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Treatment Differences in Primary and Specialty Settings in Veterans with Major Depression
Victor Puac-Polanco1, Lucinda B Leung1, Robert M Bossarte1
1From the Department of Health Care Policy, Harvard Medical School, Boston, MA (VP-P, HL, HNZ, RCK); the Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY (VP-P); the Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA (LBL); the Division of General Internal Medicine, and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA (LBL); the Department of Behavioral Medicine and Psychiatry, West Virginia University, Morgantown, (RMB); the Center of Excellence for Suicide Prevention, Canandaigua VAMC, Canandaigua, NY (RMB, HL, WRP); the VA Ann Arbor, Center for Clinical Management Research, Ann Arbor, MI (CB, JNK, EPP); the Department of Psychiatry, University of Rochester Medical Center, Rochester, NY (WRP); the Department of Medicine, University of Michigan Medical School, Ann Arbor (EPP); the Cpl Michael J Crescenz VA Medical Center, VISN 4 Mental Illness Research Education and Clinical Center, Philadelphia, PA (DWO); the Perelman School of Medicine, University of Pennsylvania, Philadelphia (DWO).
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.
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