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2023 HSR&D/QUERI National Conference Abstract

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4047 — Trends in the Utilization of Complex Interventions for Treatment Resistant Depression in the Veterans Health Administration

Lead/Presenter: Eric Hermes,  COIN - West Haven
All Authors: Hermes ED (VA Office of Mental Health and Suicide Prevention), Hoff RA (VA Office of Mental Health and Suicide Prevention) McGuire M (VA Office of Mental Health and Suicide Prevention) Holtzheimer PE (VA National Center for PTSD) Wiechers IR (VA Office of Mental Health and Suicide Prevention)

Objectives:
There are multiple interventions for treatment resistant mental health disorders, including depression. Such interventions, termed “somatic treatments”, include electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), and ketamine/esketamine, among others. The implementation of somatic treatments in the Veterans Health Administration (VA) is complex, requiring more resources and coordination compared to traditional outpatient care. This evaluation describes VA utilization of the most common somatic treatments for treatment resistant depression (TRD): ECT, rTMS, ketamine infusion, and esketamine.

Methods:
In fiscal years (FYs) 2015, 2018, 2020, and 2021, the VA Office of Mental Health and Suicide Prevention queried VA facilities on the utilization of somatic treatments. Assessments were completed electronically by facility mental health leads and reviewed by network mental health directors. Assessments included questions about the delivery of individual somatic treatments, including the number of Veterans treated at the facility or by referral to another VA or the community. Survey data were verified where possible using encounter codes as well as pharmacy and equipment databases.

Results:
Veterans utilizing any of the primary somatic treatments in FY21 numbered 3,481, a 72.0% increase from FY15 (n = 2,024). However, the number of facilities offering any somatic treatment, either at a VA or community facility, fell by 22, from 139 (98.6%) in FY15 to 117 (83.0%) in FY21. In FY21, 78 facilities (55.3%) offered ketamine (64 ketamine infusion and 70 esketamine), resulting in 893 Veterans treated (74.0% by ketamine infusion and 26% by esketamine), an 11-fold increase from FY15 (esketamine was approved for TRD in 2019). In FY21, 110 facilities (78.0%) offered rTMS and treated 1,574 patients, compared to 85 facilities (60.3%) treating 463 Veterans in FY15, over a 3-fold increase. However, the number of VA facilities offering ECT decreased, from 135 (95.7%) in FY15 to 129 (91.5%) in FY21. Similarly, the number of Veterans treated with ECT decreased, from 1,484 in FY15 to 1,014 in FY21. In addition, the proportion of Veterans treated in the community (on average 31.4% of care in FY15) increased by an average of almost 15% for three somatic treatments (ECT, rTMS, and esketamine), and decreased by 23.2% for ketamine infusion.

Implications:
The increasing number of Veterans with TRD receiving somatic treatments from FY15 to FY21 is encouraging, especially as these are complex interventions requiring significant resources, coordination, and presentation to a facility over a period with limited facility-based due to the recent pandemic. However, there are also worrisome trends such as the decreasing number of VA facilities offering any somatic treatment, especially ECT which may be the most effective and evidence-based treatment for severe TRD, as well as the increasing proportion of care sent to the community.

Impacts:
Data suggests that all forms of somatic treatments are dramatically underutilized among Veterans with TRD. Fewer than 4,000 Veterans received a somatic treatment in FY21, less than 2% of Veterans thought to have TRD. Data also suggests that the increase in patients receiving somatic treatments since FY15 may have been blunted, both by the pandemic and other currently undefined trends in care.