The impact of race and ethnicity on rates of return to psychotherapy for depression

Psychotherapy Engagement Before and After a Rapid Transition to Telehealth During COVID-19 for Older Adults With Dementia

Objective: To understand the impact of the transition to telehealth during COVID-19 on psychotherapy visits for patients with dementia. Method: Retrospective study of older adults with dementia who had at least one psychotherapy visit in the 9 months before and after the onset of COVID-19 at 3 U.S. health systems. Care disruptions were gaps of 45+ days. Descriptive statistics and logistic mixed-effects models examined factors associated with care disruption. Results: 4953 patients with dementia made 19,902 psychotherapy visits. Gaps in psychotherapy were less frequent during COVID-19 (29.4%) than before (48.9%), with the odds of a patient experiencing a care disruption during COVID-19 0.54 times the odds prior to COVID-19 (95% CI: 0.50-0.59). Almost all patient subgroups had lower adjusted odds of care disruption during COVID-19. Discussion: There were fewer disruptions in psychotherapy care following the rapid shift to virtual care. Telehealth may be a viable option for patients with dementia.

Randomized Trial of the Effectiveness of Videoconferencing-Based Versus Message-Based Psychotherapy on Depression

OBJECTIVE

The authors compared the engagement, clinical outcomes, and adverse events of text or voice message-based psychotherapy (MBP) versus videoconferencing-based psychotherapy (VCP) among adults with depression.

METHODS

The study used a sequential multiple-assignment randomized trial design with data drawn from phase 1 of a two-phase small business innovation research study. In total, 215 adults (ages ≥18 years) with depression received care from Talkspace, a digital mental health care company. Participants were initially randomly assigned to receive either asynchronous MBP or weekly VCP. All therapists provided evidence-based treatments such as cognitive-behavioral therapy. After 6 weeks of treatment, participants whose condition did not show a response on the Patient Health Questionnaire-9 or was rated as having not improved on the Clinical Global Impressions scale were randomly reassigned to receive either weekly VCP plus MBP or monthly VCP plus MBP. Longitudinal mixed-effects models with piecewise linear time trends applied to multiple imputed data sets were used to address missingness of data.

RESULTS

Participants who were initially assigned to the MBP condition engaged with their therapists over more weeks than did participants in the VCP condition (7.8 weeks for MBP vs. 4.9 weeks for VCP; p<0.001). No meaningful differences were observed between the two groups in rates of change by 6 or 12 weeks for depression, anxiety, disability, or global ratings of improvement. Neither treatment resulted in any adverse events.

CONCLUSIONS

MBP appears to be a viable alternative to VCP for treating adults with depression.

The rapid shift to virtual mental health care: Examining psychotherapy disruption by rurality status

BACKGROUND

Given the low usage of virtual health care prior to the COVID-19 pandemic, it was unclear whether those living in rural locations would benefit from increased availability of virtual mental health care. The rapid transition to virtual services during the COVID-19 pandemic allowed for a unique opportunity to examine how the transition to virtual mental health care impacted psychotherapy disruption (i.e., 45+ days between appointments) among individuals living in rural locations compared with those living in nonrural locations.

METHODS

Electronic health record and insurance claims data were collected from three health care systems in the United States including rurality status and psychotherapy disruption. Psychotherapy disruption was measured before and after the COVID-19 pandemic onset.

RESULTS

Both the nonrural and rural cohorts had significant decreases in the rates of psychotherapy disruption from pre- to post-COVID-19 onset (32.5-16.0% and 44.7-24.8%, respectively, p < 0.001). The nonrural cohort had a greater reduction of in-person visits compared with the rural cohort (96.6-45.0 vs. 98.0-66.2%, respectively, p < 0.001). Among the rural cohort, those who were younger and those with lower education had greater reductions in psychotherapy disruption rates from pre- to post-COVID-19 onset. Several mental health disorders were associated with experiencing psychotherapy disruption.

CONCLUSIONS

Though the rapid transition to virtual mental health care decreased the rate of psychotherapy disruption for those living in rural locations, the reduction was less compared with nonrural locations. Other strategies are needed to improve psychotherapy disruption, especially among rural locations (i.e., telephone visits).

Access to healthcare and depression severity in vulnerable groups the US: NHANES 2013-2018

BACKGROUND

Access to healthcare is essential for managing chronic diseases, yet it often poses a barrier, contributing to a significant burden of conditions like depression. This study aimed to investigate the association between healthcare access and depression severity in contemporary free-living adults in the US, with a focus on identifying vulnerable populations.

METHOD

Data from the National Health and Nutrition Examination Survey cycles 2013-2018 were utilized, involving 13,689 participants aged 20 years or older. Multivariable multinomial logistic regression models were conducted, adjusting for various confounding variables.

RESULTS

Approximately 17 % of US adults lacked access to healthcare, while 24 % experienced varying levels of depression severity, with 8 % having moderate-to-severe depression. More males faced challenges accessing healthcare, while more females reported diverse levels of depression. Both healthcare access and depression severity were associated with low educational attainment, low familial income, lacking spousal support, lacking health insurance coverage, and worse self-reported overall health. We found a higher vulnerability to moderate-to-severe depression among females (OR (95 % CI): 1.20 (0.91, 1.59)), individuals identifying as the Other ethnic group (1.69 (1.02, 2.79)), and those living without a spouse (1.57 (1.10, 2.26)).

LIMITATIONS

Our cross-sectional study cannot establish causality, and potential biases related to self-reported data exist.

CONCLUSIONS

Access to healthcare emerged as a crucial predictor of moderate-to-severe depression among females, individuals of the Other ethnic group, and those without a spouse. Longitudinal research is needed to confirm and enhance our understanding of factors that shape the relationship between healthcare access and depression in free-living US adults.

Psychotherapy Disruption Before and After the Transition to Virtual Mental Health Care Induced by the COVID-19 Pandemic

OBJECTIVE

This study aimed to examine population-level disruption in psychotherapy before and after the rapid shift to virtual mental health care induced by the onset of the COVID-19 pandemic in the United States.

METHODS

This retrospective study used electronic health record and insurance claims data from three U.S. health systems. The sample included 110,089 patients with mental health conditions who were members of the health systems' affiliated health plans and attended at least two psychotherapy visits from June 14, 2019, through December 15, 2020. Data were subdivided into two 9-month periods (before vs. after COVID-19 onset, defined in this study as March 14, 2020). Psychotherapy visits were measured via health records and categorized as in person or virtual. Disruption was defined as a gap of >45 days between visits.

RESULTS

Visits in the preonset period were almost exclusively in person (97%), whereas over half of visits in the postonset period were virtual (52%). Approximately 35% of psychotherapy visits were followed by a disruption in the preonset period, compared with 18% in the postonset period. Disruption continued to be less common (adjusted OR=0.45) during the postonset period after adjustment for visit, mental health, and sociodemographic factors. The magnitude of the difference in disruption between periods was homogeneous across sociodemographic characteristics but heterogeneous across psychiatric diagnoses.

CONCLUSIONS

This study found fewer population-level disruptions in psychotherapy receipt after rapid transition to virtual mental health care following COVID-19 onset. These data support the continued availability of virtual psychotherapy.

Depression associated with dietary intake of flavonoids: An analysis of data from the National Health and Nutrition Examination Survey, 2007-2010

BACKGROUND

Flavonoids may have a protective effect against depression. The purpose of this study was to examine whether flavonoid intake was associated with depression.

METHODS

This is an observational cross-sectional study. We evaluated a sample of 8183 adults from the National Health and Nutrition Examination Survey (NHANES), 2007-2010. The participants had an average age of 46.7 years, and 48.4% of them were male. Flavonoid intake was obtained through dietary recall interviews, and it included six subclasses: isoflavones, anthocyanidins, flavan-3-ols, flavanones, flavones, and flavonols. Depression was identified using the Patient Health Questionnaire (PHQ-9). Logistic regression was utilized to evaluate the association between flavonoid intake and depression. Restricted cubic splines (RCS) were utilized to investigate nonlinear associations. Differences between subgroups were explored. Mediation analysis was used to explore confounding/mediating factors. These models were adjusted for age, sex, race/ethnicity, poverty status, education, smoking status, alcohol consumption, BMI, energy intake, physical activity, and chronic diseases.

RESULTS

There were 765 individuals with depression (PHQ-9 score ≥ 10) in the sample. After adjusting for covariates, flavanones, flavones, and total flavonoid intake were associated with a lower likelihood of depression (OR (95% CI): 0.73(0.64,0.84); 0.36(0.21,0.63); 0.86(0.74,0.99), respectively). A significant inverse correlation was observed between flavonoid consumption and the somatic symptom score of the PHQ-9. We observed a stronger association between flavonoids and depression in non-Hispanic white groups. The relationship between the total flavonoid intake and depression was explained to some extent by sleep duration (13.8%).

CONCLUSIONS

Flavonoid intake was associated with lower odds of depression.

Provider Contributions to Disparities in Mental Health Care

OBJECTIVE

Disparities in diagnosis of mental health problems and in access to treatment among racial-ethnic groups are apparent across different behavioral conditions, particularly in the quality of treatment for depression. This study aimed to determine how much disparities differ across providers.

METHODS

Bayesian mixed-effects models were used to estimate whether disparities in patient adherence to antidepressant medication (N=331,776) or psychotherapy (N=275,095) were associated with specific providers. Models also tested whether providers who achieved greater adherence to treatment, on average, among non-Hispanic white patients than among patients from racial-ethnic minority groups attained lower disparities and whether the percentage of patients from racial-ethnic minority groups in a provider caseload was associated with disparities.

RESULTS

Disparities in adherence to both antidepressant medication and psychotherapy were associated with the provider. Provider performance with non-Hispanic white patients was negatively correlated with provider-specific disparities in adherence to psychotherapy but not to antidepressants. A higher proportion of patients from racial-ethnic minority groups in a provider's caseload was associated with lower adherence among non-Hispanic white patients, lower disparities in adherence to psychotherapy, and greater disparities in adherence to antidepressant medication.

CONCLUSIONS

Adherence to depression treatment among a provider's patients from racial-ethnic minority groups was related to adherence among that provider's non-Hispanic white patients, but evidence also suggested provider-specific disparities. Efforts among providers to decrease disparities might focus on improving the general skill of providers who treat more patients from racial-ethnic minority groups as well as offering culturally based training to providers with notable disparities.