Predictors of adequate depression treatment among Medicaid-enrolled adults.
ABSTRACT To determine whether Medicaid-enrolled depressed adults receive adequate treatment for depression and to identify the characteristics of those receiving inadequate treatment.
Claims data from a Medicaid-enrolled population in a large mid-Atlantic state between July 2006 and January 2008.
We examined rates and predictors of minimally adequate psychotherapy and pharmacotherapy among adults with a new depression treatment episode during the study period (N=1,098).
Many depressed adults received either minimally adequate psychotherapy or pharmacotherapy. Black individuals and individuals who began their depression treatment episode with an inpatient psychiatric stay for depression were markedly less likely to receive minimally adequate psychotherapy and more likely to receive inadequate treatment.
Racial minorities and individuals discharged from inpatient treatment for depression are at risk for receiving inadequate depression treatment.
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ABSTRACT: We have little systematic information about the extent to which standard processes involved in health care--a key element of quality--are delivered in the United States. We telephoned a random sample of adults living in 12 metropolitan areas in the United States and asked them about selected health care experiences. We also received written consent to copy their medical records for the most recent two-year period and used this information to evaluate performance on 439 indicators of quality of care for 30 acute and chronic conditions as well as preventive care. We then constructed aggregate scores. Participants received 54.9 percent (95 percent confidence interval, 54.3 to 55.5) of recommended care. We found little difference among the proportion of recommended preventive care provided (54.9 percent), the proportion of recommended acute care provided (53.5 percent), and the proportion of recommended care provided for chronic conditions (56.1 percent). Among different medical functions, adherence to the processes involved in care ranged from 52.2 percent for screening to 58.5 percent for follow-up care. Quality varied substantially according to the particular medical condition, ranging from 78.7 percent of recommended care (95 percent confidence interval, 73.3 to 84.2) for senile cataract to 10.5 percent of recommended care (95 percent confidence interval, 6.8 to 14.6) for alcohol dependence. The deficits we have identified in adherence to recommended processes for basic care pose serious threats to the health of the American public. Strategies to reduce these deficits in care are warranted.New England Journal of Medicine 07/2003; 348(26):2635-45. · 51.66 Impact Factor
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ABSTRACT: This study sought to determine the degree to which Medicaid eligibility categories modify disparities between black and white youths in the prevalence of psychotropic medication. Computerized claims for 189,486 youths aged two to 19 years who were continuously enrolled in a mid-Atlantic state Medicaid program for the year 2000 were analyzed to determine population-based annual prevalence of psychotropic medication by race or ethnicity and by whether the youths were eligible for Medicaid for reasons of family income, disability, or foster care placement. Logistic regression was used to assess the interaction of eligibility category and race. The mean annual prevalence of psychotropic medication for the population was 9.9 percent. The prevalence was 2.17 times higher for white youths than for black youths (16.5 percent compared with 7.6 percent). However, within eligibility categories, the white-to-black disparity was 3.8 among youths who were eligible for Medicaid because their family income was below the federal poverty level and 3.2 for youths enrolled in the State Children's Health Insurance Program. Medicaid eligibility categories had a profound impact on the racial disparity associated with the prevalence of psychotropic medications for youths. Eligibility category should be taken into account when ascertaining the role of access, undertreatment, and culture in disparities in mental health treatment.Psychiatric Services 03/2005; 56(2):157-63. · 2.01 Impact Factor
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ABSTRACT: Medicaid has had an enormous impact on the shape and impact of public mental health care. Medicaid mental health policy has expanded access, fostered consumerism, and created incentives for expansion of community-based providers. It also has dramatically changed the economic rules governing public mental health care, leading state governments to alter their behavior. The result has been a tilting of public mental health care toward Medicaid-covered people and services.Health Affairs 01/2003; 22(1):101-13. · 4.64 Impact Factor
Research and Methods Briefs
Predictors of Adequate Depression
Treatment among Medicaid-Enrolled
Carrie Farmer Teh, Mark J. Sorbero, Mark J. Mihalyo,
Jane N. Kogan, James Schuster, Charles F. Reynolds III,
and Bradley D. Stein
Objective. To determine whether Medicaid-enrolled depressed adults receive ade-
quate treatment for depression and to identify the characteristics of those receiving
Data Source. Claims data from a Medicaid-enrolled population in a large mid-
Atlantic state between July 2006 and January 2008.
Study Design. We examined rates and predictors of minimally adequate psycho-
therapy and pharmacotherapy among adults with a new depression treatment episode
during the study period (N51,098).
Principal Findings. Many depressed adults received either minimally adequate psy-
chotherapy or pharmacotherapy. Black individuals and individuals who began their
depression treatment episode with an inpatient psychiatric stay for depression were
markedly less likely to receive minimally adequate psychotherapy and more likely to
receive inadequate treatment.
Conclusions. Racial minorities and individuals discharged from inpatient treatment
for depression are at risk for receiving inadequate depression treatment.
Key Words. Depression, quality of care, Medicaid
Depression treatment guidelines suggest that persons diagnosed with major
depressive disorder be treated with a 4- to 8-week trial of an antidepressant
medication, a 4- to 8-week trial of psychotherapy, or a combination of the two
modalities (Agency for Health Care Policy and Research 1993; American
Psychiatric Association 2000). Recent research in primary care settings (Gold-
man, Nielsen, and Champion 1999; Unutzer et al. 2003) and in community
surveys (Wang, Berglund, and Kessler 2000; Young et al. 2001) indicates that
depressed patients do not, on average, receive treatment concordant with
rHealth Research and Educational Trust
Health Services Research
Individuals enrolled in Medicaid are disproportionately poor, racially
diverse, and have a greater prevalence of depression than other populations
(Thomas et al. 2005). In addition, Medicaid-enrolled adults face significant
barriers to depression care and have less access to mental health treatment
(Melfi, Croghan, and Hanna 1999; Melfi et al. 2000) than privately insured
individuals. Medicaid enrollees also have more severe depression and greater
depression-related medical costs than other depressed populations (Frank,
Goldman, and Hogan 2003). Ensuring high-quality depression treatment for
this vulnerable population is essential, yet little data exist on the extent to
In this study, we examine the quality of psychotherapy and pharma-
cotherapy received by Medicaid-enrolled adults undergoing treatment for
depression in outpatient mental health specialty care settings. As quality of
care across a variety of health conditions has been found to be worse for
Medicaid-enrolled individuals than commercially insured individuals (Lan-
don et al. 2007), we hypothesized that rates of receipt of guideline concordant
depressiontreatmentin this populationwould belowerthanthose reportedin
non-Medicaid populations (Wang et al. 2000). In addition, because significant
disparities in the quality of mental health treatment have been found else-
where (Rost et al. 2002; Miranda and Cooper 2004; Hinton et al. 2006), we
also hypothesized that men, racial minorities, and those living in rural
areas would be less likely than their comparison groups to receive guideline
concordant depression treatment.
Using specialty mental health care administrative data provided by a large
nonprofit managed behavioral health organization and Medicaid pharmacy
claims data provided by a large Mid-Atlantic state, we identified 1,098 adults
aged 18–64 who initiated a new episode of depression treatment between
Address correspondence to Carrie Farmer Teh, Ph.D., RAND Corporation, 4570 Fifth Avenue,
Suite 600, Pittsburgh, PA 15213; e-mail: email@example.com. Mark Sorbero, M.S., Mark Mihalyo,
M.S., James Schuster, M.D., M.B.A., Jane N. Kogan, Ph.D., and Bradley D. Stein, M.D., Ph.D.,
are with the Community Care Behavioral Health Organization, Pittsburgh, PA. Charles F. Rey-
nolds, III, M.D., Jane N. Kogan, Ph.D., and Bradley D. Stein, M.D., Ph.D., are with the De-
partment of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA.
Predictors of Adequate Depression Treatment303
October 28, 2006 and October 31, 2007. This study was conducted in com-
pliance with the University of Pittsburgh IRB.
Individuals initiated a depression treatment episode when they (1) re-
12-week period with a primary diagnosis of major depression (ICD-9 codes
296.2–296.36) or (2) were discharged from a psychiatric hospitalization with a
diagnosis of major depression. The first outpatient service or the day of dis-
charge was considered the index visit. Depression treatment episodes ended
144 days after the index visit or with any event (such as an inpatient stay) that
would have prevented the individual from receiving outpatient care. Depres-
sion treatment was categorized as a new episode if an individual had not
received any behavioral health services or antidepressant medication in the 4
months before the first service with a diagnosis of major depression (Figure 1).
first one observed. To allow enough time for the clean period and the treat-
treatment episodes where the index visit occurred between October 28, 2006
and October 31, 2007.
We excluded individuals who had received a service with a primary
diagnosis of schizophrenia, schizoaffective disorder, or bipolar I disorder in
the year before the index visit or at any point during the depression treatment
episode. We excluded dually eligible individuals who had Supplemental Se-
curity Income with Medicare because Medicaid claims would not reflectall of
the majority of the study timeframe.
12 weeks with no
Depression Treatment Episode
• 2+ outpatient claims within 12 weeks
where primary dx is depression; OR
Day after discharge from inpatient
admission where primary dx was
4+ psychotherapy visits
in first 84 days of episode
Filled antidepressant Rx for
84 of first 144 days of
Figure1: Depression Treatment Episodes
304 HSR: Health Services Research 45:1 (February 2010)
Sociodemographic variables, including age, gender, race, and Medicaid el-
igibility category, were obtained from the state’s membership and eligibility
files. Race/ethnicity was categorized as Caucasian, African American, or
other. Consistent with other analyses of Medicaid-enrolled individuals (Zito
et al. 2005), we categorized individuals into Medicaid eligibility categories
according to whether they were Medicaid eligible as a result of general as-
sistance, medical or mental health disability (e.g., Supplemental Security In-
come [SSI]), or income (e.g., Temporary Assistance to Needy Families
[TANF]). Individuals were categorized as living in an urban area if their
county of residence had a population density of greater than 1,000 individ-
Variables measuring prior inpatient psychiatric admissions and use of
behavioral services for substance abuse were developed using behavioral
health claims data. Individuals were categorized as having a prior inpatient
psychiatric admission if they had an inpatient psychiatric admission in the 12
months before the ‘‘clean period’’ (i.e., 3–15 months before the start of the
depression treatment episode). Individuals were categorized as having prior
substance abuse treatment if they had received any substance abuse treatment
services in the 12 months before the start of the depression treatment episode.
In addition, we categorized individuals based on the type of service use that
qualified them for a current depression treatment episode: inpatient, outpa-
tient with the same provider, and outpatient with different providers for the
two episode-initiating visits.
Consistent with other studies of depression quality of care, we defined min-
imally adequate psychotherapy as four or more individual, group, or family
psychotherapy visits during the first 84 days (12 weeks) of a depression treat-
ment episode (Bao, Sturm, and Croghan 2003; Schoenbaum et al. 2002; Teh
et al. 2008).
Minimally adequate pharmacotherapy was defined as having a filled
prescription for an antidepressant for 84 of the 144 days following the index
visit, a modification of the HEDIS acute antidepressant treatment, which
measures appropriate pharmacotherapy as a filled prescription for an anti-
depressant medication on 84 out of the first 114 days of treatment (HEDIS
2008). Because depression treatment episodes could begin with either an
outpatient visit or discharge from an inpatient stay, individuals initiating
Predictors of Adequate Depression Treatment305
treatment for depression may not initially see a prescribing physician (i.e., the
index visit may be with a clinical social worker). To account for any lag time
between having a visit with a nonphysician mental health worker, being re-
ferred to a prescribing physician (e.g., psychiatrist or primary care physician),
and filling a prescription, we extended the timeframe by 30 days (from 114
days, as per the HEDIS measure, to 144 days).
Inadequate treatment was defined as having neither adequate psycho-
therapy nor adequate pharmacotherapy during the treatment episode.
To determine patterns of behavioral health care and antidepressant medica-
tion use during a new episode of depression treatment, we conducted fre-
quency counts of dependent variables for the adult Medicaid population and
examined differences between groups of particular interest using t-tests and
w2-tests as appropriate. We used multivariate logistic regression models to
determine which factors were associated with receiving (1) minimally ade-
quate psychotherapy, (2) minimally adequate pharmacotherapy, and (3) in-
adequate treatment. For each outcome, the final model included all
independent variables, such that assessment of the effect of each individual
covariate controlled for the effects of all other measured covariates. Results
were considered significant at the po.05 level. Since we were concerned that
1998). All analyses were performed using the Statistical Analysis System (SAS),
version 9.1 (SAS Institute, Cary, NC).
Sample Characteristics and Service Utilization
We identified 1,098 Medicaid-enrolled adults who initiated new depression
treatment episodes between July 1, 2006 and January 31, 2008 (Table 1). The
mean age was 36.7 years (SD511.9) and nearly 70 percent were women.
Almost half were nonwhite. Approximately 80 percent (n5634) were Med-
icaid-eligible through general assistance and state expansion programs and as
TANF beneficiaries (n5634; 80 percent), while 20 percent (n5464) were
eligible as SSI beneficiaries. Very few had either had an inpatient psychiatric
admission (3 percent) or had received treatment for substance abuse (8 per-
cent). The majority of depression episodes began with two outpatient mental
306HSR: Health Services Research 45:1 (February 2010)