1. 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)

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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)

8. 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”

9. 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)

10. 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

11. 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

12. Any Antidepressant or Psychotherapy/Counseling ORP-value95% CI Caucasian--- African-American0.44<.0010.29-0.67 Hispanic0.46<.0010.30-0.69 Other0.35.0510.12-1.00 Under 180.90.7610.44-1.81 18 to 340.49<.0010.33-0.72 35 to 64--- 65+1.23.5220.65-2.35

13. Any Antidepressant or Psychotherapy/Counseling ORP-value95% CI Private Insurance--- Medicaid0.98.9360.52-1.82 Medicare1.27.4790.65-2.50 Medicaid+Medicare1.82.1450.81-4.11 Uninsured0.57.0320.34-0.95

14. Adequate Depression Care If Some Treatment Received ORP-value95% CI Caucasian--- African-American1.26.4740.67-2.35 Hispanic0.67.0990.42-1.08 Other0.72.5080.27-1.93 Under 180.82.5800.41-1.66 18 to 340.56.0220.34-0.92 35 to 64--- 65+0.72.2170.43-1.21

15. Adequate Depression Care If Some Treatment Received ORP-value95% CI Private Insurance--- Medicaid1.21.5920.61-2.40 Medicare1.13.6870.62-2.07 Medicaid+Medicare2.34.0181.16-4.74 Uninsured0.99.9570.57-1.71 Psychotherapy Tx--- Antidepressant Tx0.98.9520.54-1.79 Combination Tx2.87.0021.49-5.51

16. 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

17. 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

19. Any Antidepressant ORP-value95% CI Caucasian--- African-American0.47.0010.30-0.73 Hispanic0.47.0010.31-0.73 Other0.39.0820.14-1.13 Under 180.76.3710.41-1.40 18 to 340.40<.0010.27-0.58 35 to 64--- 65+1.35.3400.73-2.49

20. Any Antidepressant ORP-value95% CI Private Insurance--- Medicaid0.84.5890.44-1.60 Medicare1.38.2880.76-2.51 Medicaid+Medicare1.57.2490.73-3.40 Uninsured0.73.2150.45-1.20

21. Adequate Antidepressant Care If Filled At Least 1 Antidepressant Rx ORP-value95% CI Caucasian--- African-American0.74.4720.33-1.67 Hispanic0.90.6800.54-1.50 Other0.73.5190.28-1.89 Under 180.69.3080.34-1.41 18 to 340.50.0160.29-0.88 35 to 64--- 65+0.68.1550.40-1.16

22. Adequate Antidepressant Care If Filled At Least 1 Antidepressant Rx ORP-value95% CI Private Insurance--- Medicaid1.22.5490.64-2.31 Medicare1.17.5960.65-2.14 Medicaid+Medicare1.87.0680.96-3.64 Uninsured1.15.6340.64-2.08

23. Any Psychotherapy/Counseling ORP-value95% CI Caucasian--- African-American0.70.2870.36-1.35 Hispanic1.12.6310.71-1.76 Other0.64.3240.26-1.57 Under 181.40.3280.71-2.75 18 to 341.00.9840.67-1.51 35 to 64--- 65+0.58.0750.32-1.06

24. Any Psychotherapy/Counseling ORP-value95% CI Private Insurance--- Medicaid1.40.2300.81-2.44 Medicare1.08.8120.57-2.06 Medicaid+Medicare2.01.0411.03-3.94 Uninsured0.41.0040.22-0.75

25. Adequate Course of Psychotherapy If Started Psychotherapy ORP-value95% CI Caucasian--- African-American2.47.0530.99-6.16 Hispanic0.37.0070.18-0.76 Other0.27.3320.02-3.86 Under 180.33.0410.11-0.95 18 to 340.35.0170.15-0.83 35 to 64--- 65+0.19.0240.48-0.80

26. Adequate Course of Psychotherapy If Started Psychotherapy ORP-value95% CI Private Insurance--- Medicaid1.37.5720.46-4.09 Medicare2.25.1790.69-7.39 Medicaid+Medicare3.26.0720.90-11.84 Uninsured0.58.4600.14-2.47