PCPs Often First Stop for Managing Newly Diagnosed Depression

NASHVILLE, Tenn. -- Care for new depression was more commonly delivered by primary care providers (PCPs) than psychiatric providers, according to an observational retrospective study.

In a review of adults newly diagnosed with major depressive disorder, 16,987 patients were under the care of a PCP compared with 1,780 who were managed by a psychiatrist at the time of diagnosis, and only 6.2% of PCP-managed patients transitioned to a psychiatrist for their care, reported Laura Lupton, MD, of CVS Health Clinical Trial Services in Woonsocket, Rhode Island, during a poster presentation at Psych Congress 2023.

This didn't necessarily come as a surprise, Lupton explained to MedPage Today. "We know that we don't have enough psychiatrists; that's the thing that you hear over and over and over, we just don't have enough. So people have a hard time getting an appointment."

Meanwhile, "at primary care, you go to your doctor for hypertension and ... we deal with another issue, whereas to get that patient to go to psychiatry is another step," she added. "And they may or may not be willing, depending on if it's another co-payment, it's more time, and they may not be comfortable with that because of this social stigma. So they may stick with primary care."

Care also looked a little different depending on the provider. One year after depression diagnosis, 28.6% of patients seeing a PCP remained untreated compared with 16.1% of those managed by a psychiatrist.

More patients seeing a PCP were treated only with antidepressants compared with those seeing a psychiatric provider (57.7% vs 46.2%), and they were less likely to be treated with psychotherapy only (3.8% vs 8.3%) or with combination psychotherapy and antidepressants (9.9% vs 29.4%).

Furthermore, more patients under the care of a PCP compared with a psychiatrist ditched their newly prescribed antidepressant within the first year of diagnosis (33% vs 26%), and medication switches, augmentations, or new medication adds were less common (27% vs 46%).

Regardless of provider, more Medicare patients in both groups went without depression treatment than those with commercial insurance, and patients with commercial insurance were more likely to be prescribed antidepressants without psychotherapy than Medicare beneficiaries. Medicare patients under the care of a psychiatrist was the group most likely to receive psychotherapy.

Depression severity also played a role. Patients with severe depression -- defined as those with claims for a suicide attempt, inpatient visit or emergency department visit related to depression, or an ICD-10 code claim for severe depression -- were more likely to be managed by a psychiatrist than a PCP (26.7% vs 18.7%).

But Lupton pointed out that this could be a chicken-and-egg situation, as her group didn't know whether or not the patients seen in psychiatry actually had more severe cases of depression or if they were just rated as more severe by psychiatrists and may be underdiagnosed in primary care.

Patients with more comorbidities were more likely to be managed by a PCP, especially those with a score of 4 or higher on the Charlson Comorbidity Index (46% vs 12.2% treated by a psychiatrist). Not surprisingly, patients on Medicare were far more likely to have a high comorbidity score.

Finally, location also played a role in provider type. In rural areas, it was far more likely for people to see their PCP rather than a psychiatrist. Lupton highlighted the dearth of psychiatrists, particularly in these rural areas, where patients can turn to telehealth as a viable alternative.

"In a smaller rural community, I will tell you, everybody knows everybody's business. And if you see the local therapists, everybody knows that you go there," she said, adding that health literacy is another barrier to patients in rural communities seeking out psychiatrists.

Conversely, patients living in urban areas were much more likely to be managed by a psychiatric provider than a PCP, while for suburban dwellers, it was an equal split.

Data for this retrospective review came from an administrative claims database from a U.S. healthcare payer that covers 9.9 million individuals. All patients were diagnosed in an outpatient setting based on ICD-10 codes made by a PCP or psychiatric provider from early 2019 through late 2021. Data were analyzed 1 year prior to diagnosis through 1 year after.

Nearly half of patients (46.6%) who had their depression managed by a PCP had Medicare compared with 9.8% of psychiatry-managed patients. As a result, the average patient age of those managed by a PCP was much older, at 55.8 years, compared with 38.8 years for patients managed by a psychiatrist.

While baseline benzodiazepine use was similar between PCP- and psychiatry-managed patients (32% vs 35.2%), use was more common among Medicare patients, with the greatest use seen among psychiatrist-managed Medicare patients (51.4%).

"I thought that was kind of a high number," noted Lupton. "I guess that we know that if you have one mental health or behavioral health-type diagnosis, you're far more likely perhaps to have a second, so if you have depression, do you also have anxiety and in fact these patients could have been treated for anxiety up front."

Baseline anticonvulsant use was also similar between PCP- and psychiatrist-managed patients, and use was again higher among Medicare patients managed by both types of providers.

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