Project Name:
Practice Variation in High- and Low-Value Care for Mood Disorders

Principal Investigator:
Gregory Simon MD MPH

Principal Investigator Contact Information:
simon.g@ghc.org

Principal Investigator institution:
Group Health Research Institute

Funder
NIMH

Funding Period:
09/2010 – 06/2015

Abstract:
This multi-site observational study examined patient, provider, and health system influences on process of depression care in primary care and mental health specialty settings.  Comprehensive records data from five MHRN sites (Group Health Cooperative, HealthPartners, Kaiser Permanente Colorado, Kaiser Permanente Hawaii, and Kaiser Permanente Southern California) were used to identify three patient cohorts:

  • Primary care patients receiving a new diagnosis of depression with no recent history of depression treatment
  • Primary care and mental health specialty patients initiating a new episode of antidepressant treatment with a diagnosis of depression
  • Mental health specialty patients initiating a new episode of psychotherapy with a diagnosis of depression

Grant Number:
U19 MH092201 (Mental Health Research Network Cooperative Agreement)

Participating Sites:               
Group Health Cooperative                                                     
HealthPartners Institute                                
Kaiser Permanente Colorado                        
Kaiser Permanente Hawaii
Kaiser Permanente Southern California        

Investigators:
Gregory Simon MD MPH
Robert Penfold PhD
Susan Shortreed, PhD
Rebecca Rossom MD
Arne Beck PhD
Beth Waitzfelder PhD
Karen Coleman PhD

Major Goals:
To examine patient and provider contributions to variation in care (medication and psychotherapy) for depression.

Description of study sample:
The sample includes new diagnoses and new treatment episodes between 1/1/2010 and 12/31/2012.  These data are being used to address the following specific questions:

  • Among primary care patients receiving a new diagnosis of depression, how do specific patient characteristics (age, sex, race/ethnicity, severity of depression) influence both the likelihood of initiating any treatment for depression and the choice between treatments (medication or psychotherapy)
  • Among patients initiating medication treatment for depression, how are medication selection, early medication adherence, and acute-phase treatment response related to specific patient characteristics (age, sex, race/ethnicity, severity of depression)?  How do these treatment processes vary among providers?
  • Among patients initiating psychotherapy for depression, how are early treatment adherence and acute-phase treatment response related to specific patient characteristics (age, sex, race/ethnicity, severity of depression)?  How do these treatment processes vary among providers?

Current Status:
All analyses are complete.

Study Registration:
N/A

Publications:
Simon GE, Coleman KJ, Waitzfelder BE, Beck A, Rossom RC, Stewart C, Penfold RB. Adjusting Antidepressant Quality Measures for Race and Ethnicity. JAMA Psychiatry. 2015 Oct;72(10):1055-6. doi: 10.1001/jamapsychiatry.2015.1437. No abstract available. PMID:26352783

Simon GE, Rossom RC, Beck A, Waitzfelder BE, Coleman KJ, Stewart C, Operskalski B, Penfold RB, Shortreed SM.J. Antidepressants are not overprescribed for mild depression. Clin Psychiatry. 2015 Dec;76(12):1627-32. doi: 10.4088/JCP.14m09162.PMID:26580702

Simon GE, Johnson E, Stewart C, Rossom RC, Beck A, Coleman KJ, Waitzfelder B, Penfold R, Operskalski BH, Shortreed SM.  Does patient adherence to antidepressant medication actually vary between physicians?  J Clin Psychiatry.  2017 Oct 24 (epub ahead of print)

Resources:
None

Lessons Learned:

  • In MHRN health systems, we see little evidence for over-prescribing of antidepressants for mild depression.
  • Likelihood of prematurely discontinuing antidepressant medication is much higher in minority racial and ethnic groups than in non-Hispanic Whites, and these racial and ethnic differences are far larger than differences related to other demographic or clinical characteristics.
  • Likelihood of prematurely discontinuing psychotherapy for depression is modestly higher in minority racial and ethnic groups – but racial/ethnic disparities in psychotherapy adherence are smaller than disparities in antidepressant medication adherence.
  • Among primary care patients receiving a new diagnosis of depression, likelihood of initiating any specific treatment (medication or psychotherapy) is lower among minority racial or ethnic groups.  Patients from minority racial and ethnic groups are more likely to start psychotherapy than medication.
  • Failure to adjust antidepressant treatment quality measures for race and ethnicity will significantly disadvantage health systems serving members from traditionally under-served racial and ethnic groups.
  • After accounting for random variation, likelihood of prematurely discontinuing antidepressant medication varies only minimally across physicians.

 What’s next?
A follow-up study (funded during the second cycle of MHRN funding) will further explore racial and ethnic disparities in care identified in this project.