Data are from the National Health and Nutrition Examination Survey. Whiskers represent 95% CIs. The proportion of patients receiving any treatment for depression increased from 43.5% in 2007-2008 to 52.9% in 2015-2016 (odds ratio for time trends, 1.49; 95% CI, 1.01-2.19 after controlling for age, sex, and race/ethnicity).
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Rhee TG, Wilkinson ST, Steffens DC, Rosenheck RA, Olfson M. Prevalence of Treatment for Depression Among US Adults Who Screen Positive for Depression, 2007-2016. JAMA Psychiatry. 2020;77(11):1193–1195. doi:10.1001/jamapsychiatry.2020.1818
Depression is the leading cause of disability worldwide.1 Yet, most US adults who screen positive for depressive symptoms do not receive treatment.2 In the past decade, expansion of mental health care coverage through the Affordable Care Act (ACA)3 may have promoted an increase in the treatment of adults with depression. We examined trends in the prevalence of adults who screened positive for depression and the proportion receiving treatment from 2007 to 2016, with consideration of health insurance coverage.
We used 2007-2016 data from 5 waves of the National Health and Nutrition Examination Survey (NHANES), administrated by the National Center for Health Statistics of the Centers for Disease Control and Prevention,4 to examine proportions of adults aged 19 years or older who screened positive for depression, defined by a score of 10 or higher on PHQ-9, the 9-item depression module of the Patient Health Questionnaire.5 This study was deemed to be exempt from human participants review by the Yale School of Medicine’s Institutional Review Board because all data were deidentified and publicly available. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
Among individuals who screened positive for depression, evidence of treatment was considered to be a prescription for an antidepressant medication (using generic names),6 consulting a mental health professional (for reasons not specified), or both. We estimated changes in the prevalence of a positive screen for depression and receipt of treatment for depression among those who screened positive.
To examine linear trends over time, we transformed the survey-year variable from 0 (2007-2008) to 1 (2015-2016).2 Odds ratios associated with this transformed variable represent the change in the odds of treatment among those who screened positive for depression across the entire study period. We calculated unadjusted and adjusted odds ratios for changing rates. Covariates included age, sex, and race/ethnicity when estimating the association during the adjusted period. Stata, version 15.1 MP/6-Core (StataCorp) was used for all analyses, and the svy commands were used to account for the complex NHANES sampling design, including unequal probability of selection, clustering, and stratification.
Among adults who screened positive for depression between 2007 and 2016, the mean (SD) age was 46.1 (14.9) years. Most individuals were women (64.6%) and non-Hispanic white (63.6%) and had an educational attainment of a high school diploma or higher (73.0%) and insurance coverage (82.1%). The prevalence of US adults who screened positive for depression did not change significantly from 2007-2008 (8.3%, or 5.3 million adults) to 2015-2016 (7.5%, or 5.2 million adults) (adjusted odds ratio [AOR] for time trends, 0.91; 95% CI, 0.70-1.18).
The overall proportion of adults who received any treatment for depression increased from 43.5% in 2007-2008 to 52.9% in 2015-2016 (Figure). This trend was largely owing to both the use of antidepressant therapy and contact with a mental health professional (Table). Having any health insurance was associated with a greater likelihood of receiving treatment (AOR, 1.70; 95% CI, 1.49-1.94). This association was reduced following adjustment for survey year (AOR, 1.25; 95% CI, 1.05-1.49), suggesting partial mediation of health insurance. No similar significant associations were found among other sociodemographic factors (data not shown).
From 2007 to 2016, among adults who screened positive for depression, the proportion who received services increased by almost 10%. An increase in insurance coverage seemed to have a role in promoting treatment access. These trends may reflect increased coverage for mental health care following the ACA Medicaid expansion and Health Insurance Marketplace launch in 2014. Limitations include a cross-sectional survey design that prevented assessment of the timing of insurance coverage and use of mental health services, precluding causal inferences; the absence of information on medication adherence; and a lack of information about treatment outcomes. Nonetheless, this study’s findings show an increase in treatment for depression. Further research is needed to evaluate the potential causal role of the ACA and whether increased depression treatment was associated with improved outcomes.
Accepted for Publication: May 5, 2020.
Corresponding Author: Taeho Greg Rhee, PhD, MSW, Department of Public Health Sciences, School of Medicine, University of Connecticut, 263 Farmington Ave, Farmington, CT 06030 (email@example.com; firstname.lastname@example.org).
Published Online: July 1, 2020. doi:10.1001/jamapsychiatry.2020.1818
Author Contributions: Dr Rhee had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Rhee, Rosenheck, Olfson.
Acquisition, analysis, or interpretation of data: Rhee, Wilkinson, Steffens.
Drafting of the manuscript: Rhee.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Rhee, Wilkinson, Rosenheck.
Obtained funding: Rhee.
Administrative, technical, or material support: Rhee.
Supervision: Rhee, Wilkinson, Rosenheck.
Conflict of Interest Disclosures: Dr Rhee reported receiving grants from the National Institute on Aging outside the submitted work. Dr Wilkinson reported receiving grants from the Agency for Healthcare Research and Quality and National Institute of Mental Health; personal fees, and contract funding for the conduct of clinical trials administered through Yale University from Janssen Research & Development, LLC; contract research funding from Sage Therapeutics and Oui Therapeutics, LLC; and support from the American Foundation for Suicide Prevention, Brain & Behavior Research Foundation (formerly NARSAD), Patient-Centered Outcomes Research Institute, and Robert E. Leet and Clara Guthrie Patterson Foundation outside the submitted work. Dr Steffens reported receiving consulting fees from Janssen Research & Development, LLC, outside the submitted work. Dr Olfson reported receiving grants from the National Institutes of Health outside the submitted work. No other disclosures were reported.
Additional Information: Further details of the data, including description, questionnaires, sampling methodology, and data sets, are available on the National Health and Nutrition Examination Survey website.4
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