Same-Day Primary Care-Mental Health Integration Services May Facilitate Timely Receipt of Treatment for Depression
Since 2007, VA initiatives have supported the integration of mental health resources into primary care practices, known as Primary Care-Mental Health Integration (PC-MHI). VA now requires VAMCs and Community Based Outpatient Clinics (CBOCs) serving 5,000 or more Veterans to include both co-located collaborative care and care management as part of their PC-MHI programs, although not all sites currently have both components. This retrospective cohort study evaluated associations between indicators of the settings where Veterans received care on the day of an initial positive screen for depression and initiation of treatment. Specifically, this study assessed whether VA patients with same-day PC-MHI services were more likely to receive depression treatment within 12 weeks, as compared to similar patients who did not receive same-day PC-MHI. Using VA data, investigators identified a random sample of 36,263 Veterans who were VA primary care patients and had received a positive depression screen between 10/09 and 9/10. Veterans were assessed for a diagnosis of depression and for the initiation of antidepressants or psychotherapy on the day of screening, within 12 weeks, and within 6 months. [Tricyclic antidepressants were not included in this analysis because they are often used for pain or sleep indications, rather than depression.] Among Veterans with PC encounters on the screening day, setting of services received that day was categorized as PC only, PC-MHI, or Specialty Mental Health (SMH). Other measures included patient demographics, VA healthcare use in the prior year, and comorbid mental health conditions.
- A greater percentage of Veterans seen in either PC-MHI or SMH settings were diagnosed with depression on the same day of screening (68% and 60%, respectively), compared with Veterans seen in PC-only settings (30%). Also, Veterans who received same-day PC-MHI services were more likely to initiate depression-related treatment than were those receiving only PC services.
- By six months, the probability of diagnosis had increased in all groups, but PC-only patients had the lowest percentage of depression diagnoses (44%).
- Being seen in PC-MHI or SMH on the day of the depression screen increased the probability of receiving both psychotherapy and antidepressant treatment. For example, compared with Veterans seen in PC-only settings, Veterans seen in PC-MHI settings had 8.2 times greater odds of receiving psychotherapy, 2.3 times greater odds of having an antidepressant prescription fill, and 6.6 times greater odds of initiating either treatment.
- Veterans who received same-day PC-MHI services may have differed from other patients in their unmeasured treatment needs and willingness to engage in depression treatment.
- A positive depression screen is not equivalent to a diagnosis of depression, and it is uncertain what percentage of patients who receive positive screens should initiate depression-related treatment.
This study was conducted as part of the PC-MHI National Evaluation. Dr. Zivin was supported by an HSR&D Career Development Award. Drs. Bohnert, Zivin, and McCarthy are part of HSR&D's Center for Clinical Management Research, Ann Arbor, MI.
Szymanski B, Bohnert K, Zivin K, and McCarthy J. Integrated Care: Treatment Initiation Following Positive Depression Screens. Journal of General Internal Medicine November 13, 2012; E-pub ahead of print.