U.S. veterans may not always receive preferred treatment for depression

Veterans with depression may not be receiving the type of treatment they prefer, according to a recent study.

Researchers surveyed Veterans Health Administration (VHA) patients who were starting treatment for depression in 2018-2020 to examine whether the type of treatment they preferred was associated with the type they received. Patients' self-reported preferences for medication and psychotherapy were measured on self-anchoring visual analog scales from 0 to 10, with 0 indicating completely unwilling to receive the treatment and 10 indicating completely willing. Medical records were used to determine receipt of treatment and adherence over three months. The study results were published Oct. 6 by the Journal of General Internal Medicine.

The study included 2,582 patients, of whom 76.7% were men and 62.3% were of non-Hispanic White ethnicity. The mean age was 48.7 years. Patients were more likely to strongly prefer psychotherapy than medication (51.2% vs. 36.7%; P<0.001). Approximately a quarter of patients (25.1%) reported strong positive preferences for both psychotherapy and medication, 43.5% reported strong positive or positive preferences for both, 17.3% reported strong negative preferences for at least one, and 35.0% reported negative or strong negative preferences for both. Patients who preferred medication and those who preferred psychotherapy did not receive them in 32.1% and 21.8% of cases, respectively.

Patients who strongly preferred medication were substantially more likely to receive it than those who had a strong preference against it (odds ratio [OR], 17.5; 95% CI, 12.5 to 24.5), while those who strongly preferred psychotherapy were approximately twice as likely to receive it as those who expressed strong preferences against it (OR, 1.9; 95% CI, 1.0 to 3.5). No association was seen between treatment preferences and receipt of medication or combined adherence to treatment. However, patients who strongly preferred psychotherapy were more likely to adhere to it than those who strongly preferred not to receive it (OR, 3.3; 95% CI, 1.4 to 7.4).

The study had a low response rate, assessed patients' preferences about a week after treatment initiation, and did not account for treatment history, among other limitations, the researchers said. They concluded that lack of concordance between treatment preferences and treatment received was common among U.S. veterans with depression and was associated with worse adherence for psychotherapy.

“The [VHA] has invested heavily in national initiatives to increase reach of mental health services and appears to be providing largely accessible and mostly equitable care,” the authors wrote. “Given the pervasiveness and disability associated with depression, future work should continue to explore where and for whom patient preferences are not being met when doing so is not clinically contra-indicated and how the match between preferences and treatments received can be increased in the service of improving treatment adherence and outcomes.”

In related news, ACP recently published a position paper calling for policies to strengthen health care for U.S. veterans. Its recommendations include the following:

• Because of the unique, specialized role in serving our nation's veterans, lawmakers must ensure adequate funding to provide timely, high-quality health care services and to sustain the VHA's health professions education, emergency preparedness, and research programs.
• The Veterans Community Care Program (VCCP) should act as a safety-valve to ensure that veterans are able to receive timely, local, and appropriate care if it is not available to them through the VHA. VCCP clinicians should closely coordinate patient care with the VHA. ACP believes that the VCCP should not replace the VHA.
• The VHA needs to work to identify and eliminate unnecessary administrative tasks that contribute to burnout among clinicians.
• The Patient-Aligned Care Team model needs to be continued to better provide patient-centered, coordinated care. The VHA also needs to prioritize models that identify, diagnose, and treat veterans with specific care needs, including female veterans and veterans with suicide risk, depression, military sexual trauma, or substance use disorders.

The position paper was published by Annals of Internal Medicine on Oct. 5.