Vast Majority of Depressed Patients Go Untreated

Pauline Anderson

September 02, 2016

Fewer than a third of patients with depression are receiving treatment for this condition, a new survey has revealed.

Investigators at Columbia University Medical Center in New York City found that among adults who screened positive for depression, only 28.7% received any type of treatment.

The finding is "somewhat surprising," especially considering the fact that antidepressants are now the most commonly prescribed class of medications in the United States, lead author Mark Olfson, MD, told Medscape Medical News.

Dr Mark Olfson

"We don’t show trends here, so this is just about patterns, but the fact that less than a third of people who screened positive for depression received antidepressant treatment in a year is somewhat lower than I expected."

The study was published online August 29 in JAMA Internal Medicine.

The investigators note that little is known about the extent to which adults with depression receive care for the disorder and the degree to which treatment matches symptom severity.

The investigators analyzed data from the household components of the 2012 and 2013 Medical Expenditure Panel Surveys (MEPS) conducted by the Agency for Healthcare Research and Quality (AHRQ).

To screen for depression, the MEPS used the Patient Health Questionnaire–2 (PHQ-2), which asks about depressed mood and anhedonia during the past 2 weeks. Scores for the PHQ-2 range from 0 to 6, with a score of 3 or more indicating screen-positive depression.

During three interviews conducted in each survey year, respondents provided information on their use of antidepressants, antipsychotics, mood stabilizers, anxiolytic medications, and psychotherapy. They also revealed from which type of healthcare provider they received treatment for depression.

The investigators also examined psychological distress, which was assessed using the Kessler 6 (K6) scale. The K6 scale, which ranges from 0 to 24, with higher scores indicting more severe distress, asks about the frequency of mental health symptoms in the past 30 days. The authors stressed that although the K6 score correlates with several psychiatric disorders, it is not a diagnostic measure.

The survey showed that of 46,417 adult respondents, 8.4% had screen-positive depression.

Depression was almost five times more prevalent among adults in the lowest income group (18.2%) compared with the highest income group (3.2%). It was also more common among divorced, separated, or widowed (13.3%) individuals compared with their married counterparts (6.3%).

Only 28.7% of those with depression received any treatment for the disorder during the survey year. After adjusting for other covariates, the odds of receiving depression treatment were increased by being aged 35 to 64 years, female, white non-Hispanic, completing at least high school, and having health insurance.

Missed Opportunities

About 78.5% of those with depression who received no associated treatment made at least one medical visit during the survey year.

"This means that primary care physicians have opportunities to detect and either treat or refer their patients who have depression," said Dr Olfson.

On the other hand, it appeared that some patients received treatment for depression who did not have depression. About 8.1% of respondents received treatment for depression regardless of their depression screen status. Of these, only 29.9% had screen-positive depression, and 21.8% had serious psychological distress (a K6 score of 13 or higher).

This could mean that some treated patients are no longer depressed, "but the patterns do suggest that there may be overprescription of antidepressants," said Dr Olfson.

As for the type of depression treatment, use of antidepressants was the most common (87.0%), followed by psychotherapy (23.2%), anxiolytics (13.5%), antipsychotics (7.0%), and mood stabilizers (5.1%).

Most research shows that antidepressants are no better than placebo for mild depression. However, in this survey, respondents with less serious psychological distress were more likely to receive an antidepressant than those with more serious psychological distress.

"This is an important finding," said Dr Olfson. "Those with more serious psychological distress were more likely to see a psychiatrist, and you’d expect that; and they were more likely to get psychotherapy, and you’d expect that, too; but they were somewhat less likely to get an antidepressant, and you wouldn’t necessarily expect that."

This might be partly explained by the fact that it is easier for primary care physicians to prescribe antidepressants than to refer patients for psychotherapy, said Dr Olfson.

"These practitioners also tend to see less severe patients, so that might explain why the less severe group are more likely to get the antidepressants than the more severe group."

Assess Severity

According to the authors, clinicians should routinely assess depression severity and follow depression guidelines, which do not recommend antidepressants for mild symptoms.

The investigators found that psychotherapy was more frequently provided to patients with more serious psychological distress, a finding that is consistent with evidence supporting the efficacy of this treatment for moderate depression, with less benefit for mild depression.

Despite psychotherapy being effective for depression in later life, the survey found that this treatment was rarely provided to older adults, even those with serious psychological distress.

One explanation for this is that older patients are typically treated in primary care settings, where psychotherapy is less accessible. Other contributing factors, according to Dr Olfson, may be that these patients grew up in a time when psychotherapy was "somewhat more stigmatized," and many psychotherapists today gear their practice to younger patients.

Most patients treated for depression received this treatment exclusively from general medical professionals (73.3%). Fewer patients were treated by psychiatrists (23.6%) or other mental health specialists (12.6%).

Dr Olfson pointed out that patients with serious psychological distress were about twice as likely as those with less distress to be treated by a psychiatrist.

The survey results suggest that more could be done at the primary care level to better treat depression and to match patients with the best therapy, he said.

"The easiest and simplest first step in addressing gaps would be to expand the use of simple depression screening tools to increase identification of depression and to guide matching patients to appropriate depression treatment," said Dr Olfson. "Of course, it requires more than simply screening, but that to me is a strong first step to attacking what is a very complicated problem."

Dr Olfson believes the PHQ is an ideal screening tool as primary care physicians are most comfortable it, and it is a "very simple form" that can be completed by patients in waiting room.

Treatment Mismatch

Commenting on the findings for Medscape Medical News, Anita Everett, MD, president-elect of the American Psychiatric Association (APA), and chief medical officer at the Substance Abuse and Mental Health Services Administration, said several aspects of the survey are significant, including its size.

The survey results, said Dr Everett, "demonstrate that a lot of people are living with depression who are untreated" and that for those who are treated, there may be a "mismatch" in the treatments they are prescribed.

"I think there is some question about whether patients who are treated for depression are optimally treated," she said.

One thing Dr Everett found "concerning" about the survey was the "disproportionate" number of patients receiving treatment "who were on meds and on meds only."

She said she understands that patients push doctors for a quick and easy fix to get rid of their depression.

"There's a kind of tendency to say, 'If I just had a pill that would fix it, that’s easier than keeping appointments with a therapist, reading a self-help book, or using an online app.' "

The study was supported by the Agency for Healthcare Quality and Research. A coauthor received support from the National Institute on Drug Abuse. Dr Olfson and the other authors have disclosed no relevant financial relationships.

JAMA Intern Med. Published online August 29, 2016. Full text

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