The Role of Primary Care Experiences in Obtaining Treatment for Depression

Japanese primary care physicians' postpartum mental health care: A cross-sectional study

Background

Postpartum mental health care is a public health priority requiring interprofessional and interorganizational collaboration. Primary care physicians (PCPs) have the potential to play an essential role in facilitating access to health care and providing comprehensive and coordinated care for postpartum mental health problems. In Japan, however, there are no previous studies on the extent to which PCPs are involved in postpartum mental health care. Therefore, this study aimed to investigate the practices and experiences of Japanese PCPs in providing such care.

Methods

This study presents a subset of the findings from a cross-sectional study using an online questionnaire on postpartum care among Japanese PCPs. We employed descriptive analysis to examine their practices and experiences in providing general and postpartum mental health care.

Results

We received 339 valid responses from 5811 PCPs. The median proportion of the outpatients with mental health problems that PCPs regularly saw was 15%. Approximately two out of three PCPs (68.7%) reported routinely performing screening for depression and anxiety. Seventy-six percent of PCPs had the opportunity to provide care for postpartum women. Approximately one in two PCPs (47.8%) had managed cases of postpartum mental health problems and collaborated with various professionals and resources to provide care.

Conclusions

The majority of Japanese PCP participants in the study provide mental health care and have managed cases of postpartum mental health problems, collaborating with various health professionals.

Quality of Depression Care for Veterans Affairs Primary Care Patients with Experiences of Homelessness

BACKGROUND

Persons who experience homelessness (PEH) have high rates of depression and incur challenges accessing high-quality health care. Some Veterans Affairs (VA) facilities offer homeless-tailored primary care clinics, although such tailoring is not required, within or outside VA. Whether services tailoring enhances care for depression is unstudied.

OBJECTIVE

To determine whether PEH in homeless-tailored primary care settings receive higher quality of depression care, compared to PEH in usual VA primary care.

DESIGN

Retrospective cohort study of depression treatment among a regional cohort of VA primary care patients (2016-2019).

PARTICIPANTS

PEH diagnosed or treated for a depressive disorder.

MAIN MEASURES

The quality measures were timely follow-up care (3 + completed visits with a primary care or mental health specialist provider, or 3 + psychotherapy sessions) within 84 days of a positive PHQ-2 screen result, timely follow-up care within 180 days, and minimally appropriate treatment (4 + mental health visits, 3 + psychotherapy visits, 60 + days antidepressant) within 365 days. We applied multivariable mixed-effect logistic regressions to model differences in care quality for PEH in homeless-tailored versus usual primary care settings.

KEY RESULTS

Thirteen percent of PEH with depressive disorders received homeless-tailored primary care (n = 374), compared to usual VA primary care (n = 2469). Tailored clinics served more PEH who were Black, who were non-married, and who had low income, serious mental illness, and substance use disorders. Among all PEH, 48% received timely follow-up care within 84 days of depression screening, 67% within 180 days, and 83% received minimally appropriate treatment. Quality metric attainment was higher for PEH in homeless-tailored clinics, compared to PEH in usual VA primary care: follow-up within 84 days (63% versus 46%; adjusted odds ratio [AOR] = 1.61, p = .001), follow-up within 180 days (78% versus 66%; AOR = 1.51, p = .003), and minimally appropriate treatment (89% versus 82%; AOR = 1.58, p = .004).

CONCLUSIONS

Homeless-tailored primary care approaches may improve depression care for PEH.

Longitudinal study to assess antidepressant treatment patterns and outcomes in individuals with depression in the general population

BACKGROUND

Major depressive disorder (MDD) is largely managed in primary care, but physicians vary widely in their understanding of symptoms and treatments. This study aims to better understand the evolution of depression from initial diagnosis over a 3-year period.

METHODS

This was a noninterventional, retrospective, longitudinal study, with 2 waves of participant interviews approximately 3 years apart. Phone interviews were conducted using the hybrid artificial intelligence (AI) Sleep-EVAL system, an AI-driven diagnostic deep learning tool. Participants were noninstitutionalized adults representative of the general population in 8 US states. Diagnosis was confirmed according to the DSM-5 using the Sleep-EVAL System.

RESULTS

10,931 participants completed Wave 1 and 2 (W1, W2) interviews. The prevalence of MDD, including partial and complete remission, was 13.4 % and 19.6 % in W1 and W2, respectively. About 42 % of MDD participants at W1 continued to report depressive symptoms at W2. Approximately half of antidepressant (AD) users in W1 were moderately to completely dissatisfied with their treatment; 29.6 % changed their AD for a different one, with 16.4 % switching from one SSRI to another between W1 and W2. Primary care physicians were the top AD prescribers, both in W1 (45.7 %) and W2 (59%), respectively.

LIMITATIONS

Data collected relied on self-reporting by participants. As such, the interpretation of the data may be limited.

CONCLUSIONS

Depression affects a sizeable portion of the US population. Dissatisfaction with treatment, frequent switching of ADs, and changing care providers are associated with low rates of remission. Residual symptoms remain a challenge that future research must address.

Insights for Conducting Large-Scale Surveys with Veterans Who Have Experienced Homelessness

Surveys of underserved patient populations are needed to guide quality improvement efforts but are challenging to implement. The goal of this study was to describe recruitment and response to a national survey of Veterans with homeless experience (VHE). We randomly selected 14,340 potential participants from 26 U.S. Department of Veterans Affairs (VA) facilities. A survey contract organization verified/updated addresses from VA administrative data with a commercial address database, then attempted to recruit VHE through 4 mailings, telephone follow-up, and a $10 incentive. We used mixed-effects logistic regressions to test for differences in survey response by patient characteristics. The response rate was 40.2% (n=5,766). Addresses from VA data elicited a higher response rate than addresses from commercial sources (46.9% vs 31.2%, p<.001). Residential addresses elicited a higher response rate than business addresses (43.8% vs 26.2%, p<.001). Compared to non-respondents, respondents were older, less likely to have mental health, drug, or alcohol conditions, and had fewer VA housing and emergency service visits. Collectively, our results indicated a national mailed survey approach is feasible and successful for reaching VA patients who have recently experienced homelessness. These findings offer insight into how health systems can obtain perspectives of socially disadvantaged groups.

Psychometric Properties of Three Measures of Stigma Among Hispanics with Depression

While many measures of mental illness stigma have been developed, few have been validated in Hispanic populations. This study examined the psychometric properties of three stigma measures (Stigma Concerns about Mental Health Care [SCMHC], Social Distance Scale [SDS], and Latino Scale for Antidepressant Stigma [LSAS]) among a depressed, Hispanic sample. Data were collected during baseline assessments for two studies taking place in primary care settings (N = 500). Psychometric and factor validity were tested for each measure. Confirmatory factor analyses indicated adequate model fit, and adequate internal consistency reliability was found for all three measures. Stigma scores significantly differed by education level and gender. Findings from this analysis provide support for the use of the SCMHC, SDS, and LSAS in a depressed, Hispanic population. Assessing barriers to depression treatment, including stigma, are critical in engaging Hispanics in care and eliminating disparities for the population.

Treatment Differences in Primary and Specialty Settings in Veterans with Major Depression

INTRODUCTION

The Veterans Health Administration (VHA) supports the nation's largest primary care-mental health integration (PC-MHI) collaborative care model to increase treatment of mild to moderate common mental disorders in primary care (PC) and refer more severe-complex cases to specialty mental health (SMH) settings. It is unclear how this treatment assignment works in practice.

METHODS

Patients (n = 2610) who sought incident episode VHA treatment for depression completed a baseline self-report questionnaire about depression severity-complexity. Administrative data were used to determine settings and types of treatment during the next 30 days.

RESULTS

Thirty-four percent (34.2%) of depressed patients received treatment in PC settings, 65.8% in SMH settings. PC patients had less severe and fewer comorbid depressive episodes. Patients with lowest severity and/or complexity were most likely to receive PC antidepressant medication treatment; those with highest severity and/or complexity were most likely to receive combined treatment in SMH settings. Assignment of patients across settings and types of treatment was stronger than found in previous civilian studies but less pronounced than expected (cross-validated AUC = 0.50-0.68).

DISCUSSION

By expanding access to evidence-based treatments, VHA's PC-MHI increases consistency of treatment assignment. Reasons for assignment being less pronounced than expected and implications for treatment response will require continued study.

Primary care experiences of veterans with opioid use disorder in the Veterans Health Administration

BACKGROUND

While patients with substance use disorders (SUDs) are thought to encounter poor primary care experiences, the perspectives of patients with opioid use disorder (OUD), specifically, are unknown. This study compares the primary care experiences of patients with OUD, other SUDs and no SUD in the Veterans Health Administration.

METHODS

The sample included Veterans who responded to the national Patient-Centered Medical Home Survey of Healthcare Experiences of Patients, 2013-2015. Respondents included 3554 patients with OUD, 36,175 with other SUDs, and 756,386 with no SUD; 742 OUD-diagnosed patients received buprenorphine. Multivariable multinomial logistic regressions estimated differences in the probability of reporting positive and negative experiences (0-100 scale) for patients with OUD, compared to patients with other SUDs and no SUD, and for OUD-diagnosed patients treated versus not treated with buprenorphine.

RESULTS

Of all domains, patients with OUD reported the least positive experiences with access (31%) and medication decision-making (35%), and the most negative experiences with self-management support (35%) and provider communication (23%). Compared to the other groups, patients diagnosed with OUD reported fewer positive and/or more negative experiences with access, communication, office staff, provider ratings, comprehensiveness, care coordination, and self-management support (adjusted risk differences[aRDs] range from |2.9| to |7.0|). Among OUD-diagnosed patients, buprenorphine was associated with more positive experiences with comprehensiveness (aRD = 8.3) and self-management support (aRD = 7.1), and less negative experiences with care coordination (aRD = -4.9) and medication shared decision-making (aRD = -5.4).

CONCLUSIONS

In a national sample, patients diagnosed with OUD encounter less positive and more negative experiences than other primary care patients, including those with other SUDs. Buprenorphine treatment relates positively to experiences with care comprehensiveness, medication decisions, and care coordination. As stakeholders encourage more primary care providers to manage OUD, it will be important for healthcare systems to attend to patient access and experiences with care in these settings.

US Integrated Delivery Networks Perspective on Economic Burden of Patients with Treatment-Resistant Depression: A Retrospective Matched-Cohort Study

OBJECTIVE

Our objective was to assess healthcare resource utilization (HRU) and costs among patients with major depressive disorder (MDD) with and without treatment-resistant depression (TRD) and those without MDD in US Integrated Delivery Networks (IDNs).

METHODS

This was a retrospective matched-cohort study. The Optum© Integrated Claims Electronic Health Record de-identified database was used to identify adult patients with TRD (January 2011-June 2017) across US IDNs. TRD patients were propensity score matched 1:1 with non-TRD MDD and non-MDD patients on demographics. Rates of HRU and costs were compared up to 2 years following the first antidepressant pharmacy claim (or randomly imputed date for non-MDD patients) using negative binomial and ordinary least squares regressions, respectively, with 95% confidence intervals (CIs) from nonparametric bootstraps (costs only) adjusted for baseline comorbidity index and costs.

RESULTS

All 1582 TRD patients were matched to non-TRD MDD and non-MDD patients and evaluated. TRD patients were on average 46 years old, and 67% were female. Mean duration of observation was 20.1, 19.6, and 17.9 months in the TRD, non-TRD MDD, and non-MDD cohorts, respectively. Patients with TRD had significantly higher rates of HRU than did non-TRD MDD patients (inpatient visits 0.35 vs. 0.16 per patient per year [PPPY]; adjusted incidence rate ratio [IRR] 2.04 [95% CI 1.74-2.39]) and non-MDD patients (0.35 vs. 0.09 PPPY, adjusted IRR 3.05 [95% CI 2.54-3.66]). TRD patients incurred significantly higher costs PPPY than did non-TRD MDD patients ($US25,807 vs. 13,701, adjusted cost difference $US9479 [95% CI 7071-11,621]) and non-MDD patients ($US25,807 vs. 8500, adjusted cost difference $US11,433 [95% CI 8668-13,876]).

CONCLUSIONS

HRU and costs associated with TRD are significant in US IDNs.

The Role of the Patient-Centered Medical Home in Treating Depression

PURPOSE OF REVIEW

This review discusses the role of the patient-centered medical home (PCMH) in treating depression, focusing on findings from primary care-based studies and their implications for the PCMH.

RECENT FINDINGS

Pharmacotherapy, psychotherapy, and collaborative care are evidence-based treatments for depression that can be delivered in primary care and extended to diverse populations. Recent research aligns with the core components of the PCMH model. The core components of the PCMH are critical elements of depression treatment. Comprehensive care within the PCMH addresses medical and behavioral health concerns, including depression. Psychiatric and psychological care must be flexibly delivered so services remain accessible yet patient-centered. To ensure the quality and safety of treatment, depression symptoms must be consistently monitored. Coordination within and occasionally outside of the PCMH is needed to ensure patients receive the appropriate level of care. More research is needed to empirically evaluate depression treatment within the PCMH.