Medical providers often fail to treat depression. We examined whether treatment is more aggressive in a setting with accessible mental health resources, the Veterans Health Administration (VA). VA and non-VA primary care physicians and medical specialists viewed a videotape vignette portraying a patient meeting criteria for major depression and then answered interviewer-administered questions about management. We found that 24% of VA versus 15% of non-VA physicians would initiate guideline-recommended treatment (antidepressants or mental health referral, or both) (P = .09). Among those who identified depression as likely, 42% of VA versus 19% of non-VA physicians would treat (P = .002): 23% versus 3% recommended mental health referral (P < .001) and 21% versus 17% an antidepressant (P = .67). Although many patients with major depression may not receive guideline-recommended management, VA physicians do initiate mental health referral more often than do non-VA physicians. Access to mental health services may prove valuable in the campaign to increase physician adherence to depression clinical guidelines.
Pantilat SZ, Chesney M, Lo B. Effect of incentives on the use of indicated services in managed care. West J Med. 1999;170:137-142.
2.
Greenfield S, Nelson EC, Zubkoff M, et al.Variations in resource utilization among medical specialties and systems of care. Results from the medical outcomes study. JAMA. 1992;267:1624-1630.
3.
Meredith LS, Rubenstein LV, Rost K, et al.Treating depression in staff-model versus network-model managed care organizations. J Gen Intern Med. 1999;14:39-48.
4.
Allison JJ, Kiefe CI, Weissman NW, et al.Relationship of hospital teaching status with quality of care and mortality for Medicare patients with acute MI. JAMA. 2000;284:1256-1262.
5.
Allocation Resource Center. Fiscal Year 2000 Funding Allocations-Final Data Release-December 20, 1999; VERA 2000 Information and Reports; Veterans Health Administration. Available at: vaww.arc.med.va.gov.
6.
Petersen LA, Normand SL, Daley J, et al.Outcome of myocardial infarction in Veterans Health Administration patients as compared with medicare patients. N Engl J Med. 2000;343: 1934-1941.
7.
Jha AK, Shlipak MG, Hosmer W, et al.Racial differences in mortality among men hospitalized in the Veterans Affairs health care system. JAMA. 2001;285:297-303.
8.
Peabody JW, Luck J. How far down the managed care road? A comparison of primary care outpatient services in a Veterans Affairs medical center and a capitated multispecialty group practice. Arch Intern Med. 1998;158:2291-2299.
9.
Katon W, Schulberg H. Epidemiology of depression in primary care. Gen Hosp Psychiatry. 1992;14:237-247.
10.
Regier DA, Goldberg ID, Taube CA. The de facto US mental health services system: a public health perspective. Arch Gen Psychiatry. 1978;35:685-693.
11.
Stewart RB, Blashfield R, Hale WE, et al.Correlates of Beck Depression Inventory scores in an ambulatory elderly population: symptoms, diseases, laboratory values, and medications. J Fain Pract. 1991;32:497-502.
12.
Borson S, Barnes RA, Kukull WA, et al.Symptomatic depression in elderly medical outpatients. I. Prevalence, demography, and health service utilization. J Am Geriatr Soc. 1986;34:341-347.
13.
Murray CJ, Lopez AD. Alternative projections of mortality and disability by cause 1990-2020: Global Burden of Disease Study. Lancet. 1997;349:1498-1504.
14.
Callahan CM, Wolinsky FD, Stump TE, et al.Mortality, symptoms, and functional impairment in late-life depression. J Gen Intern Med. 1998;13:746-752.
15.
Covinsky KE, Fortinsky RH, Palmer RM, et al.Relation between symptoms of depression and health status outcomes in acutely ill hospitalized older persons. Ann Intern Med. 1997;126:417-425.
16.
Coulehan JL, Schulberg HC, Block MR, et al.Treating depressed primary care patients improves their physical, mental, and social functioning. Arch Intern Med. 1997;157:1113-1120.
17.
Sturm R. How expensive is unlimited mental health care coverage under managed care?JAMA. 1997;278:1533-1537.
18.
Wells KB. Depression in general medical settings. Implications of three health policy studies for consultation-liaison psychiatry. Psychosomatics. 1994;35:279-296.
19.
Freund KM, Moskowitz MA, Lin TH, et al.Early antidepressant therapy for elderly patients. Am J Med. 2003;114:15-19.
20.
Depression Guideline Panel. Depression in Primary Care. Vol 2. Treatment of Major Depression. Clinical Practice Guideline, Number 5. Rockville Md: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1993. AHCPR Publication 93-0551.
21.
Wells KB, Sherbourne C, Schoenbaum M, et al.Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA. 2000;283:212-220.
22.
Simon GE, Grothaus L, Durham ML, et al.Impact of visit co-payments on outpatient mental health utilization by members of a health maintenance organization. Am J Psychiatry. 1996; 153:331-338.
23.
Jones LR, Parlour RR, Badger LW. Mental health services in primary health care: yet another era of disillusionment?Med Care. 1982;20:1222-1232.
24.
Soumerai SB, McLaughlin TJ, Ross-Degnan D, et al.Effects of a limit on Medicaid drug-reimbursement benefits on the use of psychotropic agents and acute mental health services by patients with schizophrenia. N Engl J Med. 1994;331:650-655.
25.
Hirschfeld RM, Keller MB, Panico S, et al.The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression. JAMA. 1997;277:333-340.
26.
Iezzoni L. Risk Adjustment for Measuring Healthcare Outcomes. 2nd ed.Chicago: Health Administration Press;1997.
27.
Biernacki P, Waldorf D. Snowball sampling: problems and techniques of chain referral sampling. Sociological Methods Res. 1981;10:141-163.
28.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed.Washington, DC: American Psychiatric Press;1994.
29.
Feldman HA, McKinlay JB, Potter DA, et al.Nonmedical influences on medical decision making: an experimental technique using videotapes, factorial design, and survey sampling. Health Serve Res. 1997;32:343-366.
30.
McKinlay JB, Lin T, Freund K, et al.The unexpected influence of physician attributes on clinical decisions: results of an experiment. J Health Soc Behav. 2002;43:92-106.
31.
Depression Guideline Panel. Depression in Primary Care. Vol 1. Detection and Diagnosis. Clinical Practice Guideline Number 5. Rockville Md: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research;1993. AHCPR Publication 93-0550.
32.
Rost K, Williams C, Wherry J, et al.The process and outcomes of care for major depression in rural family practice settings. J Rural Health. 1995;11:114-121.
33.
Williams JW Jr, Rost K, Dietrich AJ, et al.Primary care physicians' approach to depressive disorders. Effects of physician specialty and practice structure. Arch Fami Med. 1999;8:58-67.
34.
van Os TW, Ormel J, van den Brink RH, et al.Training primary care physicians improves the management of depression. Gen Hosp Psychiatry. 1999;21:168-176.
35.
Callahan CM, Hendrie HC, Dittus RS, et al.Improving treatment of late life depression in primary care: a randomized clinical trial. J Am Geriatr Soc. 1994;42:839-846.
36.
Callahan CM, Dittus RS, Tierney WM. Primary care physicians' medical decision making for late-life depression. J Gen Intern Med. 1996;11:218-225.
37.
Carney PA, Dietrich AJ, Eliassen MS, et al.Recognizing and managing depression in primary care: a standardized patient study. J Fain Pract. 1999;48:965-972.
38.
Cooper-Patrick L, Powe NR, Jenckes MW, et al.Identification of patient attitudes and preferences regarding treatment of depression. J Gen Intern Med. 1997;12:431-438.
39.
Hankin CS, Spiro A III, Miller DR, et al.Mental disorders and mental health treatment among US Department of Veterans Affairs outpatients: the Veterans Health Study. Am J Psychiatry. 1999;156:1924-1930.
40.
Rosenheck R, DiLella D. Department of Veterans Affairs National Mental Health Program Performance Monitoring System: Fiscal Year 1999 Report (Draft). West Haven: Northeast Program Evaluation Center, VA Connecticut Healthcare System; February 2, 2000.
41.
Kessler RC, McGonagle KA, Zhao S, et al.Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry1994;51:8-19.
42.
Moos RH, Mertens JR. Patterns of diagnoses, comorbidities, and treatment in late-middle-aged and older affective disorder patients: comparison of mental health and medical sectors. J Am Geriatr Soc. 1996;44:682-688.
43.
Friedman MJ, Schnurr PP, McDonagh-Coyle A. Post-traumatic stress disorder in the military veteran. Psychiatr Clin North Am. 1994;17:265-277.
44.
Kazis LE, Miller DR, Clark J, et al.Health-related quality of life in patients served by the Department of Veterans Affairs: results from the Veterans Health Study. Arch Intern Med. 1998; 158:626-632.
45.
Rost K, Nutting P, Smith J, et al.The role of competing demands in the treatment provided primary care patients with major depression. Arch Fam Med. 2000;9:150-154.
46.
Klinkman MS. Competing demands in psychosocial care. A model for the identification and treatment of depressive disorders in primary care. Gen Hosp Psychiatry. 1997;19:98-111.
47.
Wilson NJ, Kizer KW. The VA health care system: an unrecognized national safety net. Health Aff (Millwood). 1997;16:200-204.
48.
Mitchell JM, Hadley J, Sulmasy DP, et al.Measuring the effects of managed care on physicians' perceptions of their personal financial incentives. Inquiry. 2000;37:134-145.
49.
Grumbach K, Osmond D, Vranizan K, et al.Primary care physicians' experience of financial incentives in managed-care systems. N Engl J Med. 1998;339:1516-1521.
50.
Peabody JW, Luck J, Glassman P, et al.Comparison of vignettes, standardized patients, and chart abstraction: a prospective validation study of 3 methods for measuring quality. JAMA. 2000;283:1715-1722.
51.
Hornbrook MC, Hurtado AV, Johnson RE. Health care episodes: definition, measurement and use. Med Care Rev. 1985;42:163-218.
52.
Ayanian JZ, Hauptman PJ, Guadagnoli E, et al.Knowledge and practices of generalist and specialist physicians regarding drug therapy for acute myocardial infarction. N Engl J Med. 1994; 331:1136-1142.
53.
Meredith LS, Wells KB, Camp P. Clinician specialty and treatment style for depressed outpatients with and without medical comorbidities. Arch Fam Med. 1994;3:1065-1072.
54.
Banazak DA. Late-life depression in primary care. How well are we doing?J Gen Intern Med. 1996;11:163-167.
55.
Cowper PA, DeLong ER, Peterson ED, et al.Geographic variation in resource use for coronary artery bypass surgery. IHD Port Investigators. Med Care. 1997;35:320-333.
56.
Ashton CM, Petersen NJ, Souchek J, et al.Geographic variations in utilization rates in Veterans Affairs hospitals and clinics. N Engl J Med. 1999;340:32-39.
57.
Sandvik H. Criterion validity of responses to patient vignettes: an analysis based on management of female urinary incontinence. Fam Med. 1995;27:388-392.
58.
Greenberg PE, Stiglin LE, Finkelstein SN, et al.The economic burden of depression in 1990. J Clin Psychiatry. 1993;54:405-418.
59.
Wickizer TM, Lessler D. Do treatment restrictions imposed by utilization management increase the likelihood of readmission for psychiatric patients?Med Care. 1998;36:844-850.
