Significant Number of Veterans with Depression May Not Be Receiving their Preferred Treatment
BACKGROUND:
Patient-centered care aims to be “respectful of and responsive to individual patient preferences, needs, and values,” including receiving preferred treatments unless clinically contraindicated. Depression can be effectively treated with two first-line options: psychotherapy and/or antidepressant medication. By integrating mental healthcare into primary care, VA offers a unique opportunity to examine the effects of patient preferences on depression treatment receipt and adherence. Therefore, this study examined whether treatment preferences predict types of depression treatment received and adherence to those treatments. Between 2018 and 2020, investigators recruited 2,582 Veterans (77% male) who were initiating treatment for depression in any VA healthcare facility. Main outcome measures included patients’ self-reported preferences for medication and psychotherapy, in addition to the receipt of treatment and adherence (refilling medications, attending 3+ psychotherapy sessions) over three months. Investigators also adjusted for sociodemographics, geographic variables, clinical features (depression severity, life stressors, comorbidity, childhood adversities), and treatment setting.
FINDINGS:
- Mismatches between treatment preferences and type received were common and associated with worse treatment adherence for psychotherapy: 32% of VA patients who preferred medication and 22% of VA patients who preferred psychotherapy did not receive those treatments.
- More patients reported strong positive preferences for psychotherapy compared to medication (51% vs 37%) and strong negative preferences for medication compared to psychotherapy (16% vs 2%).
- Patients did not prefer (25%) or adhere (18%) to combined psychotherapy/medication treatment.
- Patients in primary care settings without full-time embedded mental health staff had lower odds of receiving (but not adhering to) psychotherapy than patients in specialty mental healthcare settings.
IMPLICATIONS:
- VA has invested heavily in national initiatives to increase mental health services and provides largely accessible and mostly equitable care. Future work should continue to explore where and for whom patient preferences are not being met when doing so is not clinically contraindicated – and how the match between preferences and treatments received can be increased in the service of improving treatment adherence and outcomes.
LIMITATIONS:
- Preferences were assessed an average of one week after initiating treatment; patient preferences prior to that time might have been somewhat different.
- This study did not account for prior treatment history, as the success or failure of prior treatment may influence patients’ preferences and clinician judgement in depression treatment.
AUTHOR/FUNDING INFORMATION:
Dr. Leung is part of HSR&D’s Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP) in Los Angeles, CA
Leung L, Ziobrowski H, Puac-Polanco V, et al. Are Veterans Getting their Preferred Depression Treatment? A National Observational Study in the Veterans Health Administration. Journal of General Internal Medicine. October 6, 2021; online ahead of print.
