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Depression Treatment Preferences of VA Primary Care Patients

Received January 17, 2006; revised June 13, 2006; accepted July 6, 2006. From the Center for the Study of Chronic, Comorbid Mental and Physical Disorders, Portland VA Medical Center, Portland, OR. Send correspondence and reprint requests to Steven K. Dobscha, M.D., Portland VA Medical Center, P.O. Box 1034 (R&D 66), Portland, OR 97207. e-mail: steven.dobscha{at}va.gov
© 2007 The Academy of Psychosomatic Medicine

ABSTRACT

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The authors identified veterans’ depression treatment preferences and explored relationships between preferences, process of care, and clinical outcomes. Patients entering a collaborative depression intervention trial in primary care completed an assessment of treatment preferences. Medical record review was used to identify treatments offered and received over a 12-month period. Of 314 patients, 32% preferred antidepressants; 19%, individual counseling; 18%, anti-depressants plus counseling; 7%, group counseling; and 25%, "watchful waiting." Although the treatment that was offered was associated with treatment preferences, being offered preferred treatment was not associated with receiving treatment or with changes in depression severity or satisfaction over time.

INTRODUCTION

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According to World Health Organization projections, depression will be the second-leading cause of disability in the developed world by 2020.¹ Depression is especially common in primary care, and many patients are treated for depression by primary care clinicians.^2,3 However, despite efforts to improve screening and clinician education, depression remains underrecognized and undertreated in primary care settings.² Also, poor adherence can contribute to undertreatment, and depression itself can exacerbate adherence problems.^4,5

Patients’ attitudes and treatment preferences have the potential to affect adherence, and investigators have begun to identify depression treatment preferences of various patient populations.^6–10 In a systematic review of studies of primary care patient depression treatment preferences,¹⁰ a majority of patients preferred counseling therapies over pharmacotherapy.

In another recently published study of depression treatment preferences of veterans,¹¹ two-thirds of patients preferred a combination of medication plus counseling. Preferences have been shown to be associated with gender and previous experience with medication or psychotherapy.¹¹

The relationship between depression treatment preferences and clinical outcomes is less clear. Qualitative data suggest that patients may be less likely to adhere to treatments they do not accept or prefer.^7,12 Some quantitative studies have detected relationships between treatment preferences and clinical outcomes,^6,8,9,11 whereas others have not seen these effects.^13,14

The objectives of the current study were to identify treatment preferences of veterans participating in a randomized trial of a collaborative intervention for depression in a VA primary care setting and to explore relationships between preferences, process of care, and patient outcomes over 12 months.

METHOD

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In July 2002, we initiated a randomized, controlled trial of a low-intensity collaborative intervention for depression in primary care (DEP–PC).^15,16 The local institutional review board reviewed and approved the study, and written informed consent was obtained from all patient and clinician participants. Forty-one primary care clinicians (28 physicians and 13 nurse-practitioners and physician assistants) from five clinics of one VA Medical Center participated. To decrease variability in baseline depression-related knowledge and skills, primary care clinicians participated in the MacArthur Foundation Depression Education Program¹⁷ before the study. This program, in two 4-hour sessions, addressed communication skills and knowledge related to recognizing and managing depression; however, specific training regarding soliciting and responding to patient treatment preferences was not included.

After the education program, clinicians were randomized to receive the collaborative intervention or usual care, and each patient’s intervention status was the same as his or her clinician’s intervention status. The intervention consisted of one early patient-educational contact by a care manager, ongoing depression monitoring, and communication of depression-severity scores and treatment recommendations to clinicians over 12 months. Lack of improvement could trigger additional recommendations, a single consultation visit with the intervention psychiatrist, or referral to mental health services. The referral process for mental health services (including waiting time for appointments) was the same regardless of whether the intervention team or primary care clinician (intervention or usual care) made the referral. Usual-care clinicians had access to initial and follow-up depression severity scores (available in the medical record).

Subjects were recruited for DEP–PC by screening patients with upcoming primary care appointments by telephone, using the Patient Health Questionnaire (PHQ).^18–21 Those scoring 10–25 (moderate-to-severe depression) were scheduled for study enrollment interviews within 2 weeks of phone screening. The primary DEP–PC inclusion criterion was a repeat PHQ score of 10–25 or Hopkins Symptom Check List (HSCL; [SCL–20])²² score 1.0 at the enrollment interview. Patients with very severe depression (PHQ scores: 26–27), active suicidal ideation, treatment by mental health specialists within the past 6 months, cognitive impairment, or history of psychotic symptoms, bipolar disorder, or terminal illness were excluded. Between July 2002 and October 2003, a total of 3,103 patients completed phone screening, and 375 subsequently enrolled in the DEP–PC.

At DEP–PC study entry, we inquired about patients’ treatment preferences with five items adapted from Dwight-Johnson et al.²³ (see Appendix 1). Treatment preference options included antidepressants, individual counseling, group counseling, antidepressants plus counseling, and "wait and see (no treatment; ["watchful waiting"]). Patients also completed the Post-Traumatic Stress Disorder (PTSD) Checklist (PCL),²⁴ the Dysthymia stem from the Affective Disorders section of the World Health Organization Composite International Diagnostic Interview (CIDI),²⁵ and the Alcohol Use Disorder Identification Test (AUDIT–C).²⁶

All clinicians received notification when their patients enrolled in the study, as well as baseline PHQ scores and brief, general guidelines for diagnosis and treatment (see Appendix 2). Clinicians did not receive reports of patients’ treatment preferences, and patient preferences were not used to determine DEP–PC intervention status.

The date of the study enrollment interview was used as the start date for the 12-month follow-up period. PHQ depression severity scores and four items addressing global and depression-related treatment satisfaction^27,28 were measured at 6 and 12 months. Using a checklist derived from the Depression Guideline Measure,²⁹ electronic patient medical records were reviewed to identify and classify treatment approaches: 1) An antidepressant was considered offered when a prescription was entered into the computer; 2) Individual counseling was considered offered when a mental health referral was generated by the primary care clinician, as patients must first meet with a mental health clinician before receiving counseling; 3) Group treatment was considered offered when a referral for a specific group was generated; and 4) "Watchful waiting" was considered offered when a progress note indicated that the primary care clinician had considered depression but actively chose not to initiate treatment. Consultation visits with the DEP–PC intervention psychiatrist were not counted as mental health visits. Each medical record was reviewed by at least two research assistants; interrater reliability was good-to-excellent ( 0.75 for all items),^29,30 and an investigator (S. Dobscha) arbitrated coding discrepancies.

To identify treatment received, mental health appointment and antidepressant prescription data for all patients were extracted from a regional VA Data Warehouse. This database contains information from each clinical facility in the region and from national VA databases, and reliability checks are performed regularly. Two types of antidepressants, tricyclic antidepressants 50 mg per day or trazodone, were not classified as antidepressants for the current study because they are usually prescribed for conditions other than depression at this institution.

Statistical Analysis
For our primary analysis, we examined preferences and outcomes of patients in the overall sample. In a secondary analysis, we examined preferences and outcomes of patients who were not taking antidepressants at study entry. Because patient treatment preferences, baseline depression severity, posttraumatic stress disorder (PTSD) and dysthymia status did not vary at the provider level, mixed models were not used in the analysis. Chi-square tests were used for categorical and binomial dependent variables, and t-tests and ANOVA were used to compare continuous dependent variables. Tukey’s honestly significant difference (HSD) was used for post-hoc paired comparisons. All analyses were performed with SPSS 12.0 or 13.0 for Windows.

RESULTS

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Of 375 patients enrolled in DEP–PC, 5 gave no response or more than one response to the treatment preferences question, and 5 reported receiving antidepressant medications from non-VA clinicians. Also, over the course of DEP–PC, 51 enrollees (14%) deviated from group assignment (because of change in clinician) or study protocol. Thus, 61 patients were excluded from the analysis. Characteristics of the 314 patients in the final study sample, and by treatment preference, are shown in Table 1. Notably, comorbid illnesses were prevalent, and 39% of participants were taking antidepressants at the time of study entry.

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TABLE 1. Patient Characteristics Overall and by Treatment Preference

Treatment Preferences
Antidepressant medication was preferred most often (32%), followed by watchful waiting (25%), individual counseling (19%), antidepressants plus counseling (18%), then group therapy (7%). Treatment preferences were associated with baseline PHQ depression severity, PTSD diagnosis (²=10.13; p=0.04), and being on antidepressants at study entry (²=41.33; p<0.001). Patients preferring antidepressants alone or with counseling had more severe depression than other preference groups (F=2.84; p=0.02). Treatment preferences also varied by employment status; patients preferring individual counseling, alone or with antidepressants, were more likely to have worked in the previous 12 months (²=12.87; p=0.01).

Treatment Offered
Eighty-two percent of patients (258/314) were offered at least one form of active treatment (antidepressants and/or individual or group mental health referral) during the study period. Table 2 describes treatment offered, by preference category. Except for group therapy, treatments offered were associated with patient preferences. Patients offered any active treatment had more severe depression than patients not offered active treatment (PHQ score: 14.4 versus 11.4; t=4.61; p<0.001), and patients with PTSD and dysthymia were more frequently offered active treatment than patients without these disorders (88% versus 78%; ²=5.05; p=0.03; 91% versus 74%: ²=15.37; p<0.001, respectively). DEP–PC intervention status improved the probability of being offered active treatment (87% versus 77%; ²=5.18; p=0.02).

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TABLE 2. Treatment Offered During the Study Year, by Treatment Preference

Treatment Received
Overall, 78% of patients (244/314) received some form of active depression treatment (filled a prescription or attended a mental health appointment). Table 3 shows treatment received according to preference category. Patients who received active treatment had greater baseline depression severity than patients who did not receive active treatment (PHQ score: 14.3 versus 12.3; t=3.26, p=0.001), and patients with PTSD and dysthymia were more likely to receive active treatment than patients without these disorders (86% versus 72%; ²=7.79; p=0.005; 86% versus 70%; ²=10.46; p=0.001, respectively). Alcohol use disorder (p=0.79) and DEP–PC intervention status (p=0.11) were not significantly associated with receiving active treatment.

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TABLE 3. Treatment Course Over 12 Months

Although having a preference for a treatment was associated with being offered that treatment, it was not associated with receiving that treatment. Although patients preferring medication with or without counseling were significantly more likely to fill antidepressant prescriptions than patients preferring other options (84% versus 62%; ²=18.79; p<0.001), after controlling for whether antidepressants were prescribed (offered), this difference became nonsignificant (93% versus 91%; p=0.50). Among patients offered mental health referrals, 82% of those preferring counseling attended at least one mental health appointment, as compared with 86% of patients with other preferences (p=0.59). Of patients preferring individual counseling and antidepressants and who were offered these treatments, 90% attended at least one mental health appointment and filled at least one prescription for an antidepressant, as compared with 77% among other treatment-preference groups (p=0.25).

Treatment Outcomes
We detected no significant associations between treatment preference and change in depression severity (PHQ Change score). There were no associations between being offered or receiving one’s preferences and depression change scores. Within the subgroup of DEP–PC intervention patients, there were also no associations between treatment preferences and depression severity over time. Although we found that patients offered any active treatments were more satisfied with their medical treatment at 6 months (PHQ Change: 3.61 versus 3.15; t=2.77; p=0.006) and 12 months (PHQ Change: 3.49 versus 3.12; t=2.10; p=0.04), there were no associations between being offered or receiving a preferred treatment and patient satisfaction.

Patients Not Taking Antidepressants at Baseline
Among patients not taking antidepressants at study entry (N=191), 36% preferred antidepressants; 34%, counseling (individual or group) without medications; and 31% preferred watchful waiting. In contrast, among patients who were taking antidepressants at study entry, 72% preferred antidepressants (²=40.43; p<0.001); 13% preferred counseling without medications (²=52.7; p<0.001); and 15% preferred watchful waiting (²=40.62; p<0.001).

Of the patients not taking antidepressants at baseline, 65% were subsequently prescribed antidepressants. Patients not taking antidepressants at baseline who preferred antidepressants with or without counseling were more likely to be offered antidepressants than patients preferring other options (77% versus 59%; ²=6.19; p=0.013). However, patients not taking antidepressants at baseline were less likely than patients taking antidepressants at baseline to fill prescriptions when antidepressants were offered (86% versus 98%; ²=10.54; p=0.001).

Patients not taking antidepressants at baseline who preferred counseling were more likely to be referred for individual mental health appointments than patients preferring other treatment options (31% versus 15%; ²=6.89; p=0.009), but were not more likely to attend mental health appointments, after controlling for whether individual mental health appointments were offered (p=0.34). Finally, as with the overall sample, there were no significant associations between treatment preference, receiving preferred treatment, and changes in depression severity among patients not on antidepressants at study entry.

DISCUSSION

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Half of the veterans in our sample preferred antidepressants or antidepressants-plus-counseling, and one-quarter preferred watchful waiting. Eighty-two percent of veterans were offered some type of treatment, which was most frequently antidepressants. Treatment offered was associated with treatment preferences, depression severity, comorbid PTSD, and dysthymia. However, being offered a treatment that had been preferred was not associated with receiving that treatment. Finally, there were no significant associations between treatment preferences, receiving preferred treatment, and satisfaction or changes in depression severity.

Similar to findings of previous studies, ours found that patients with greater baseline depression severity were more likely to be offered and receive antidepressant therapy and that patients taking antidepressants at baseline were more likely to prefer antidepressants.^11,23 In contrast to subjects in several studies,^6,8,23,31,32 veterans in our sample found antidepressants to be preferable to psychotherapy. Among veterans not taking antidepressants at study entry, however, preferences were more evenly divided among antidepressants, counseling, and watchful waiting. Our findings are thus somewhat consistent with Lin et al.’s¹¹ study of a VA primary care population showing that a majority of veterans find medications or medications-plus-counseling to be preferable. Differences in preference may reflect demographic differences between veterans and other groups, as well as other factors, such as patients’ knowledge about depression,^10,23 clinician training, or the clinical resources that are available.

Despite an increased rate of preference for antidepressants, the results also show that a sizable number of veterans prefer individual counseling. Yet, relatively few were referred for individual mental health appointments. Veterans rated group treatment as least preferable, and the few who preferred it were not referred to it. Although group treatment can be effective, our results suggest that veterans and clinicians may need more education about the potential benefits of group treatment.

There are several potential limitations of this study. First, the high prevalence of psychiatric comorbidity in our sample might limit generalizability to other populations. However, other studies of veterans have shown similar levels of comorbidity,^33,34 which suggests that the results are likely to be generalizable to other veteran populations. Second, all clinicians were notified when patients entered the study. This likely increased rates of detection and initial treatment of depression above rates that might otherwise be found in many clinical settings. On the other hand, neither intervention nor usual-care clinicians were alerted to patients’ depression treatment preferences; this would also be consistent with what occurs in most clinical settings. Third, we relied primarily on chart review to determine treatment offered and received, rather than observing actual clinical interactions or interviewing patients and clinicians about the content of their interactions. Finally, our measures of treatment received (for example, attending at least one mental health visit and filling prescriptions) very likely overestimate actual adherence over time.

Nonetheless, our results document the depression treatment preferences of veterans and suggest that receiving treatment and clinical response are not associated with having particular preferences or with being offered one’s preferred treatment in this setting. Further study involving observation of actual clinical interactions and use of more sensitive measures of treatment received over time would be helpful to better clarify the relationships among preferences, treatment offered and received, and clinical outcomes.

ACKNOWLEDGMENTS

 
The authors gratefully acknowledge Nancy Cuilwik, Megan Crutchfield, and Marsha Perkett, who performed the chart review activities necessary for this study.

The views expressed in this manuscript are those of the authors and do not necessarily represent the views of the VA Center, Portland, OR; Department of Psychiatry, Oregon Health and Science University, Portland; Research and Development Service, Portland VA Medical Center, Portland OR; Division of Hospital and Specialty Medicine, Portland VA Medical Center, Portland OR; or the Department of Medicine, Oregon Health and Science University, Portland.

The research reported here was supported by the VA, Veterans Health Administration, and Health Services Research and Development Service Projects MHI 20-020 and RCD04129.

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APPENDIX 1. VA Depression Treatment Preference Questions

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APPENDIX 2. Patient Health Questionnaire (PHQ) Scoring Guide for Participating Clinicians35

REFERENCES

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Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via Google Scholar Articles by Dobscha, S. K. Articles by Gerrity, M. S. Search for Related Content PubMed Citation Articles by Dobscha, S. K. Articles by Gerrity, M. S. Other Patient Groups/Issues Primary Care Depression

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