiety or Depression by Race/ethnicity for
Psychiatric Specialties
Predicted Diagnoses of Depression/Anxiety by
Race/ethnicity for Primary Care Specialties
75.0%
7.0%
70.0%
6.0%
5.8%
68.6%
66.2%
65.0%
5.0%
60.0%
59.8%
57.1%
55.0%
53.4%
4.8%
4.7%
4.0%
3.0%
53.0%
50.3%
50.0%
Percent
Percent
62.7%
3.8%
3.5%
3.1%
2.8%
3.0%
2.8%
2.0%
Black - Primary Care
Black - Psychiatry
46.6%
Hispanic - Psychiatry
45.0%
Hispanic - Primary Care
1.0%
White - Primary Care
White - Psychiatry
40.0%
0.0%
1995-1997
1998-2000
Time period
2001-2003
1995-1997
1998-2000
Time period
2001-2003
Predicted Prescriptions of Antidepressants by
Race/ethnicity for Primary Care Specialties
Predicted Prescriptions of Antidepressants by
Race/ethnicity for Psychiatric Specialties
9.0%
65.0%
8.4%
8.0%
61.1%
60.0%
59.2%
59.6%
57.6%
5.6%
55.0%
53.3%
50.0%
6.0%
50.4%
48.4%
Percent
Percent
55.0%
7.1%
7.0%
5.2%
5.1%
5.0%
4.0%
3.0%
4.3%
4.2%
3.4%
3.3%
Black - Primary Care
Black - Psychiatry
45.0%
Hispanic - Psychiatry
44.0%
White - Psychiatry
Hispanic - Primary Care
2.0%
White - Primary Care
1.0%
0.0%
40.0%
1995-1997
1998-2000
Time period
2001-2003
1995-1997
1998-2000
Time period
2001-2003
Conclusions
• Primary care visits involving black and Hispanic
patients, and psychiatric visits involving black
patients, are significantly less likely to result in a
diagnosis of depression or anxiety.
• Psychiatric specialists are equally likely to
prescribe antidepressants to black or Hispanic
patients (as compared with whites), but primary
care office visits involving black or Hispanic
patients are less likely to result in a prescription
for antidepressants.
• These differences remain remarkably consistent
over time.
Significance/Implications for Policy
• Differences in rates of diagnoses and treatment
may be a consequence of physician knowledge
and ability to identify the disorder, differences in
the pathways to care for psychiatric specialties
versus primary care, and/or differences in
patient preferences.
• Although interventions aimed at improving
depression identification and care in primary
care may help to reduce disparities, other factors
outside the medical care setting may also need
to be targeted.