Are patients with depression and substance use disorder getting an appropriate level of care? Our Journal Club piece investigates.
Major depressive disorder (MDD) is the leading cause of global disease burden.1 Between 2018 and 2019 the prevalence of MDD in the United States has continued to increase among all age groups.2 Patients with these disorders are twice as likely to suffer from a comorbid substance use disorder (SUD) compared with the general population, and the severity of the S6UD parallels that of MDD.3 The comorbidity poses treatment challenges, and patients have been found to have poor outcomes (eg, increased substance use, more severe disease burden, higher rates of suicide attempts and behaviors), as well as an overall increased mortality.4
The tight association between MDD and SUD does not necessarily hint at causation, as substance use can lead to mental health symptoms and conditions; mental illness can lead to self-medicating with substance use; and both conditions may co-occur independently as in the case of overlapping predisposing genetic factors. For patients with the comorbidity treatment gaps exist. 90% of those with SUD do not get MDD treatment, and 55% of those with MDD do not get SUD treatment when addressed independently, while 33% of them get no treatment at all.2
Both MDD and SUD are in the DSM-5 and hence it is our responsibility to treat them as part of our routine psychiatric practice. Treating depression and substance use independently and in isolation of each other is incongruent with best practices and leads to detrimental outcomes.5 Guidelines recommend simultaneous and integrated treatment with pharmacotherapy and/or psychotherapy for MDD depending on disease severity.6,7
As for how closely these guidelines are followed, no study to date has investigated whether those with the SUD comorbidity receive similar MDD care to those without SUD among the pharmacotherapy and psychotherapy-based treatment modalities, or the degree to which specific SUDs are differentially associated with the receipt of guideline-specific MDD treatment. Coughlin and colleagues8 attempt to do just that.
Question. Do patients with MDD and comorbid SUD receive similar, guideline-concordant, care as those without SUD?
Type of study. Retrospective cohort analysis of 53,034 patients in whom MDD was diagnosed in the 2017 fiscal year in the US Veterans Health Administration (VHA).8
Population. The patients were all veterans receiving care through the US Veterans Health Administration system. They all had a diagnosis of depression made in 2017.
Method. Electronic medical record data was reviewed to identify patients from both inpatient and outpatient encounters who were diagnosed with depression using ICD-10 codes and Patient Health Questionnaire (PHQ) screens. The PHQ was required to have been documented within a 30-day window of the depression diagnosis in order to capture active depressive episodes. Exclusionary criteria targeted patients with a past depressive diagnosis or who had received prescription antidepressants (except trazodone) or psychotherapy in the past 12 months prior to the index diagnosis date. Also excluded were those with positive PHQ scores documented between 30 days and 12 months before the index depression diagnosis. Patient with comorbid bipolar disorder, schizophrenia, psychosis, personality disorder or developmental disorders, or those with more than 30 days of inpatient treatment in the last year were also excluded. Patients with comorbid SUD were identified as receiving a SUD diagnosis in the year before the depression diagnosis, as identified using ICD-10 codes meant to capture alcohol, opioid, cannabis, cocaine, stimulants, and other SUDs.
The outcomes measure assessed was adherence to treatment guidelines. For this, the authors used Healthcare Effectiveness Data and Information Set (HEDIS), which is a set of performance measurement tools developed and maintained by the National Committee for Quality Assurance (NCQA) and widely used to assess where improvements can make a difference. HEIDIS is intended to allow comparisons among various health plans, systems, as well as adherence to national benchmarks and guidelines.
Among patients who received an initial prescription for antidepressants within 90 days of the index, depressive disorders to HEDIS based measures related to pharmacotherapy were applied. These resulted in measurements of adequate acute phase treatment (receipt of an antidepressant prescription within 90 days of diagnosis that provides medication for at least 84 of the 114 days following initial prescription); adequate continuation phase treatment (continuing antidepressant for 180 of the first 231 days following initial script).
Psychotherapy (identified using CPT codes) was also examined using metrics analogous to HEDIS. Here they evaluated both acute phase treatment (psychotherapy sessions that occurred within 90 days of the index depression diagnosis), as well as continuous phase treatment (at least 3 psychotherapy sessions in the 12 weeks following the first session). Additionally, the authors considered the confounding element that psychotherapy could be delivered for both depressive disorders and SUDs hence, in the analysis-only sessions for whichdepressive disorders were the primary diagnosis were included.
The authors also aimed to adjust for patient demographics (age, gender, race, geographical locality, and distance from the VA) and clinical characteristics (comorbid mental health disorders, measured by the Elixhauser score for severity).
Statistical analysis. Sample characteristics across all described covariates were compared between those with and without SUD. Four multivariate logistic regression models were conducted to assess the associations between the presence of a SUD diagnosis and adequate acute and continuous phase antidepressant or psychotherapy treatment. Adjustments for covariates were done for each model.
The authors estimated percentages of those receiving treatment across each of the depression care metrics (those with and without comorbid SUD) as the marginal means of balanced population based on the model. Associations of specific SUDs with depression treatment were examined via the 4 models with each SUD independently analyzed. Authors also descriptively examined the setting where patients with SUD were receiving depression treatment.
Among the 53,034 participants diagnosed with a new episode of depression during the 2017 fiscal year, 52.9% received antidepressant treatment and 34.9% received psychotherapy within 90 days following diagnosis. Of this cohort, 14.2% had a SUD diagnosis in the year prior to the depression diagnosis.
Patients with SUD comorbidity had more visits in mental health and primary care settings in the year following the depressive diagnosis (average of 14.1 visits [SD 18.1] compared with 10.2 visits [SD 10.9] among those without SUD). Unfortunately, despite this higher opportunity for depression treatment, those with SUD received significantly less guideline-concordant depressive treatment across all metrics.
Before adjusting for covariates, observed rates show acute and continuation-phase antidepressants were provided to 59.4% and 36.3% of those with SUD and MDD versus 66.2% and 44.8% of those with just MDD (Table 1). In terms of psychotherapy, 31.6% and 26.8% of those with SUD received acute and continuation-phase treatment respectively, compared to 35.4% and 32.2% of those with just MDD (Table 2). For those with SUD, most received treatment in metal health clinics (47% psychotherapy [N = 1117]; 59.1% antidepressants [N = 2390]); or in primary care/mental health integration clinics (42.7% psychotherapy [N = 1014] and 31.8% antidepressants [N = 1287]). A very small minority received depression treatment in SUD specialty clinics (3.5% psychotherapy [N = 83] and 2.5% antidepressants [N = 102]).
In terms of patient characteristics, those with SUD were slightly younger, male, African American, homeless, and had comorbid psychiatric conditions. Those without SUDs were more likely to be service connected, live in rural areas, and have more comorbid diagnosed medical conditions.
Patients with SUD had lower odds of receiving guideline-concordant care, specifically 21% lower odds of receiving acute antidepressant treatment, 13% lower odds of initial psychotherapy treatment, 26% lower odds of adequate continuation of antidepressant, and 19% lower odds of continuation of psychotherapy.
Based on predicted probabilities of receipt of guideline-concordant depression treatment, an estimated 55% of individuals with comorbid SUD, compared with 61% without, received adequate acute antidepressant treatment, and 27% of individuals with comorbid SUD, compared with 29% without, received initial psychotherapy. As for cotinuation of treatment, 33% of individuals with comorbid SUD, compared with 40% without, received adequate continuation of antidepressants, and 22% of individuals with SUD, compared with 25% without, received adequate continuation of psychotherapy.
In terms of specific SUDs, lower quality depression care was evident across all evaluated substance types. Alcohol and cannabis use disorders were associated with significantly lower odds of adequate continuation of antidepressants (adjusted OR 0.81, 95% CI = 0.75, 0.88, p < 0.001 and adjusted OR 0.74, 95% CI = 0.63, 0.87, p < 0.001 respectively). Alcohol and cocaine use disorders were associated with lower odds of initiation of psychotherapy for depression (adjusted OR 0.86, 95% CI = 0.81, 0.91, p < 0.001 and adjusted OR 0.78, 95% CI = 0.66, 0.92, p < 0.001 respectively). Alcohol use disorders alone were associated with lower odds of adequate psychotherapy continuation (adjusted OR 0.81, 95% CI = 0.72, 0.90, p < 0.001).
There were also several covariates associated with lower odds of guideline-concordant care. These included homelessness, racial and ethnic minority groups, those in rural areas, and those with high psychiatric disease burden living farther away from a health care facility.
The Bottom Line
This retrospective review study of patients in the Veteran Healthcare Administration system points to a treatment gap in the delivery of guideline-concordant care for depression among those with SUD compared with those without it.
This study assessed an interesting question: do patients with comorbid MDD and SUD receive different care for depression than those without SUD? Consistent with previous data9,10 in a large national sample of veteran patients within the VHA system, the authors found that having the comorbid SUD diagnosis is associated with lower quality of depression treatment compared with those without it.8 After accounting for various demographic, medical, and psychiatric factors, patients with SUD had lower odds of adequate acute phase treatment (21% and 13% lower for antidepressant and psychotherapy, respectively) and lower odds of adequate continuation of treatment (26% and 19% lower for antidepressant and psychotherapy, respectively) for depression. This discrepancy in guideline-concordant care for depression comes despite patients with SUD having higher health care utilization (more visits and medical encounters) and hence more opportunities for MDD treatment initiation. Knowledge of this treatment gap is important because SUD and MDD affect each other bidirectionally, and the most effective approaches involve concurrent treatment.
There are several limitations to this study. As the authors point out, this sample is limited to veterans in care within the VHA system. The generalization outside this system, and to civilians with various insurance coverages, is unknown. Additionally, the analysis does not include or account for services rendered outside the VHA system, where it is not uncommon for veterans to seek care from.
The diagnosis of MDD as well as SUD is identified here based on ICD-10 codes entered in the electronic health records, which can at times contain errors or not even be entered at all.
There is no mention of how closely providers actually adhere to the use of screening tools such as PHQ-9. It is also necessary to consider that there are other widely available tools that are not accounted for here. It is important to keep in mind that lack of training in the assessment and treatment of complex presentations such as comorbidity leads to inaccurate beliefs and stigmas, an inability to accurately identify co-occurring disorders,11-13 a lack of awareness of appropriate referral sources,14,15 and a lack of preparedness to treat co-occurring disorders.16 The providers caring for these patients are not explicitly defined here as to whether they are highly trained physicians or independently practicing nurse practitioners.17
The severity of the MDD is not specifically described here via the use of any objective measure.8 Because engagement (or refusal) in treatment represents a patient-specific barrier, having a significant MDD severity, which patients with SUD comorbidity do, can lead to low motivation and lack of interest and future outlook, and hence would make it less likely for patients to be interested in and pursue treatment as well as adhere to it.
The sample selection criteria (new diagnosis of depression in fiscal year 2017 and a positive PHQ depression screen 30 days surrounding time of diagnosis) may lead to limits of generalizability of findings to the degree that these criteria may not capture most patients with depression (ie, preexisting diagnosis, noncompletion or adherence with depression screen).
Worthy of mention is that in the context of certain substances (ie, stimulant or cannabis), MDD may have psychotic features and hence require treatment with nontraditional modalities such as antipsychotics, rather than antidepressants. Within the limits of the study design it is also difficult to determine whether the MDD is due substance use or withdrawal.
The primary outcome measures here were based on the HEDIS, which has been criticized in the past for how its individual measures provide a narrow view of health care quality and interventions. There is also a question about whether attainment of their measures actually indicate better outcomes. In this study, the indicators of adequate acute and continuous phases of care (which are most often used measures of the quality of depression care) certainly do not encapsulate all features relevant to high-quality depression care. Nonetheless, HEDIS is part of NCQA’s accreditation process and attainment is globally used as incentive for many health plans and Centers for Medicare & Medicaid Services.
The data generated here is consistent with the challenges in treating patients with an SUD comorbidity and it points toward the need to better address the rapidly expanding dual-diagnosis population. From here, next steps towards improvement of delivery of care to this population should include efforts at specifically identifying barriers that account to this gap, whether clinician related, institutional or system.
Dr Stanciu is assistant professor of psychiatry at Dartmouth’s Geisel School of Medicine and Director of Addiction Services at New Hampshire Hospital, Concord, NH. He is Addiction Section Editor for Psychiatric TimesTM. The author reports no conflicts of interest concerning the subject matter of this article.
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