Association between chronic illness complexity and receipt of evidence-based depression care

Background: The rate of guideline concordance with antidepressant treatment for persons with depression is low. The problem may be even more pronounced for patients with depression and other multiple chronic conditions (MCC). Objectives: To study, for persons with new depressive episodes, the association between MCC and the likelihood of receiving guidelineconcordant depression treatment. Research Design: Retrospective cohort study using Veterans Affairs administrative data. Subjects: A total of 43,189 Veterans Affairs patients who had a new depressive episode during 2007 were included. Measures: We assessed whether patients had an adequate supply of antidepressants during acute and continuation phases of depression treatment, which indicates guideline-concordant care. We determined the association between comorbid conditions and receipt of adequate antidepressant supplies after adjusting for potential confounders. Results: Compared with patients with depression alone, those with comorbid cardiovascular/cerebrovascular disease, peptic ulcer/gastroesophageal reflux disease (GERD), or arthritis were 8%-13% more likely to receive adequate antidepressant supplies during the acute phase. Patients with depression and substance/alcohol abuse were 15% less likely to receive adequate supplies in the acute treatment phase. Those with cardiovascular/cerebrovascular disease or peptic ulcer/GERD were 9%-10% more likely to receive continuation phase guideline-concordant depression treatment. Patients with comorbid substance/alcohol abuse were 19% less likely to receive continuation phase guideline-concordant depression treatment. Relatively few of the most prevalent MCC clusters were significantly associated with receipt of guideline-concordant depression treatment. Conclusions: There was no consistent association between specific clusters of chronic conditions and adequate antidepressant supplies. There continues to be need for practice-level and system-level interventions to increase quality of depression treatment, particularly among persons with certain comorbid conditions such as cardiovascular/ cerebrovascular disease, peptic ulcer/GERD, and arthritis.