VHA mandates annual screening for depression for all Veterans in primary care. However, even after a positive screen for depression, patients may delay seeking treatment for many years, despite the fact that effective treatment is available which can substantially improve their clinical outcomes and quality of life. Therefore, it is highly beneficial to understand the individual factors that account for delays in getting treatment for depression.
We aimed to longitudinally examine Veterans' illness perceptions of depression and its treatment at the beginning of a depression episode to determine whether or not illness perceptions predict treatment engagement. We also tested Leventhal's self-regulation model of illness behavior as a potential model of help-seeking behavior among Veterans with depression. Our main study hypothesis was: Veterans who perceive depression as a health threat (e.g., more severe symptoms, relating to cause and controllability) will be more likely to receive guideline-concordant depression treatment three months after a positive depression screen than Veterans who do not perceive depression as a health threat.
Veterans who received a positive PHQ-2 screen in primary care at three VA medical centers, and who had not received a diagnosis of depression nor a prescription for any anti-depressant in the previous 12 months (as determined by chart review) were eligible for the study. Eligible Veterans were mailed a questionnaire assessing illness perceptions of depression, as measured by the Illness Perception Questionnaire-Revised (IPQ-R) adapted for depression, and past treatment for depression. A subsequent chart review was conducted to document whether these Veterans received HEDIS guideline-concordant depression treatment three months later. We used fixed effects Glimmix models to predict the probability of receiving guideline-concordant depression treatment, with specific IPQ-R and interaction items selected from logistic stepwise regression models. We also explored the social and contextual factors surrounding decisions to seek or not seek treatment for depression through semi-structured interviews with a sub-sample of participants who did or did not receive depression treatment.
Of the 271 Veterans who participated, 92 (34%) received guideline-concordant depression treatment three months following a positive screen. Conducting chart reviews until six months post positive-screen did not change this proportion. Veterans who reported more severe symptoms (OR=4.65), and those who believed they could control their depression (OR=2.95) were more likely to receive guideline-concordant treatment at three months post-positive screen. Those who believed that nothing could control depression (OR=2.43) or who attributed the cause of depression to stress (OR=1.65) or feelings of grief or loss (OR=1.30) were less likely to receive guideline-concordant treatment. However, among Veterans who had not received any treatment in the past five years, the probability of receiving guideline-concordant treatment was higher among those who believed that stress (OR=2.34) and their own risky behaviors (OR=3.31) caused their depression, and the probability of receiving guideline-concordant treatment was lower among those who thought that their symptoms would last a short time (OR=3.81). Grounded thematic analyses of 23 interviews indicated that illness perception constructs (such as consequences, controllability, severity of symptoms and cause) were discussed by Veterans as serving as barriers or facilitators to seeking treatment for depression.
Veterans in this study who perceived their depression symptoms as significant threats to their health were more likely to seek treatment. Many veterans are not receiving high quality depression treatment following a positive screen in primary care. Discussing potential causes of symptoms, the ability of treatment to control these symptoms, and how long symptoms may last are important areas for providers to focus on in order to encourage greater uptake of depression treatment in primary care.
- Hill JN, Locatelli SM, Bokhour BG, Fix GM, Solomon J, Mueller N, LaVela SL. Evaluating broad-scale system change using the Consolidated Framework for Implementation Research: challenges and strategies to overcome them. BMC research notes. 2018 Aug 4; 11(1):560.
- Elwy AR, Glickman ME, Bokhour BG, Dell NS, Mueller NM, Zhao S, Osei-Bonsu PE, Rodrigues S, Coldwell CM, Ngo TA, Schlosser J, Vielhauer MJ, Pirraglia PA, Eisen SV. Using Mixed Methods to Examine the Role of Veterans' Illness Perceptions on Depression Treatment Utilization and HEDIS Concordance. Medical care. 2016 Jun 1; 54(6):e35-42.
- Elwy AR, Groessl EJ, Eisen SV, Riley KE, Maiya M, Lee JP, Sarkin A, Park CL. A systematic scoping review of yoga intervention components and study quality. American journal of preventive medicine. 2014 Aug 1; 47(2):220-32.
- Rodrigues S, Bokhour B, Mueller N, Osei-Bonsu PE, Zhao S, Glickman M, Eisen SV, Elwy AR. Impact of stigma on veteran treatment seeking for depression. American Journal of Psychiatric Rehabilitation. 2014 May 28; 17(2):128-146.
- Osei-Bonsu PE, Bokhour BG, Glickman ME, Rodrigues S, Mueller NM, Dell NS, Zhao S, Eisen SV, Elwy AR. The role of coping in depression treatment utilization for VA primary care patients. Patient education and counseling. 2014 Mar 1; 94(3):396-402.
- Osei-Bonsu PE, Bokhour BG, Glickman ME, Rodrigues S, Mueller NM, Dell NS, Zhao S, Eisen SV, Elwy AR. The role of coping in depression treatment utilization in VA primary care patients. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 24; Baltimore, MD.
- Rodrigues S, Bokhour BG, Osei-Bonsu PE, Mueller N, Glickman ME, Zhao S, Eisen SV, Elwy AR. A mixed methods examination of the impact of stigma on Veterans’ treatment seeking for depression in VHA primary care. Poster session presented at: AcademyHealth Annual Research Meeting; 2012 Jun 12; Orlando, FL.
- Elwy AR, Dell NS, Zhao S, Glickman ME, Bokhour BG, Pirraglia PA, Coldwell CM, Ngo TA, Vielhauer MJ, Eisen SV. Engaging in treatment for depression: the role of veterans' illness perceptions. Paper presented at: Society of Behavioral Medicine Annual Meeting and Scientific Sessions; 2011 Apr 28; Washington, DC.
- Elwy AR, Dell NS, Zhao S, Glickman ME, Bokhour BG, Pirraglia PA, Coldwell CM, Ngo TA, Vielhauer MJ, Rothendler JA, Eisen SV. Getting to treatment for depression: the role of veterans’ illness perceptions. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 15; Washington, DC.
Mental, Cognitive and Behavioral Disorders, Health Systems
Depression, Primary care