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Racial and Ethnic Differences in Receipt of Antidepressants and Psychotherapy by Veterans With Chronic Depression
Ana R. Quiñones, Ph.D.; Stephen M. Thielke, M.D.; Kristine A. Beaver, M.P.H.; Ranak B. Trivedi, Ph.D.; Emily C. Williams, Ph.D.; Vincent S. Fan, M.D.
Psychiatric Services 2014; doi: 10.1176/appi.ps.201300057
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Dr. Quiñones is with the Health Services Research and Development Service, Portland Veterans Affairs (VA) Medical Center, and the Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland (e-mail: quinones@ohsu.edu). Dr. Thielke is with the Geriatric Research, Education, and Clinical Center, Puget Sound VA Medical Center, and the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle. Ms. Beaver, Dr. Trivedi, Dr. Williams, and Dr. Fan are with the Health Services Research and Development Service, Puget Sound VA Medical Center, Seattle. Dr. Williams is also with the Department of Health Services, University of Washington, Seattle.

Copyright © 2014 by the American Psychiatric Association

Abstract

Objective  This study characterized racial-ethnic differences in treatment of veterans with chronic depression by examining antidepressant and psychotherapy use among non-Hispanic black, non-Hispanic white, Hispanic, Asian, and American Indian–Alaska Native (AI/AN) veterans.

Methods  Logistic regression models were estimated with data from the U.S. Department of Veterans Affairs (VA) medical records for a sample of 62,095 chronically depressed patients. Data (2009–2010) were from the VA External Peer Review Program. Three primary outcome measures were used: receipt of adequate antidepressant therapy (≥80% medications on hand), receipt of adequate psychotherapy (at least six sessions in six months), and receipt of guideline-concordant treatment (either of these treatments).

Results  Compared with whites, nearly all minority groups had lower odds of adequate antidepressant use and guideline-concordant care in unadjusted and adjusted models (antidepressant adjusted odds ratio [AOR] range=.53–.82, p<.05; guideline-concordant AOR range=.59–.83, p<.05). Although receipt of adequate psychotherapy was more common among veterans from minority groups in unadjusted analyses, differences between Hispanic, AI/AN, and white veterans were no longer significant after covariate adjustment. After adjustment for distance to the VA facility, the difference between black and white veterans was no longer significant.

Conclusions  A better understanding of how patient preferences and provider and system factors interact to generate differences in depression care is needed to improve care for patients from racial-ethnic minority groups. It will become increasingly important to differentiate between health service use patterns that stem from genuine differences in patient preferences and those that signify inequitable quality of depression care.

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Figure 1 Adjusted prevalence of adequate depression care among veterans with chronic depression, by racial-ethnic groupa

a Guideline-concordant therapy: either ≥6 psychotherapy sessions or an ≥80% supply of antidepressants

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Table 1Characteristics of 62,095 veterans with chronic depression, by racial-ethnic groupa
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a Values are percentages unless otherwise noted.

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b Data were missing for 141 veterans (.2%). Total never married=8,087 (13.0%)

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c Used as a proxy indicator of low socioeconomic status

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d Data were missing for 632 veterans (1.0%).

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e Possible scores range from 0 to 17, with higher scores indicating increasing comorbidity.

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f Data were missing for 2,489 veterans (4.0%).

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g Sufficient prescriptions to take the medication for at least 80% of the 6-month follow-up period

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h ≥6 sessions in the 6-month follow-up period

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i Either adequate antidepressant therapy or adequate psychotherapy

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Table 2Receipt of adequate depression care by 62,095 veterans with chronic depression, by racial-ethnic group
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a Adequate antidepressant therapy: sufficient prescriptions to take the medication for at least 80% of the 6-month follow-up period; adequate psychotherapy: ≥6 sessions in the 6-month follow-up period; guideline-concordant treatment: either adequate antidepressant therapy or adequate psychotherapy

Table Footer Note

b Adjusted for age, sex, race, marital status, socioeconomic status, smoking status, alcohol use, substance abuse diagnosis, posttraumatic stress disorder diagnosis, Charlson-Deyo comorbidity score, any primary care visits 1 year before index depression visit, and any mental health visits 1 year before index depression visit

Table Footer Note

c Adjusted for all of the above plus distance from patient’s residence to parent facility (where the patient was diagnosed for depression)

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