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Article Excerpt
In order to characterize depression treatment-as-usual in a large primary care practice in the United States with colocated mental health care, and to examine predictors of receiving any treatment and receiving adequate treatment, primary care patients were systematically approached in waiting rooms. Those with a minimum level of depression symptoms (n = 91) were asked to participate in a study in which they completed assessments of mental health service use, depression symptoms, and related problems. Results suggested that most patients with elevated depressive symptoms were receiving some type of mental health care, indicating they had been identified as depressed. However, only half were receiving "minimally adequate care." Minority patients were less likely to receive any care. Patients who were more depressed, demonstrated poorer problem-solving ability, and had poorer physical health were more likely to receive any treatment and to receive minimally adequate treatment for depression. These results suggest that, even in the context of colocated mental health care, there is still room for improving treatment of depressed patients.
Keywords: depression, primary health care, treatment
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Depression is one of the most common conditions in primary care settings.
Estimates for the prevalence of major depressive disorder (MDD) in primary care range from 6% to 14% (Barrett, Barrett, Oxman, & Gerber, 1988; Coyne, Fechner-Bates, & Schwenk, 1994; Simon & VonKorff, 1995). Primary care physicians are the sole providers of care for many depressed patients: recent estimates suggest that 40% of United States residents receiving mental health treatment are treated in the general medical health sector alone (Uebelacker, Wang, Berglund, & Kessler, 2006).
Previous research suggests that not all depressed primary care patients are receiving adequate depression treatment. A large study found that, in 1997, between 48% and 60% of patients in managed primary care with current or recent major depression received mental health treatment at an index primary care visit (Wells, Schoenbaum, Unutzer, Lagomasino, & Rubenstein, 1999). Of those receiving treatment, there are varying estimates of rates of adequate treatment. Data from a large epidemiological study (National Comobidity Survey Replication, or NCS-R) suggest that only 15% of patients with major depression who were seen in the general medical sector received "minimally adequate" (i.e., guideline concordant) treatment, compared to 52% of those seen in the mental health specialty sector (Wang et al., 2005). These differences in minimally adequate treatment may be due in part to the frequency of follow-up visits rather than antidepressant dosages. Simon et al. (Simon, Von Korff, Rutter, & Peterson, 2001) found psychiatrists are more likely than primary care physicians to provide adequate follow-up care after an antidepressant prescription; however, there were no differences in rates of minimally adequate dosages of antidepressants (rates were approximately 50% in both groups).
Recent trends in primary care research and practice have suggested that colocated or integrated mental health may improve the care and treatment outcomes of patients with mental health problems (Blount, 2003; Unutzer et al., 2002). Primary care patients may be more likely to follow up on a mental health referral to a colocated provider than an off-site provider (Bartels et al., 2004). Several large health care organizations, such as the Veterans Administration (VA), now have programs to promote and maintain integrated primary care (Butler et al., 2008). Most naturalistic studies of depression treatment in primary care, as cited above, have not examined the patterns of care specifically in practices where colocated care is available. Mauksch and colleagues (Mauksch et al., 2007) did report that rates of mental health visits in general (not specific to depression) increased from before to after a quality improvement program (including integrated mental health care) was initiated at a low-income primary care clinic.
Given this background, in the current study, we examined mental health treatment-as-usual among depressed patients in a large primary care practice in the U.S. with colocated mental health specialists. Specifically, we examined: (a) type of treatment that patients received; (b) the characteristics of patients who did (vs. did not) receive mental health treatment; and (c) the characteristics of patients who did (vs. did not) receive minimally adequate mental health treatment. Given the fact of colocated care, we predicted that rates of depression treatment and rates of adequate depression treatment would be higher than those cited in some of the previous literature. However, we believed that predictors of treatment and treatment adequacy would be similar to that found in previous research. We hypothesized that minority status and lower income would be associated with decreased likelihood of receiving treatment and receiving adequate treatment, and having chronic depression, more severe depression, or poorer physical health would be associated with increased likelihood of receiving treatment and receiving adequate treatment. We also examined some predictors not typically...
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