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2023 HSR&D/QUERI National Conference Abstract

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4139 — Depression Diagnoses and Treatment for Veterans in Primary Care: Evaluating the Impact of the COVID-19 Pandemic

Lead/Presenter: Brittany Cornwell,  SMITREC
All Authors: Cornwell BL (Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention), Szymanski BR (Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention) Smith CA (Office of Mental Health and Suicide Prevention, VA Central Office) McCarthy JF (Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention)

Objectives:
A national emergency concerning COVID-19 was declared on March 13, 2020. The pandemic was associated with substantial shifts in delivery of Veterans Health Administration (VHA) Primary Care-Mental Health Integration (PCMHI) services, from primarily in-person care to primarily virtual care. Little is known regarding whether these changes affected patterns of treatment for patients with new depression diagnoses in PC/PCMHI settings. We examined trends in depression-related treatment initiation within 7 days of a new diagnosis, comparing Veterans diagnosed before versus after the start of the pandemic.

Methods:
We identified 324,838 VHA patients with a new depression diagnosis in PC or PCMHI encounters, excluding those with depression diagnoses or treatment in the prior 365 days. We classified individuals by whether they were diagnosed before (3/1/19-2/29/20) or after (3/13/20-3/12/21) the start of the COVID-19 pandemic. Using multivariable logistic regression, we assessed the odds of initiating psychotherapy, antidepressant medications, or both, and of receipt of mental health evaluation and management (EandM) encounters, within 7 days of diagnosis, adjusting for demographic, comorbidity, and utilization measures.

Results:
In the pre-COVID period, there were 190,104 (58.5%) patients with new depression diagnoses, and 134,734 (41.5%) during the COVID-19 period. Patients diagnosed with depression during-COVID-19 were more likely to be diagnosed in a virtual encounter (p < 0.001) and had lower adjusted odds of initiating any depression treatment (OR: 0.90; 95% CI:0.88-0.91) and specifically psychotherapy treatment (OR: 0.74; 95% CI:0.72–0.75), and they had higher odds of initiating antidepressant medications (OR: 1.13; 95% CI:1.10–1.16) and having only EandM visits within 7 days (OR: 1.26; 95% CI:1.23-1.28). Adjusting for the time period, those diagnosed through video-telehealth-to-home encounters were more likely than patients diagnosed in-person to initiate psychotherapy (OR: 1.42; 95% CI:1.37-1.47) and less likely to initiate antidepressants (OR: 0.73; 95% CI:0.70-0.75). Those diagnosed through video telehealth within or across VHA facilities (VTEL) were more likely to initiate psychotherapy (OR: 1.20; 95% CI:1.10-1.31), while those diagnosed via telephone encounters were less likely to initiate either treatment (OR: 0.62; 95% CI:0.61-0.64).

Implications:
In the year following the COVID-19 emergency declaration, 55,370 fewer Veterans received new depression diagnoses in PC settings than in the prior year. In adjusted analyses, Veterans diagnosed during the pandemic were less likely to receive psychotherapy and more likely to receive antidepressant treatment. Also, Veterans diagnosed during the pandemic were more likely to only have EandM encounters within 7 days, without psychotherapy or antidepressant receipt. Study findings suggest pandemic-related access barriers which may have limited treatment seeking and recognition of need among Veterans with depression.

Impacts:
In response to COVID-19 pandemic changes, Veterans with depression may have limited access to treatment, including psychotherapy, with greater reliance on watchful waiting through EandM encounters. Video telehealth may be more effective than telephone care for engaging patients in initial depression treatment. It is important to ensure access and enhance delivery of psychotherapy for Veterans with depression. VHA should continue pandemic-related monitoring of diagnosis and treatment patterns for Veterans in Primary Care to support mental health access and care delivery.