Analysis of Quality of Care After Screening for Depressive Symptoms in Primary Care

November 2022

The Veterans Health Administration (VA) screens patients in primary care for depression annually. Whether this screening leads to appropriate follow-up and treatment that meets guidelines is unclear. The goal of a retrospective cohort study of patients in the VA system was to quantify how many patients receive timely follow-up and treatment. A secondary goal was to identify clinical or demographic factors associated with these outcomes.

The investigators examined electronic medical records from patients who visited 82 VA hospitals and clinics in the southwestern region of the United States for primary care between October 1, 2015, and September 30, 2019. Patients were included if they were considered positive for depressive symptoms by the 2-item Patient Health Questionnaire, had follow-up visits with the VA, did not have depression in the previous 6 months, and were judged to have depression by a physician.

Quality assurance guidelines were used to determine appropriate follow-up care for depressive symptoms. Timely follow-up was defined as ≥3 mental health or psychotherapy visits, or ≥3 primary care visits for depression within 84 days of screening positive for depressive symptoms. Minimally appropriate treatment was defined as ≥60 days of antidepressant prescriptions, ≥4 mental health visits, or ≥3 psychotherapy visits within 1 year of a positive screening for depressive symptoms.

Of the 607,730 veterans who took the 2-item Primary Health Questionnaire in primary care, 8% were positive for new-onset depressive symptoms. Of the 33,694 veterans who screened positive and had not had recent mental healthcare visits, 45% were judged to have depression by a physician. The mean age of these patients was 52 years and 88% were men.

The investigators found that 32% of these patients who had depression received timely follow-up, and minimally appropriate treatment within 1 year was completed for 77% of patients. They also examined which factors were associated with meeting the guidelines for patient care quality. Younger age, comorbid mental illness, and Black race were associated with increased odds of receiving timely follow-up. However, physical comorbidities were associated with a lack of timely follow-up.

In contrast, only younger age and comorbid mental illness were associated with minimally appropriate treatment. Both factors were associated with higher odds of receiving minimal treatment. The investigators did find some differences in the types of treatment received between different racial and ethnic groups, although no overall disparities in receiving treatment were seen. Significantly lower rates of antidepressant treatment and higher rates of mental health or psychotherapy visits were found for Black and Hispanic patients compared with White patients.

The results showed that approximately two-thirds of patients did not receive timely follow-up after screening and one-quarter did not receive minimally appropriate treatment within 1 year. Some limitations of the study were the inability to measure the success of therapy or obtain data for patients who sought care elsewhere after screening. “Although the VA’s investments in depression screening and subsequent follow-up care and treatment have seemingly closed some disparity gaps (in mental health comorbidities and race), several others remain (in age and in physical health comorbidities),” the investigators concluded.

Source

Leung LB, Chu K, Rose D, et al. Electronic population-based depression detection and management through universal screening in the Veterans Health Administration. JAMA Netw Open. 2022;5(3):e221875.

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