Trends in Treatment and Spending for Patients Receiving Outpatient Treatment of Depression in the United States, 1998-2015

The efficacy and safety of Zuranolone for treatment of depression: A systematic review and meta-analysis

RATIONALE

Zuranolone, a newly FDA-approved synthetic neurosteroid, shows promise in treating depression.

OBJECTIVES

Our aim is to evaluate Zuranolone's efficacy and safety in treating depression.

METHODS

Five databases were searched until September 2023 for relevant randomized clinical trials evaluating the efficacy and safety of zuranolone. The potential risk of bias in the included trials was evaluated by the Cochrane Risk of Bias II guideline Data were extracted and pooled using Review Manager Software (RevMan 5.3).

RESULTS

An analysis of eight studies highlights Zuranolone's efficacy in treating depression compared to placebo across most of the outcomes. Notably, the 30mg and 50mg doses demonstrated significant improvements in reducing HAM-D scores by over 50% within a 15-day follow-up (RR) of 1.46 (95% CI [1.27, 1.68], p < 0.0001) and 1.14 (95% CI [1.01, 1.3], p = 0.04). Additionally, the HAM-D ≤ 7% score analysis revealed significant enhancements with the 30mg dose over both 15-day (RR = 1.82, 95% CI [1.44, 2.31], p < 0.0001) and 45-day (RR = 1.43, 95% CI [1.16, 1.77], p = 0.0008) durations. Adverse Events Drug Discontinuation demonstrated no overall significant difference (OR = 1.33, 95% CI: [0.79, 2.23], p = 0.282). Further, specific adverse events, such as headache, showed no significant overall difference between Zuranolone and placebo (OR = 1.11, 95% CI: [0.84, 1.47], p = 0.47), with dose-dependent analysis revealing less headache in the 30 mg group.

CONCLUSION

Zuranolone demonstrates favorable tolerability and safety, particularly at 30mg and 50mg doses after 15 days, suggesting its potential and effective treatment for depression.

The Economics of Treatment for Depression

The global prevalence of depression has risen over the past three decades across all socioeconomic groups and geographic regions, with a particularly rapid increase in prevalence among adolescents (aged 12-17 years) in the United States. Depression imposes large health, economic, and societal costs, including reduced life span and quality of life, medical costs, and reduced educational attainment and workplace productivity. A wide range of treatment modalities for depression are available, but socioeconomic disparities in treatment access are driven by treatment costs, lack of culturally tailored options, stigma, and provider shortages, among other barriers. This review highlights the need for comparative research to better understand treatments' relative efficacy, cost-effectiveness, scalability, and potential heterogeneity in efficacy across socioeconomic groups and country and cultural contexts. To address the growing burden of depression, mental health policy could consider reducing restrictions on the supply of providers, implementing digital interventions, reducing stigma, and promoting healthy lifestyles.

Factors Associated With Discharge Against Medical Advice in US Adolescents Hospitalized for Suicidal Ideation or Suicide Attempt

OBJECTIVE

Little is known about factors associated with discharge against medical advice (DAMA) in adolescent acute care hospitalization for suicidal ideation (SI) and suicide attempt (SA). Our study seeks to determine whether certain socioeconomic factors or hospital characteristics are associated with DAMA in this population.

METHOD

This retrospective cross-sectional study used data from the National Inpatient Sample from the 2015 fourth quarter to 2019. We included children 10 to 19 years of age hospitalized with a primary or secondary International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis of SI or SA. Exposures were patient socio-demographics and hospital characteristics. The outcome was DAMA. Logistic regression generated odds ratios (ORs) with 95% CIs to measure the association between each patient and hospital characteristics and DAMA.

RESULTS

Of 476,755 hospitalizations meeting inclusion criteria, 3,825 (0.8%) were DAMA. After adjusting for socio-demographics and hospital characteristics, predictive factors for DAMA were age 16 to 19 years (OR = 1.41; CI = 1.08-1.82), self-pay status (OR = 1.43; CI = 1.12-1.83), hospital region South and West (OR = 1.55; CI = 1.10-2.20 and OR = 1.79; CI = 1.26-2.54, respectively), and urban non-teaching status of the hospital (OR = 1.90; CI = 1.42-2.55). Hispanic patients were less likely to be DAMA (OR = 0.66; CI = 0.51-0.85).

CONCLUSION

Variations in DAMA probabilities by age, insurance status, hospital teaching status, and hospital regions suggest a need for a better understanding of this uncommon outcome.

No Improvement In Mental Health Treatment Or Patient-Reported Outcomes At Medicare ACOs For Depression And Anxiety Disorders

Accountable care organizations (ACOs) have become Medicare's dominant care model because policy makers believe that ACOs will improve the quality and efficiency of care for chronic conditions. Depression and anxiety disorders are the most prevalent and undertreated chronic mental health conditions in Medicare. Yet it is unknown whether ACOs influence treatment and outcomes for these conditions. To explore these questions, this longitudinal study used data from the 2016-19 Medicare Current Beneficiary Survey, linked to validated depression and anxiety symptom instruments, among diagnosed and undiagnosed fee-for-service Medicare patients with these conditions. Among patients not enrolled in ACOs at baseline, those who newly enrolled in ACOs in the following year were 24 percent less likely to have their depression or anxiety treated during the year than patients who remained unenrolled in ACOs, and they saw no relative improvements at twelve months in their depression and anxiety symptoms. Better-designed incentives are needed to motivate Medicare ACOs to improve mental health treatment.

Development of a model to predict antidepressant treatment response for depression among Veterans

BACKGROUND

Only a limited number of patients with major depressive disorder (MDD) respond to a first course of antidepressant medication (ADM). We investigated the feasibility of creating a baseline model to determine which of these would be among patients beginning ADM treatment in the US Veterans Health Administration (VHA).

METHODS

A 2018-2020 national sample of n = 660 VHA patients receiving ADM treatment for MDD completed an extensive baseline self-report assessment near the beginning of treatment and a 3-month self-report follow-up assessment. Using baseline self-report data along with administrative and geospatial data, an ensemble machine learning method was used to develop a model for 3-month treatment response defined by the Quick Inventory of Depression Symptomatology Self-Report and a modified Sheehan Disability Scale. The model was developed in a 70% training sample and tested in the remaining 30% test sample.

RESULTS

In total, 35.7% of patients responded to treatment. The prediction model had an area under the ROC curve (s.e.) of 0.66 (0.04) in the test sample. A strong gradient in probability (s.e.) of treatment response was found across three subsamples of the test sample using training sample thresholds for high [45.6% (5.5)], intermediate [34.5% (7.6)], and low [11.1% (4.9)] probabilities of response. Baseline symptom severity, comorbidity, treatment characteristics (expectations, history, and aspects of current treatment), and protective/resilience factors were the most important predictors.

CONCLUSIONS

Although these results are promising, parallel models to predict response to alternative treatments based on data collected before initiating treatment would be needed for such models to help guide treatment selection.

Depressive Multimorbidity and Trajectories of Functional Status among Older Americans: Differences by Racial/Ethnic Group

OBJECTIVE

This study aims to evaluate the impact of depressive multimorbidity (ie, including depressive symptoms) on the long-term development of activities of daily living (ADL) and instrumental activities of daily living (IADL) limitations according to racial/ethnic group in a representative sample of US older adults.

DESIGN

Prospective, observational, population-based 16-year follow-up study of nationally representative sample.

SETTING AND PARTICIPANTS

Sample of older non-Hispanic Black, Hispanic, and nonHispanic White Americans from the Health and Retirement Study (2000‒2016, N = 16,364, community-dwelling adults ≥65 years of age).

METHODS

Data from 9 biennial assessments were used to evaluate the accumulation of ADL-IADL limitations (range 0‒11) among participants with depressive (8-item Center for Epidemiologic Studies Depression score≥4) vs somatic (ie, physical conditions only) multimorbidity vs those without multimorbidity (no or 1 condition). Generalized estimating equations included race/ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White), baseline age, sex, body mass index, education, partnered, and net worth.

RESULTS

Depressive and somatic multimorbidity were associated with 5.18 and 2.95 times greater accumulation of functional limitations, respectively, relative to no disease [incidence rate ratio (IRR) = 5.18, 95% confidence interval, CI (4.38,6.13), IRR = 2.95, 95% CI (2.51,3.48)]. Hispanic and Black respondents experienced greater accumulation of ADL-IADL limitations than White respondents [IRR = 1.27, 95% CI (1.14, 1.41), IRR = 1.31, 95% CI (1.20, 1.43), respectively].

CONCLUSIONS AND IMPLICATIONS

Combinations of somatic diseases and high depressive symptoms are associated with greatest accumulation of functional limitations over time in adults ages 65 and older. There is a more rapid growth in functional limitations among individuals from racial/ethnic minority groups. Given the high prevalence of multimorbidity and depressive symptomatology among older adults and the availability of treatment options for depression, these results highlight the importance of screening/treatment for depression, particularly among older adults with socioeconomic vulnerabilities, to slow the progression of functional decline in later life.

Nonpharmacologic and Pharmacologic Treatments of Adults in the Acute Phase of Major Depressive Disorder: A Living Clinical Guideline From the American College of Physicians

DESCRIPTION

The purpose of this guideline from the American College of Physicians (ACP) is to present updated clinical recommendations on nonpharmacologic and pharmacologic interventions as initial and second-line treatments during the acute phase of a major depressive disorder (MDD) episode, based on the best available evidence on the comparative benefits and harms, consideration of patient values and preferences, and cost.

METHODS

The ACP Clinical Guidelines Committee based these recommendations on an updated systematic review of the evidence.

AUDIENCE AND PATIENT POPULATION

The audience for this guideline includes clinicians caring for adult patients in the acute phase of MDD in ambulatory care. The patient population includes adults in the acute phase of MDD.

RECOMMENDATION 1A

ACP recommends monotherapy with either cognitive behavioral therapy or a second-generation antidepressant as initial treatment in patients in the acute phase of moderate to severe major depressive disorder (strong recommendation; moderate-certainty evidence).

RECOMMENDATION 1B

ACP suggests combination therapy with cognitive behavioral therapy and a second-generation antidepressant as initial treatment in patients in the acute phase of moderate to severe major depressive disorder (conditional recommendation; low-certainty evidence). The informed decision on the options of monotherapy with cognitive behavioral therapy versus second-generation antidepressants or combination therapy should be personalized and based on discussion of potential treatment benefits, harms, adverse effect profiles, cost, feasibility, patients' specific symptoms (such as insomnia, hypersomnia, or fluctuation in appetite), comorbidities, concomitant medication use, and patient preferences.

RECOMMENDATION 2

ACP suggests monotherapy with cognitive behavioral therapy as initial treatment in patients in the acute phase of mild major depressive disorder (conditional recommendation; low-certainty evidence).

RECOMMENDATION 3

ACP suggests one of the following options for patients in the acute phase of moderate to severe major depressive disorder who did not respond to initial treatment with an adequate dose of a second-generation antidepressant: • Switching to or augmenting with cognitive behavioral therapy (conditional recommendation; low-certainty evidence) • Switching to a different second-generation antidepressant or augmenting with a second pharmacologic treatment (see Clinical Considerations) (conditional recommendation; low-certainty evidence) The informed decision on the options should be personalized and based on discussion of potential treatment benefits, harms, adverse effect profiles, cost, feasibility, patients' specific symptoms (such as insomnia, hypersomnia, or fluctuation in appetite), comorbidities, concomitant medication use, and patient preferences.

Mental Health Service Utilization Rates Among Commercially Insured Adults in the US During the First Year of the COVID-19 Pandemic

Importance

The COVID-19 pandemic has been associated with an elevated prevalence of mental health conditions and disrupted mental health care throughout the US.

Objective

To examine mental health service use among US adults from January through December 2020.

Design, Setting, and Participants

This cohort study used county-level service utilization data from a national US database of commercial medical claims from adults (age >18 years) from January 5 to December 21, 2020. All analyses were conducted in April and May 2021.

Main Outcomes and Measures

Per-week use of mental health services per 10 000 beneficiaries was calculated for 5 psychiatric diagnostic categories: major depressive disorder (MDD), anxiety disorders, bipolar disorder, adjustment disorders, and posttraumatic stress disorder (PTSD). Changes in service utilization rates following the declaration of a national public health emergency on March 13, 2020, were examined overall and by service modality (in-person vs telehealth), diagnostic category, patient sex, and age group.

Results

The study included 5 142 577 commercially insured adults. The COVID-19 pandemic was associated with more than a 50% decline in in-person mental health care service utilization rates. At baseline, there was a mean (SD) of 11.66 (118.00) weekly beneficiaries receiving services for MDD per 10 000 enrollees; this declined by 6.44 weekly beneficiaries per 10 000 enrollees (β, -6.44; 95% CI, -8.33 to -4.54). For other disorders, these rates were as follows: anxiety disorders (mean [SD] baseline, 12.24 [129.40] beneficiaries per 10 000 enrollees; β, -5.28; 95% CI, -7.50 to -3.05), bipolar disorder (mean [SD] baseline, 3.32 [60.39] beneficiaries per 10 000 enrollees; β, -1.81; 95% CI, -2.75 to -0.87), adjustment disorders (mean [SD] baseline, 12.14 [129.94] beneficiaries per 10 000 enrollees; β, -6.78; 95% CI, -8.51 to -5.04), and PTSD (mean [SD] baseline, 4.93 [114.23] beneficiaries per 10 000 enrollees; β, -2.00; 95% CI, -3.98 to -0.02). Over the same period, there was a 16- to 20-fold increase in telehealth service utilization; the rate of increase was lowest for bipolar disorder (mean [SD] baseline, 0.13 [16.72] beneficiaries per 10 000 enrollees; β, 1.40; 95% CI, 1.04-1.76) and highest for anxiety disorders (mean [SD] baseline, 0.20 [9.28] beneficiaries per 10 000 enrollees; β, 9.12; 95% CI, 7.32-10.92). When combining in-person and telehealth service utilization rates, an overall increase in care for MDD, anxiety, and adjustment disorders was observed over the period.

Conclusions and Relevance

In this cohort study of US adults, we found that the COVID-19 pandemic was associated with a rapid increase in telehealth services for mental health conditions, offsetting a sharp decline in in-person care and generating overall higher service utilization rates for several mental health conditions compared with prepandemic levels.

Comparison of depression care provided in general practice in Norway and the Netherlands: registry-based cohort study (The Norwegian GP-DEP study)

BACKGROUND

Depression is highly prevalent in general practice, and organisation of primary health care probably affects the provision of depression care. General practitioners (GPs) in Norway and the Netherlands fulfil comparable roles. However, primary care teams with a mental health nurse (MHN) supplementing the GP have been established in the Netherlands, but not yet in Norway. In order to explore how the organisation of primary mental care affects care delivery, we aimed to examine the provision of GP depression care across the two countries.

METHODS

Registry-based cohort study comprising new depression episodes in patients aged ≥ 18 years, 2011-2015. The Norwegian sample was drawn from the entire population (national health registries); 297,409 episodes. A representative Dutch sample (Nivel Primary Care Database) was included; 27,362 episodes. Outcomes were follow-up consultation(s) with GP, with GP and/or MHN, and antidepressant prescriptions during 12 months from the start of the depression episode. Differences between countries were estimated using negative binomial and Cox regression models, adjusted for patient gender, age and comorbidity.

RESULTS

Patients in the Netherlands compared to Norway were less likely to receive GP follow-up consultations, IRR (incidence rate ratio) = 0.73 (95% confidence interval (CI) 0.71-0.74). Differences were greatest among patients aged 18-39 years (adj IRR = 0.64, 0.63-0.66) and 40-59 years (adj IRR = 0.71, 0.69-0.73). When comparing follow-up consultations in GP practices, including MHN consultations in the Netherlands, no cross-national differences were found (IRR = 1.00, 0.98-1.01). But in age-stratified analyses, Dutch patients 60 years and older were more likely to be followed up than their Norwegian counterparts (adj IRR = 1.21, 1.16-1.26). Patients in the Netherlands compared to Norway were more likely to receive antidepressant drugs, adj HR (hazard ratio) = 1.32 (1.30-1.34).

CONCLUSIONS

The observed differences indicate that the organisation of primary mental health care affects the provision of follow-up consultations in Norway and the Netherlands. Clinical studies are needed to explore the impact of team-based care and GP-based care on the quality of depression care and patient outcomes.

Television watching, reading, cognition, depression and life satisfaction among middle-aged and older populations: A group-based trajectory modelling analysis of national data

This retrospective cohort study aimed to identify heterogeneous cognition, depression, and life satisfaction trajectory groups, and to examine the independent contributions of watching television and reading to these trajectories among middle-aged and older adults. A sample was taken from the Taiwan Longitudinal Study on Aging (TLSA) with measures of cognition, depression, life satisfaction, watching television, and reading during 12 years of follow-up (N = 4440). Group-based trajectory models and multinomial logistic regressions were used. The findings showed that the cohort was separated into three global cognition groups of low-cognition (n = 376), declining-cognition (n = 805), and maintained-cognition (n = 2718); three episodic memory groups of high-declining (n = 540), middle-stable (n = 2066), and improving groups (n = 1293); three depression groups of low-to-low (n = 2571), median-to-high (n = 960), and high-to-high groups (n = 368); and three life satisfaction groups of low- (n = 1133), middle- (n = 977), and high-level groups (n = 1789). Also, the findings demonstrated that after adjusting for covariates, those who did not watch television or read at the baseline had independently significantly increased odds of having lower global cognitive function, higher depression, and lower life satisfaction over time versus those who watched television or read almost every day. Based on the findings obtained, group-based trajectories of cognition, depression, and life satisfaction scores identified distinct subgroups among TLSA participants. Moreover, the findings suggest that healthcare providers need to develop more targeted population interventions to ensure successful aging. Healthcare providers can encourage older adults, particularly new retirees, to participate in leisure activities (i.e., watching television and reading) to reduce prevalence rates of cognitive impairment and depression.

Musculoskeletal Pain Management and Patient Mental Health and Well-being

Orthopaedic trauma patients have high rates of psychiatric disorders, which put them at risk for worse outcomes after injury and surgery, including worse pain. Mental health conditions, such as depression and anxiety, can affect the perception of pain. Pain can also exacerbate or contribute to the development of mental illness after injury. Interventions to address both mental health and pain among orthopaedic trauma patients are critical. Balancing safety and comfort amid a drug overdose epidemic is challenging, and many clinicians do not feel comfortable addressing mental health or have the resources necessary. We reviewed the literature on the complex relationship between pain and mental health and presented examples of scalable and accessible interventions that can be implemented to promote the health and recovery of our patients. Interventions described include screening for depression in the orthopaedic trauma clinic and the emergency department or inpatient setting during injury and using a comprehensive and evidence-based multimodal pain management regimen that blends pharmacologic alternatives to opioids and physical and cognitive strategies to manage pain.

Trend in rural-urban disparities in access to outpatient mental health services among US adults aged 18-64 with employer-sponsored insurance: 2005-2018

PURPOSE

This study estimates the rural-urban differences in outpatient service utilization and expenditures for depression, anxiety disorder, and substance use disorder, and the evolving mental health provider mix for privately insured US adults aged 18-64 during 2005-2018.

METHODS

We used the IBM MarketScan Commercial Claims and Encounters Database for individuals covered by employer-sponsored health insurance, from 2005 to 2018, with a yearly total number of beneficiaries ranging from 17.5 to 53.1 million. Claims for nonelderly adults with mental health and substance abuse coverage are included. Outcomes include rates of outpatient service utilization for depression, anxiety disorder, and substance use disorder; counts of outpatient visits; expenditure and share of the out-of-pocket cost; and the mental health services provider mix.

FINDINGS

Rural enrollees were less likely than urban enrollees to use outpatient mental health services for depression by 1.2% (percentage points) in 2005 and 0.6% in 2018. Among those who used outpatient mental health services, rural enrollees had fewer outpatient visits than their urban counterparts (difference: 1.8-2.4 visits for depression, 1.2-1.7 visits for anxiety disorder, and 0.7-2.1 visits for substance use disorder). Rural patients paid less per year for mental health outpatient visits of the 3 conditions but incurred a higher share of out-of-pocket expenses. Rural and urban patients differ in the mix of mental health providers, with rural enrollees relying more on primary care providers than urban enrollees.

CONCLUSIONS

Rural-urban disparities in access to mental health services persist during 2005-2018 among a population with private insurance.

Depression Screening and Behavioral Health Integration in Musculoskeletal Trauma Care

OBJECTIVES

To report our experiences in implementing a behavioral health integration pathway, including a validated depression screening and referral to care.

DESIGN

Retrospective case series.

SETTING

Single surgeon's musculoskeletal trauma outpatient practice during calendar year 2019.

PATIENTS

All patients presenting to the practice during 2019 were included (n = 573).

INTERVENTION

We piloted the usage of Patient Health Questionnaire (PHQ)-2 and PHQ-9 screening. An evidence-based, real-time treatment protocol embedded in the electronic health record was triggered when a patient screened positive for depression including an automated behavioral health integration pathway.

MAIN OUTCOME MEASUREMENTS

The percentage of patients screened, the results of the PHQ screening, and the number of patients referred and enrolled in behavioral health programs were collected.

RESULTS

Of the 573 patients, 476 (83%) received the PHQ-2 screening, 80 (14%) had a current screening on file (within 1 year), and 17 (3.0%) were not screened. One hundred seventy-two patients (36%) had a PHQ-2 score of 2 or greater and completed the PHQ-9; of them, 60 (35% of patients screened with full PHQ-9, 13% of patients screened) screened positive for symptoms of moderate depression (PHQ-9 score ≥10), and 19 (4.0%) reported passive suicidal ideation (PHQ-9 item 9). Fifty of these patients were referred to behavioral health through the pathway, and 8 patients enrolled in the program. Ten patients were not referred because of a technical error that was quickly resolved. Patients reporting suicidal ideation were managed with psychiatric crisis resources including immediate virtual consult in the examination room.

CONCLUSIONS

This case series demonstrates the feasibility of screening patients for depressive symptoms and making necessary referrals to behavioral health in outpatient musculoskeletal trauma care. We identified 50 patients with depression and appropriately triaged them for further care in our community.

Trends in Outpatient Treatment for Depression in Survivors of Stroke in the United States, 2004-2017

BACKGROUND AND OBJECTIVES

Depression is highly prevalent and persistent among survivors of stroke. It is unknown how treatment for depression among survivors of stroke has changed in the evolving context of stroke care and mental health care in the general United States (US) population, especially among vulnerable sociodemographic subgroups who bear higher risks for stroke and unfavorable post-stroke outcomes and experience disparities in access to and quality of stroke and mental health care. The study examined temporal trends in outpatient treatment for depression among survivors of stroke in the US between 2004 and 2017.

METHODS

The study sample consisted of 10243 adult survivors of stroke and 264645 adults without stroke drawn from the Medical Expenditure Panel Survey, a nationally representative survey in the US. Trends in outpatient treatment for depression and potential unmet needs in the stroke population, including variations across sociodemographic subgroups, were examined and compared with the non-stroke population.

RESULTS

The rate of receipt of outpatient treatment for depression among survivors of stroke was 17.7% in 2004-2005 and 16.0% in 2016-2017 (adjusted odds ratio for period change [aOR]=0.90, 95% CI=0.71-1.15). Older, male, non-Hispanic Black and Hispanic survivors of stroke were less likely to receive treatment for depression. Approximately two-thirds of survivors of stroke that screened positive for depression received no outpatient treatment during a calendar year. The sociodemographic disparities and treatment gap persisted during the study period, which differed from the non-stroke population. Among survivors of stroke who received any treatment for depression, there was a remarkable increase in use of psychotherapy (aOR=2.26, 95% CI=1.28-4.01), despite its less frequent use compared with pharmacotherapy.

DISCUSSION

Although depression is common after stroke, the majority of survivors of stroke receive no mental health treatment. This gap has remained largely unchanged over the past decades, with substantial sociodemographic differences. Efforts are needed to improve depression care for survivors of stroke and reduce disparities.

Quantifying the Economic Impact of Depression for Spine Patients in the United States

STUDY DESIGN

This was a retrospective cross-sectional analysis.

OBJECTIVE

The objective of this study was to estimate the incremental health care costs of depression in patients with spine pathology and offer insight into the drivers behind the increased cost burden.

SUMMARY OF BACKGROUND DATA

Low back pain is estimated to cost over $100 billion per year in the United States. Depression has been shown to negatively impact clinical outcomes in patients with low back pain and those undergoing spine surgery.

MATERIALS AND METHODS

Data was collected from the Medical Expenditure Panel Survey from 2007 to 2015. Spine patients were identified and stratified based on concurrent depression International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Health care utilization and expenditures were analyzed between patients with and without depression using a multivariate 2-part logistic regression with adjustments for sociodemographic characteristics and Charlson Comorbidity Index.

RESULTS

A total of 37,094 patients over 18 years old with a spine condition were included (mean expenditure: $7829±241.67). Of these patients, 7986 had depression (mean expenditure: $11,455.41±651.25) and 29,108 did not have depression (mean expenditure: $6837.89±244.51). The cost of care for spine patients with depression was 1.42 times higher (95% confidence interval, 1.34-1.52; P<0.001) than patients without depression. The incremental expenditure of spine patients with depression was $3388.22 (95% confidence interval, 2906.60-3918.96; P<0.001). Comorbid depression was associated with greater inpatient, outpatient, emergency room, home health, and prescription medication utilization and expenditures compared with the nondepressed cohort.

CONCLUSIONS

Spine patients with depression had significantly increased incremental economic cost of nearly $3500 more annually than those without depression. When extrapolated nationally, this translates to an additional $27.5 billion annually in incremental expenditures that can be attributed directly to depression among spine patients, which equates to roughly 10% of the total estimated spending on depression nationally. Strategies focused on optimizing the treatment of depression have the potential for dramatically reducing health care costs in spine surgery patients.

Depression complexity prevalence and outcomes among veterans affairs patients in integrated primary care

INTRODUCTION

The Veterans Health Administration (VA) Primary Care-Mental Health Integration (PC-MHI) initiative targets depression (MDD), anxiety/posttraumatic stress disorder (PTSD) and alcohol misuse (AM) for care improvement. In primary care, case finding often relies on depression screening. Whereas clinical practice guidelines solely inform management of depression, minimal information exists to guide treatment when psychiatric symptom clusters coexist. We provide descriptive clinical information for care planners about VA PC patients with depression alone, depression plus alcohol misuse, and depression with complex psychiatric comorbidities (PTSD and/or probable bipolar disorder).

METHOD

We examined data from a VA study that used a visit-based sampling procedure to screen 10,929 VA PC patients for depression; 761 patients with probable major depression completed baseline measures of health and care engagement. Follow-up assessments were completed at 7 months.

RESULTS

At baseline, 53% of patients evidenced mental health conditions in addition to depression; 10% had concurrent AM, and 43% had psychiatrically complex depression (either with or without AM). Compared with patients with depression alone or depression with AM, those with psychiatrically complex depression evinced longer standing and more severe mood disturbance, higher likelihood of suicidal ideation, higher unemployment, and higher levels of polypharmacy. Baseline depression complexity predicted worse mental health status and functioning at follow-up.

DISCUSSION

A substantial proportion of VA primary care patients with depression presented with high medical multimorbidity and elevated safety concerns. Psychiatrically complex depression predicted lower treatment effectiveness, suggesting that PC-MHI interventions should co-ordinate and individualize care for these patients. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Treatment selection using prototyping in latent-space with application to depression treatment

Machine-assisted treatment selection commonly follows one of two paradigms: a fully personalized paradigm which ignores any possible clustering of patients; or a sub-grouping paradigm which ignores personal differences within the identified groups. While both paradigms have shown promising results, each of them suffers from important limitations. In this article, we propose a novel deep learning-based treatment selection approach that is shown to strike a balance between the two paradigms using latent-space prototyping. Our approach is specifically tailored for domains in which effective prototypes and sub-groups of patients are assumed to exist, but groupings relevant to the training objective are not observable in the non-latent space. In an extensive evaluation, using both synthetic and Major Depressive Disorder (MDD) real-world clinical data describing 4754 MDD patients from clinical trials for depression treatment, we show that our approach favorably compares with state-of-the-art approaches. Specifically, the model produced an 8% absolute and 23% relative improvement over random treatment allocation. This is potentially clinically significant, given the large number of patients with MDD. Therefore, the model can bring about a much desired leap forward in the way depression is treated today.

Cognitive behavioral therapy for depressive disorders: Outcomes from a multi-state, multi-site primary care practice

BACKGROUND

Individuals with depressive disorders often present to and seek treatment in primary care. Integrated behavioral health services within this setting can improve access to evidence-based cognitive behavioral therapy (CBT). However, limited information exists on the effectiveness of CBT for depression in primary care.

METHODS

Of the 1,302 participants with a primary depressive disorder referred by their primary care provider, 435 endorsed moderate to severe depression at baseline and engaged in at least one CBT session. A psychotherapy tracking database was used to collect relevant data, which included demographics, clinical characteristics, treatment outcomes, and CBT intervention use.

RESULTS

Participants with moderate to severe depression who participated in CBT reported a significant decrease in depression and anxiety symptoms at the end of treatment (p ≤ .001, d = 0.52-0.78). Rates of reliable change, response, and remission and types of CBT interventions used differed between major and persistent depressive disorders.

LIMITATIONS

Multiple limitations must be noted, which are related to the naturalistic study design, inclusion and exclusion criteria, sample operationalization, symptomatic measurement, time-limited and focused assessment, data collection strategies, and psychological services. Together, these temper the conclusions that can be drawn.

CONCLUSION

Significant reductions in depression and anxiety symptoms were reported by participants with depressive disorders who engaged in short-term CBT within primary care. This study indicates that CBT can be implemented within primary care and suggests that primary care patients with depression can benefit from integrated psychological services, supporting population-based models of care.

Short-Term Changes in Internalizing Symptoms and Help-Seeking Attitudes During the Coronavirus Pandemic

Introduction: Existing data suggest that American adults experience added emotional difficulties amid the coronavirus disease outbreak. Psychotherapy can help mitigate mental health concerns; still, many individuals with unmet mental health needs refrain from professional help-seeking. According to theory of reasoned action, negative help-seeking attitudes are key barriers to engagement with mental health services. Given that individuals with severe distress are more likely to seek therapy than individuals with mild psychopathology symptoms, greater initial and increasing levels of internalizing symptoms amid the coronavirus outbreak likely are linked to increasingly favorable attitudes toward professional help-seeking. Method: In the early months of the coronavirus pandemic, American community adults, N = 831 [49.0% Asian Americans], Mage = 46.78, 50.2% women, were recruited for a panel survey study conducted over the course of three weeks. At each time point, participants completed questionnaires to assess their internalizing symptoms associated with depression and anxiety as well as their openness to and perceived value/need in treatment seeking. Results: Very few participants—especially Asian Americans —were seeking counseling during the study period. Latent growth curve results showed a general decline in internalizing symptoms, and no changes in openness to and perceived need in professional help-seeking. Whereas there were no time-varying correlations between internalizing symptoms and help-seeking attitudes, individuals with greater baseline internalizing symptoms generally were more open to seeking professional help and perceived less value in mental health services. Sensitivity analyses showed patterns in the Asian American subsample similar to those in the overall sample. Discussion: Implications for research and clinical practice are discussed.

Impacts on and Care of Psychiatric Patients during the Outbreak of COVID-19

The outbreak of coronavirus disease (COVID-19) in December 2019 has led to massive lifestyle, economic, and health changes. The COVID-19 pandemic has had broad impacts on psychiatric patients, exacerbating symptoms such as psychosis, depression, and suicidal ideation. Therefore, we aimed to review the psychological impacts of COVID-19 on psychiatric patients and mental healthcare staff and provide practical guidance for medical staff and authorities.

The main findings of this review included the impacts of COVID-19 on psychiatric patients and mental health professionals as well as the transformation of mental health care. Greater consideration should be given to the care of patients with psychosis and depression because of their lack of self-care ability, neurocognitive impairment, and impaired immune function. Depressive symptoms can be exacerbated due to several factors, such as economic crises, social isolation, and limited physical activity. Unemployment and financial problems can lead to an increased suicide rate. Consequently, mental healthcare workers’ workload can increase, which could lead to burnout and psychological symptoms such as insomnia, depression, and anxiety.

A transformation of psychiatric care is needed during the time of the pandemic. While emergency care should be maintained, outpatient care should be limited to decrease viral spread. Shifting care to telemedicine and community-based psychiatry can be helpful. Inpatient services should be adapted by tightening admission criteria, shortening the length of hospital stays, suspending some group activities, limiting visitors, and preparing for quarantine if necessary. Mental healthcare workers can be supported with telecommunication, appropriate work shifts, alternative accommodations, and good communication between the team leader and staff.

Incremental Economic Burden of Depression in Ophthalmic Patients

PURPOSE

We sought to analyze the incremental economic burden of depression on adults with concurrent ophthalmic conditions in the United States.

DESIGN

Retrospective cross-sectional study.

METHODS

Using the Medical Expenditure Panel Survey from 2016 to 2018, ophthalmic patients with ≥1 outpatient visit were identified by International Classification of Diseases, 10th revision, Clinical Modification codes and stratified based on the presence of concurrent depression. A multivariate 2-part regression model was used to determine incremental economic burden, health care sector utilization, and expenditures.

RESULTS

Of 7279 ophthalmic patients, 1123 (15.43%) were diagnosed with depression (mean expenditures $17,017.25 ± $2019.13) and 6156 patients (84.57%) without depression (mean expenditures $9924.50 ± $692.94). Patients with depression were more likely to be female, white, lower income, use Medicare/Medicaid, and to have comorbidities (P < .001). These patients faced $5894.86 (95% confidence interval $4222.33-$7348.36, P < .001) in incremental economic expenditures because of depression, resulting in an additional $22.4 billion annually when extrapolating nationally. These patients had higher utilization for all health care service sectors (P < .025 for all) and higher expenditures for outpatient (P = .022) and prescription medications (P = .029) when adjusted for sociodemographic variables and comorbidities. Depression was responsible for 6.9% of inpatient admissions (the second-leading cause) for this cohort of patients.

CONCLUSION

Ophthalmic patients with depression had a higher incremental economic burden and health care service sector utilization and expenditures. Patients with ophthalmic pathologies, including dry eye syndrome, blindness, and retinopathies, were more likely to be depressed. As psychiatric and ophthalmic conditions may have a bidirectional relationship, exacerbating disease severity and financial burden for patients with both, ophthalmologists may need to be more cognizant of the burden of depression among patients.

Trends in treatment for patients with depression in general practice in Norway, 2009-2015: nationwide registry-based cohort study (The Norwegian GP-DEP Study)

Background

Depression is highly prevalent, but knowledge is scarce as to whether increased public awareness and strengthened government focus on mental health have changed how general practitioners (GPs) help their depressed patients. This study aimed to examine national time trends in GP depression care and whether trends varied regarding patient gender, age, and comorbidity.

Methods

Nationwide registry-based cohort study, Norway. The study population comprised all residents aged 20 years or older with new depression diagnoses recorded in general practice, 2009–2015. We linked reimbursement claims data from all consultations in general practice for depression with information on demographics and antidepressant medication. The outcome was type(s) of GP depression care during 12 months from the date of diagnosis: (long) consultation, talking therapy, antidepressant drug treatment, sickness absence certification, and referral to secondary mental health care. Covariates were patient gender, age, and comorbidity. The data are presented as frequencies and tested with generalized linear models.

Results

We included 365,947 new depression diagnoses. Mean patient age was 44 years (SD = 16), 61.9 % were women, 41.2 % had comorbidity. From 2009 to 2015, proportions of patients receiving talking therapy (42.3–63.4 %), long consultations (56.4–71.8 %), and referral to secondary care (16.6–21.6 %) increased, while those receiving drug treatment (31.3–25.9 %) and sick-listing (58.1–50 %) decreased. The trends were different for gender (women had a greater increase in talking therapy and a smaller decrease in sick-listing, compared to men), age (working-aged patients had a smaller increase in talking therapy, a greater increase in long consultations, and a smaller decrease in antidepressant drug use, compared to older patients) and comorbidity (patients with mental comorbidity had a smaller increase in talking therapy and a greater increase in long consultations, compared to those with no comorbidity and somatic comorbidity).

Conclusions

The observed time trends in GP depression care towards increased provision of psychological treatment and less drug treatment and sick-listing were in the desired direction according to Norwegian health care policy. However, the large and persistent differences in treatment rates between working-aged and older patients needs further investigation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06712-w.

From Mental Health Industry to Humane Care. Suggestions for an Alternative Systemic Approach to Distress

The article proposes a rough outline of an alternative systemic approach to mental health issues and of a more humane mental health care system. It suggests focusing on understanding mental distress as stemming from problems in living, using medications as agents facilitating psychotherapy, or as a last resort and short-term help, according to the principles of harm reduction. It argues that understanding drugs as psychoactive substances and studying the subjective effects they produce could lead to better utilization of medications and improvements in terms of conceptualizing and assessing treatment effects. Qualitative research could be particularly useful in that regard. It also advocates a radical departure from current diagnostic systems and proposes a synthesis of already existing alternatives to be used for both research and clinical purposes. Accordingly, a general idea for an alternative mental health care system, based on a combination of Open Dialogue Approach, Soteria houses, individual and group psychotherapy, cautious prescribing, services helping with drug discontinuation, peer-led services and social support is presented. The proposition could be seen as a first step towards developing a systemic alternative that could replace the currently dominating approach instead of focusing on implementing partial solutions that can be co-opted by the current one.

The Increasing Economic Burden with Additional Steps of Pharmacotherapy in Major Depressive Disorder

OBJECTIVES

Major depressive disorder (MDD) is a common and serious disorder with significant impact on patients and families. The goal of this retrospective cohort study was to determine the economic burden among patients with MDD stratified by number of treatment lines needed for episode resolution.

METHODS

Truven Health Analytics MarketScan^® claims data were used to identify US patients (≥ 18 years) who were diagnosed with MDD and started on an antidepressant between 2013 and 2017. A generalized linear model estimated direct and employment-related costs for the first 12 months following initiation of treatment across cohorts with increasing number of lines of MDD pharmacotherapy. Analyses were adjusted for demographics and clinical factors.

RESULTS

A total of 73,597 patients with MDD comprising the commercial (n = 66,459) and Medicare (n = 7138) populations met selection criteria. Patients who completed treatment for their episode with a single line of antidepressant had the lowest total adjusted direct costs (commercial $9975; Medicare $14,628) followed by those who completed with two lines (commercial $11,723; Medicare $15,526) and those treated with three or more lines of antidepressant regimens (commercial $21,259; Medicare $20,964). Patients who completed treatment with two lines as opposed to one incurred significantly higher direct costs (commercial +$1748, p < 0.0001; Medicare +$898, p = 0.0092). Patients who completed treatment with one line had the lowest employment-related costs compared to other groups.

CONCLUSIONS

There was an increased economic burden associated with delay of episode resolution as early as the second line compared to the first line in MDD.

Pharmacogenomics guided versus standard antidepressant treatment in a community pharmacy setting: A randomized controlled trial

The literature on pharmacogenomics as a tool to support antidepressant precision is burgeoning. Recently, a more active role has been argued for pharmacists in pharmacogenomic testing, with both pharmacists and family physicians perceiving pharmacist‐led testing as a valuable method by which to scale this innovation for depression treatment. In this prospective, single‐blind randomized controlled design, we evaluated the impact of pharmacogenomics guided versus standard antidepressant treatment of depression and anxiety, implemented in three large community pharmacies. Participants were 213 outpatients diagnosed with major depressive disorder and/or generalized anxiety disorder, randomized to receive pharmacogenomics guided (n = 105) or standard antidepressant treatment (n = 108); participants were blinded to the study. Patient reported outcomes of depression, anxiety, disability, and treatment satisfaction were assessed at months 0, 1, 3, and 6. Hypotheses were investigated using mixed effect models on the full data. All clinical outcomes improved significantly. The primary outcome (depression) and two secondary outcomes (generalized anxiety and disability) exhibited significant time by group interactions indicating that they improved for participants who received pharmacogenomics guided treatment more so than they did for participants who received standard treatment. Treatment satisfaction improved similarly for both groups. Results contribute to a growing body of work evaluating the impact of pharmacogenomics testing to inform antidepressant medication treatment for depression and anxiety, and provides important initial evidence for the role of pharmacists in care delivery. Pharmacogenomic testing may be a valuable tool to allow pharmacists to more effectively collaborate in facilitating clinical treatment decisions. ClinicalTrials.gov registration: (NCT03591224).

National Trends in Outpatient Mental Health Service Use Among Adults Between 2008 and 2015

OBJECTIVE

This study sought to characterize recent trends in mental health visits of adult outpatients to primary care physicians (PCPs), specialty mental health providers (SMHPs), and other providers (non-primary care physicians, specialists other than SMHPs, nurse practitioners, and physician assistants). Trends determined by degree of patients' psychological distress and in the types of treatments received within different settings were also examined.

METHODS

Data were from the household component of the nationally representative Medical Expenditure Panel Survey for the 2008-2011 and 2012-2015 periods for adults ages ≥18 years (N=13,111) who had a mental health outpatient visit. Bivariate logistic regression was used to compare means between the two periods.

RESULTS

The percentage of adults having mental health outpatient visits increased between the two periods, largely driven by an increase in visits with providers other than SMHPs and PCPs, which rose from 11.9% (N=667) to 15.5% (N=1,048). Outpatient mental health visits with PCPs decreased from 29.0% (N=1,802) to 26.8% (N=1,945). The proportion of respondents with mental health outpatient visits increased both among those with high psychological distress and among those with low or no psychological distress (from 30.7% [N=1,332] to 36.2% [N=1,491] and from 6.0% [N=4,516] to 6.9% [N=5,772], respectively). The percentage of respondents receiving only psychotropic medication decreased over the two periods.

CONCLUSIONS

Mental health outpatient visits for adults increased between 2008 and 2015, and visits with SMHPs remained relatively stable during that time. A greater understanding of recent trends in types of outpatient mental health services may help identify targets for future mental health workforce studies.

Can loss of agency and oppositional perturbation associated with antidepressant monotherapy and low-fidelity psychological treatment dilute the benefits of guideline-consistent depression treatment at the population level?

Despite major expansions of evidence-based treatments of common mental disorders in recent decades, especially antidepressant medication, the point prevalence of depression has not decreased; instead it probably increased in young adults. We question whether antidepressants (AD)-monotherapy and low-fidelity-to-guideline psychological treatment (PT) might have no effect or even adverse effects in some patients and contexts that dilute the benefits of treatment at the population level, making it harder for population-based studies to detect treatment-driven prevalence reductions. Randomized Clinical Trial (RCT)s have not identified these effects because AD-monotherapy and low-fidelity PT are uncommon in RCTs where treatment protocols are specified and carefully monitored, unlike treatment in real-world settings. Second, RCTs may have missed the bigger picture of ultimate outcomes due to too short follow-ups. We elaborate two mechanisms through which AD-monotherapy and low-fidelity PT could produce adverse effects on long-term illness course. Both mechanisms are speculative and we outline how to test.

Depression and suicidal ideation: association of physical, mental, social, and spiritual health status

PURPOSE

The aim of this study was to determine if multidimensional (physical, mental, social, spiritual) health status could predict the presence of depressive symptoms and suicidal ideation in the general population.

METHODS

We administered a population-based, cross-sectional survey to 1200 participants from the general Korean population. The survey included the 5 Health Status Questionnaire (5HSQ) for self-rated health status, Patient Health Questionnaire-9 (PHQ-9) for depression, and a question from the PHQ-9 for suicidal ideation. Multiple logistic regression was performed to estimate the association of significant socio-demographic factors and self-rated health status with depression and suicidal ideation.

RESULTS

Physical health status was associated with depression in both men and women (men: adjusted odds ratio [aOR], 4.69; 95% confidence interval [CI] 2.44-9.00; women: aOR, 2.05; 95% CI 1.13-3.72) while spiritual health status only affected men (aOR, 5.50; 95% CI 2.59-11.65) and mental health status only women (aOR, 3.92; 95% CI 2.03-7.54). Social health status was associated with suicidal ideation in men (aOR, 4.87; 95% CI 2.74-19.99) while mental health status was associated with suicidal ideation in women (aOR, 4.31; 95% CI 1.90-9.76).

CONCLUSION

Physical, mental, social, and spiritual self-rated health statuses were all found to be associated with an individual's predisposition to depression and suicidal ideation with notable differences between men and women.

Treatment Modalities and Perceived Effectiveness of Treatment Among Adults With Depression

Patient-reported outcomes of mental health treatment, such as perceived effectiveness, are important. They indicate whether treatment is perceived to reduce symptoms and minimize psychiatric disability. Outpatient treatment for depression typically includes medication or counseling, either alone or in combination. This study examines the relationship between treatment modality and perceived effectiveness of treatment. Using a sample of adults who received outpatient treatment for depression from the 2015-2016 National Survey on Drug Use and Health (N = 4169), logistic regressions estimated the odds of rating treatment as effective among persons who received medication only, counseling only, and a combination of medication and counseling. There were no differences in perceived effectiveness between counseling only and medication only. However, receiving both was associated with greater odds of rating treatment as effective. Poor self-rated health and severe mental illness were associated with lower perceived effectiveness of medication. Those with substance use problems had lower odds of rating counseling and both counseling and medication as effective. A combined treatment for depression may be perceived as better than single-modality treatment. Therefore, there might be benefits to increasing access to both forms of treatment for persons less likely to rate either single modality as effective.

How protected classes in Medicare Part D influence U.S. drug sales, utilization, and price

When the Medicare Part D prescription drug benefit was implemented in 2006, six drug classes were designated "protected classes." Because responsibility for obtaining favorable drug prices depends on private insurers' abilities to negotiate with pharmaceutical manufacturers using the threat of formulary exclusion, the protected class designation could undermine the insurers' ability to control spending and utilization of drugs in these six classes. I estimate the effect of the protected class policy on U.S. national drug sales, utilization, and price using 2001-2010 IMS Health National Sales Perspectives data and Verispan Vector One: National data and controlling for drug and year fixed effects. I find that protected status beginning in 2006 led to $112-121 million per drug per year higher U.S. sales for drugs in protected classes relative to unprotected drugs. Greater sales were driven by the antidepressant, antipsychotic, anticonvulsant, and antineoplastic classes. Subsequent analyses on a subset of drugs reveal that increases in both price and quantity are responsible for the growth of sales in protected class drugs. These results are important for informing the recent and ongoing deliberation by the Medicare program over whether to remove several classes from protection.

Somatic symptoms in treatment-naïve Hispanic and non-Hispanic patients with major depression

BACKGROUND

Somatic complaints are a major driver of health care costs among patients with major depressive disorder (MDD). Some epidemiologic and clinical data suggest that Hispanic and non-Hispanic Black patients with MDD endorse higher levels of somatic symptoms than non-Hispanic White patients.

METHODS

Somatic symptoms in 102 Hispanic, 61 non-Hispanic Black, and 156 non-Hispanic White patients with treatment-naïve MDD were evaluated using the somatic symptom subscale of the Hamilton anxiety rating scale (HAM-A). The other seven items of the HAM-A comprise the psychic anxiety subscale, which was also evaluated across ethnicities.

RESULTS

Hispanic patients reported significantly greater levels of somatic symptoms than non-Hispanic patients, but levels of psychic anxiety symptoms did not differ by ethnicity. Levels of somatic symptoms did not significantly differ between Black and White non-Hispanic patients. Within the Hispanic sample, somatic symptom levels were higher only among those who were evaluated in Spanish; Hispanics who spoke English showed no significant differences versus non-Hispanics.

CONCLUSIONS

In this medically healthy sample of patients with MDD, monolingual Spanish-speaking Hispanic patients endorsed high levels of somatic symptoms. Clinicians should be mindful that the depressive experience may manifest somatically and be judicious in determining when additional medical work-up is warranted for somatic complaints.

National Prescription Patterns of Antidepressants in the Treatment of Adults With Major Depression in the US Between 1996 and 2015: A Population Representative Survey Based Analysis

Few studies have delineated the real-world, long-term trends of prescription patterns of antidepressants for patients with major depressive disorder (MDD). This study aims to describe their vicissitudes in the nationally representative sample of the US from 1996 to 2015 and explore their characteristics. We used the Medical Expenditure Panel Survey, a nationally representative database of the US population, between 1996 and 2015. We estimated the prevalence of MDD among adults, calculated the proportions of those on antidepressant treatment as well as those on specific drugs through the two decades, and determined their dosages in 2015. We conducted multivariable regression to find possible factors related to their suboptimal prescriptions. The prevalence of adults diagnosed with MDD increased from 6.1% (95% CI, 5.7-6.6%) in 1996 to 10.4% (9.7-11.1%) in 2015. The proportion of patients without any antidepressant therapy decreased but still accounted for 30.6% (28.3-33.1%) in 2015. Sertraline and fluoxetine were among the most frequently prescribed antidepressants throughout the 20 years, while the trend for some new drugs changed dramatically. 16.1% (12.5-20.2%) of patients of MDD on antidepressant monotherapy were prescribed with suboptimal doses in 2015; the risk was lower for those who had higher Body Mass Index (OR 0.94 [0.90-0.99]), longer-term prescriptions (OR 0.92 [0.87-0.97]), and the risk was higher for those who were prescribed with tricyclic antidepressants (OR 11.21 [2.12-59.34], compared with serotonin reuptake inhibitors (SSRIs)), and antidepressants other than SSRIs and serotonin and norepinephrine reuptake inhibitors (OR 4.12 [1.95, 8.73], compared with SSRIs). This study confirmed the growing numbers of patients with MDD and the increase in the antidepressant prescriptions among them. However, the existence of patients without any antidepressant prescriptions or with suboptimal prescriptions and the variable prescription patterns through the decades might suggest some unresolved gaps between evidence and practice.