Effect of care setting on evidence-based depression treatment for veterans with COPD and comorbid depression

BACKGROUND: Patients with chronic obstructive pulmonary disorder (COPD) frequently have co-occurring depressive disorders and are often seen in multiple-care settings. Existing research does not assess the impact of care setting on delivery of evidence-based depression care for these patients. OBJECTIVE: To examine the prevalence of guideline-concordant depression treatment among these co-morbid patients, and to examine whether the likelihood of receiving guideline-concordant treatment differed by care setting. DESIGN: Retrospective cohort study. PATIENTS: A total of 5,517 veterans with COPD that experienced a new treatment episode for major depressive disorder. MEASUREMENTS AND MAIN RESULTS: Concordance with VA treatment guidelines for depression; multivariate analyses of the relationship between guideline-concordant depression treatment and care setting. More than two-thirds of the sample was over age 65 and 97% were male. Only 50.6% of patients had guideline-concordant antidepressant coverage (defined by the VA). Fewer than 17% of patients received guideline recommended follow-up (≥3 outpatient visits during the acute phase), and only 9.9% of the cohort received both guideline-concordant antidepressant coverage and follow-up visits. Being seen in a mental health clinic during the acute phase was associated with a 7-fold increase in the odds of receiving guideline-concordant care compared to primary care only. Patients seen in pulmonary care settings were also more likely to receive guideline-concordant care compared to primary care only. CONCLUSIONS: Most VA patients with COPD and an acute depressive episode receive suboptimal depression management. Improvements in depression treatment may be particularly important for those patients seen exclusively in primary care settings.