Educational Differences in Treatment of Individuals Diagnosed With Major Depression: A Register-Based Cohort Study

In individuals with depression, lower socioeconomic position is associated with poorer prognostic outcomes, which may be attributed to inequitable care. We investigated educational differences in treatment of individuals diagnosed with depression at a psychiatric hospital.

This nationwide register-based cohort study included 156,922 Danish citizens with a first-time psychiatric hospital diagnosis of depression (ICD-10: F32-F33) between 2000 and 2022. Highest attained educational level was categorized as short, medium, or long. Treatment data included antidepressant prescriptions, electroconvulsive therapy (ECT), and contacts with private practicing psychiatrists or psychologists. Logistic regression and Cox proportional hazard regression models with adjustments for covariates were used to estimate associations between educational level and treatment before and after diagnosis.

Within 2 years before diagnosis, 72.0% of individuals had redeemed at least one antidepressant prescription, and 83.8% had initiated or continued pharmacological treatment within 2 years after diagnosis. Education was not associated with redeemed prescriptions of antidepressants regardless of type before diagnosis, whereas long education was associated with higher rates of treatment with any type of antidepressants after diagnosis. For specific antidepressants, individuals with long education were less likely to redeem prescriptions for noradrenergic and specific serotonergic antidepressants (NaSSAs) and more likely to redeem monoamine oxidase inhibitors (MAOIs) and newer antidepressants such as vortioxetine. Longer educated also more often consulted private practicing mental health specialists both before and after diagnosis, respectively. After diagnosis, individuals with long education were also more likely to receive ECT.

Educational differences in pharmacological treatment and private specialist visits among individuals with depression are present both before and after their first hospital contact. Individuals with long education seem more likely to receive specialized and high-value care (ECT, MAOIs, newer antidepressants, and consultations with private psychiatrists and psychologists) compared to individuals with short or medium education.