Treatment Differences in Primary and Specialty Settings in Veterans with Major Depression

INTRODUCTION: The Veterans Health Administration (VHA) supports the nation’s largest Primary Care-Mental Health Integration collaborative care model–(PC-MHI)–to increase treatment of mild to moderate common mental disorders in primary care and refer more severe-complex cases to specialty settings. It is unclear, though, how this treatment assignment works in practice. METHODS: 2,610 patients who sought incident episode VHA treatment for depression between December 2018 and June 2020 completed a baseline self-report questionnaire about depression severity-complexity. Patients with active suicidality or history of severe mental disorders were excluded. Administrative data were used to determine settings and types of treatment over the next 30 days. RESULTS: Thirty-four percent (34.2%) of depressed patients received treatment in a primary care (PC) setting and 65.8% in a specialty setting (SMH). PC patients had less severe and fewer comorbid depressive episodes than those in SMH. Patients with the lowest severity and/or complexity were most likely to receive PC antidepressant medication treatment, whereas those with the highest severity and/or complexity were most likely to receive combined (i.e., medication and psychotherapy) treatment in SMH settings. Although this assignment of patients across settings and types of treatment was stronger than found in previous civilian studies, it was less pronounced than expected (cross-validated AUC=.50-.68). DISCUSSION: By expanding access to evidence-based treatments, VHA’s PC-MHI increases consistency of treatment assignment with clinical characteristics of depressed patients. Increased understanding of reasons for this assignment being less pronounced than expected and implications for treatment response will require continued study.