Care from Mental Health Providers Preferred to PCPs
By Annette M. Boyle
LOS ANGELES — Recent research uncovered some good news and bad news when it comes to female veterans and depression: Women experience depression at much higher rates than men but also are more likely to receive adequate care and report symptom improvement.
The study, published in Women’s Health Issues, found that 20% of women veterans screened positive for probable major depression in a primary care setting compared to only 12% of men, a 66% increase in prevalence, according to the study team from the VA Greater Los Angeles Healthcare System.1
In addition, women veterans more frequently experienced significant psychological comorbidities, with 48% of those with depression also screening positive for posttraumatic stress disorder (PTSD) and 65% indicating they had general anxiety. By contrast, 38% of men with depression had likely PTSD. Men with that diagnosis had similar rates of generalized anxiety but higher rates of alcohol misuse, 23.8% vs. 15.2%.
“The trend in the data indicates that women are more likely to present with both depression and anxiety disorders, and we know from previous studies that there is also high comorbidity with physical conditions,” explained lead author Teri D. Davis, PhD, Health Services scientist at the VA and psychology instructor at California State University, Fullerton. Consequently, Davis pointed out, “women veterans are likely to have a very complex clinical presentation which requires sophisticated and long-term treatment.”
Despite this complexity, more women veterans appear to be getting the care they need. The researchers found that 57% of the women initially identified with depression received adequate depression care, compared to 39% of men. Adequate care was considered four or more mental health specialist visits in the six months following the positive screen or having taken a selective serotonin reuptake inhibitor (SSRI) or bupropion for at least 26 days in the last month or for more than 25 days per month in three consecutive months during the six-month follow-up period. More to the point, a higher percentage of women reported improvement in the symptoms of depression seven months after screening—46% vs. 39%.
One reason for the better outcomes could lie with women veterans’ preferences for care. “Women are more likely to go to mental health providers and may prefer nonprescribers for depression care. There is some indication they want therapy with medication,” to address their depression and change their behaviors, Davis told U.S. Medicine.
Not surprisingly, then, the women in the study were twice as likely to have had at least four visits with a mental health specialist in the prior six months than the men, 30.4% vs. 14.5%. They also were more than 50% more likely to have had any contact with a mental health specialist during the follow-up period (67.4% vs. 43.4%) and twice as likely to have ever had contact with a mental health specialist (73.3% vs. 35.4%).
Participants in the study were asked, “If you were depressed or had other emotional troubles and could choose who would help you, how likely would you be to choose each of the following …?” and instructed to rate how likely they were to choose a primary care physician, psychiatrist, spiritual counselor or other mental health professional (psychologist, social worker, nurse). Less than half of women veterans (47.8%) said they preferred to receive care for their depression from a primary care physician, while 67.8% of men did. Women preferred psychiatrists (60.9%) and “another mental health specialist” (68.9%) over primary care physicians for depression care; for men, primary care providers were the top choice.
The VA’s integration of mental health care in primary care offers options that can reflect the preferences of women and men for depression care and can improve outcomes for all veterans, Davis said.
“We need primary care to screen for depression, anxiety and trauma, and we need them to prepare patients for long-term care, particularly those with multiple comorbidities,” Davis said. “We had been losing too many veterans on referral to mental health specialists because of stigma. Integration has cut down suicide rates and made mental health more accessible. Now we need to make it more individualized.”
The authors noted that “planning for PC-MHI [primary care-mental health integration] care should better accommodate the clinical characteristics and care preferences we observed.” They advocated a stepped-care model that referred women with more complicated mental health profiles first for problem-focused psychotherapy in primary care, when available, and then to therapy with mental health specialists. The authors noted that a more-comprehensive treatment model could help the more than 50% of women who do not currently experience symptom reduction with the care they are receiving.
Earlier referrals to mental health specialists also might help veterans find the right drug and dose to achieve symptom relief. “Physicians often start patients on too low a dose of one antidepressant, which won’t work for everyone. That’s why there are multiple new drugs. If a patient isn’t responding well to a medication, a psychiatrist in primary care could analyze the symptom pattern and help a patient find something more effective,” Davis noted.
Davis recommends primary care physicians start by talking to their patients to find out more about their preferences for care and to explain their options. “We know that many patients with depression are medically noncompliant,” she observed. “If the treatment we offer doesn’t match their preferences, they are unlikely to improve, because they simply won’t take the medication or come for their visits.”
- Davis TD, Campbell DG, Bonner LM, Bolkan CR, Lanto A, Chaney EF, Waltz T, Zivin K, Yano EM, Rubenstein LV. Women Veterans with Depression in Veterans Health Administration Primary Care: An Assessment of Needs and Preferences. Women’s Health Issues. 2016 Nov-Dec;26(6):656-666.