The quality of care for depressive and anxiety disorders in the United States

Young AS, Klap R, Sherbourne CD, Wells KB. The quality of care for depressive and anxiety disorders in the United States. Paper presented at: VA HSR&D National Meeting; 2000 Mar 1; Washington, DC.

Objective: Depressive and anxiety disorders are prevalent conditions that cause substantial morbidity. While efficacious treatments exist, little is known about quality of care for these disorders nationally. This study estimates the rate of appropriate treatment among the United States population with depressive and anxiety disorders, and examines the effect of medical insurance, provider type, and individual characteristics on use of appropriate care. Methods: Data were obtained using a cross-sectional telephone survey conducted during 1997 and 1998. We identified, from a national sample, 1641 adults with a probable 12-month depressive or anxiety disorder by brief diagnostic interview. We estimated visits to general medical providers and mental health specialists, and use of appropriate psychotropic medication or counseling. We examined the effect of individual characteristics, provider type, and medical insurance type on use of appropriate care using multivariate regression models. Results: During the past year, 82% of adults with a probable depressive or anxiety disorder saw a healthcare provider, and most visits were in primary care. While 19% had seen a specialist, only 2% saw a specialist without seeing a primary care provider. Within adults with a probable disorder, 21% received appropriate medication and 18% received appropriate counseling. In all, 31% used some appropriate treatment (95% Confidence Interval, 28 - 34%). Individuals visiting primary care providers had significantly lower rates of appropriate treatment than people visiting mental health specialists (21% versus 65%, p < .001). Rates of appropriate treatment were significantly lower for men, African Americans, the less educated, and adults under 30 or over 59 years old. Insurance status and income did not have unique effects on use of appropriate care. Conclusions: The majority of adults in the U.S. with a probable depressive or anxiety disorder receive no appropriate care for their disorder. While this holds across diverse groups, rates of appropriate care are lower in certain demographic subgroups. These findings emphasize the importance of public education, interventions that increase access to effective care, and targeting subgroups at particularly high risk for poor care. Impact Statements: Public and patient education efforts are needed to increase the extent to which people value treatment for common psychiatric disorders and seek out appropriate care. Quality improvement efforts should focus on strategies that bring effective treatments to people - whether through improving practice infrastructure or implementing outreach programs. Clinical research has made substantial progress in establishing efficacious treatments, and progress must now proceed on dissemination to the public, especially for vulnerable sub-populations.