Treatment Gaps Remain for Adults Who Screen Positive for Depression

Gaps in the treatment of depression exist with many people who screen positive for depression not receiving treatment, according to a study published in JAMA Internal Medicine.

The study also found that most who were treated did not screen positive. The findings suggest that it is important to align patients with appropriate treatments and healthcare providers.

“Little is known about the extent to which adults with depression in the United States receive depression care and, among those who receive treatment, the extent to which patients are matched based on their illness severity to appropriate depression treatments and health care professionals.,” the study’s authors wrote.

There has been increased attention on screening adults for depression since the US Preventive Services Task Force (USPSTF) recommendation, which also supports the effectiveness of antidepressants, certain psychotherapies, and their combination. The USPSTF has also highlighted the need to integrate behavioral health services within primary care.

Mark Olfson, MD, MPH, of the College of Physicians and Surgeons of Columbia University in New York City, and colleagues analyzed data from 46,417 adults who responded to the Medical Expenditure Panel Surveys (MEPS) in 2012 and 2013. MEPS uses the Patient Health Questionnaire-2 brief screen for depressed mood and anhedonia during the past 2 weeks to screen for depression, and assesses psychological distress with the Kessler 6 scale, which queries the frequency of mental health symptoms in the past 30 days. Patients were also classified by sociodemographic characteristics and health insurance status.

A total of 8.4% of adults in the study screened positive for depression. Screen-positive depression was nearly 5 times more prevalent among adults in the lowest compared with the highest income group. Depression was also common among adults who were separated, divorced, or widowed; who had public health insurance; or who had less than a high school education.

Fewer than one-third (28.7%) of adults who screened positive for depression received any treatment for depression during the survey year. After adjusting for other factors, the odds of receiving depression treatment among those with screen-positive depression treatment was increased by being aged 35 to 64 years, female, white, non-Hispanic, having at least completed high school, and having health insurance.

An estimated 8.1% of the 46,417 adults followed received treatment for depression regardless of the results of a depression screening. Among those treated, 29.9% had a positive depression screening or serious psychological distress (21.8%).

The most common treatment for depression (87%) was antidepressant medication, followed by psychotherapy (23.2%), anxiolytics (13.5%), antipsychotics (7.0%), and mood stabilizers (5.1%). Most people with depression were treated by general medical professionals, but patients with serious psychological distress were more likely to be treated by a psychiatrist than were patients in less distress.

Because most screen-positive untreated adults made at least 1 annual medical visit, the researchers conclude that primary care models that involve depression care managers and consulting specialists may have opportunities to narrow the gap in untreated depression. Research has shown that, compared with depressed primary care patients who receive standard care, those who receive integrated mental health services tend to achieve more favorable depression outcomes.

Patients with less serious distress were more likely than those with serious distress to receive antidepressants, a pattern that the authors said may include a tendency to overestimate the effectiveness of antidepressants in treating mild depression, insufficient time to provide alternative interventions for mild depression, and errors in clinical assessment.

Psychotherapy was less commonly provided than antidepressants but was more frequently provided to patients with more serious than with less serious psychological distress. About 1 in 5 patients treated for depression received both antidepressants and psychotherapy.

Patients with serious psychological distress were about twice as likely as those with less distress to be treated by a psychiatrist, which may reflect a tendency for psychiatrists to care for patients with more severe mental health conditions. However, this pattern did not extend to older patients, African Americans, patients with less education, and uninsured patients. The researchers suggest that integrated care models provide more opportunities to promote depression care that is neither too intensive nor insufficient for each patient’s clinical need and would promote better mental health care among racial/ethnic minorities, low-income people, people with less education, and no insurance.