Research paperThe association between geographic access to providers and the treatment quality of pediatric depression
Introduction
Major depressive disorder (MDD) (referred as depression in this article) affects around 2% to 3% children and 11% adolescents in the United States (Avenevoli et al., 2015, Mojtabai et al., 2016, Son and Kirchner, 2000). Early-age onset depression is associated with significant short- and long-term consequences (Glied and Pine, 2002, Keenan-Miller et al., 2007). In the short-term, suicide is the worst adverse effect of depression with 94% of suicide cases have undiagnosed or diagnosed depression among children and adolescents (Glied and Pine, 2002, Marcelli, 1998). While in the long-term, depression is associated with interpersonal difficulties, school dropout, substance use disorder, and unemployment (Bostic et al., 2005, Bujoreanu et al., 2011, Dunn and Goodyer, 2006).
Early diagnosis and treatment are critical to avoid the adverse consequences of depression in children and adolescents. Cognitive behavior therapy and interpersonal therapy (referred to as psychotherapy in this study) are guideline-recommended first-line treatment options for mild pediatric depression and antidepressants are recommended for those with moderate to severe depression along with psychotherapy (Cheung et al., 2013). Weekly psychotherapy for a period of 12–16 weeks has been recommended (Cheung et al., 2013). If symptoms do not improve after 2–3 weeks of psychotherapy, pharmacotherapy or a combination of pharmacotherapy and psychotherapy should be considered (Cheung et al., 2013). The recommended minimal treatment duration of pharmacotherapy ranged from 3–6 months depending on the disease severity (Cheung et al., 2013).
Previous studies have reported that only 30–40% of adolescents with depression received treatment and of those treated, approximately 50% were adherent to treatment (Eisenberg and Chung, 2012, Fontanella et al., 2011, Merikangas et al., 2011, Mojtabai et al., 2016, Soria-Saucedo et al., 2016a). Several factors have been associated with low treatment utilization in pediatric depression patients which includes not having a source of healthcare, race/ethnicity, socioeconomic status, insurance status, the severity of depression and stigma associated with mental disorder (Avenevoli et al., 2015, Duhoux et al., 2012, Wu et al., 2001).
There has been no study investigating the association of geographic access to providers with the likelihood of treatment engagement, and the treatment completion among children and adolescents with depression. Patients with depression need to pay frequent visits to their providers (every 1 to 2 weeks) for treatment (e.g. psychotherapy) and/or medication monitoring (Cheung et al., 2018), which may have placed a significant travel burden on families that have children with depression. According to studies conducted on adult samples with depression, travel distance to providers has a negative effect on the likelihood of receiving psychotherapy, and the completion of depression related treatment (Fortney et al., 1999, Pfeiffer et al., 2011).
Geographic distribution of health care resources within metropolitan areas often interacts with the geographic distribution of racial/ethnic groups, and poverty (Lê Cook et al., 2013, Ronzio et al., 2006, Shi and Starfield, 2001). Similar to most metropolitan areas in the US, the majority of poor Hispanics and Blacks in Houston live in the inner city with a cluster of their own racial/ethnic groups (Lee et al., 2008, Massey et al., 1991). Congruent with the demographic and economic distribution of the population, health care resources tend to be also sparser (provider density, availability of mental health facility, public transport) in neighborhoods where minorities live in comparison to the neighborhood where Whites reside (Williams and Collins, 2001).
Therefore, our study aimed to investigate the association of geographic access to providers (travel distance and provider density) with the racial/ethnic variations in treatment quality (treatment engagement and treatment completion) among Medicaid and Children's Health Insurance Program (CHIP) enrolled pediatric patients with newly diagnosed major depressive disorder.
Section snippets
Study setting and data sources
The study was a retrospective cohort analysis conducted using multiple data sources. The primary data source was the medical and pharmacy insurance claims data obtained from the Texas Children's Health Plan (TCHP). TCHP is a Houston based pediatric Medicaid managed care program, which offers Medicaid and CHIP in more than 20 counties in southeast Texas. In addition to the medical and pharmacy claims, TCHP data also included patient's characteristics (date of birth, gender, race/ethnicity) and
Study population
There were 4022 patients who received a new major depressive disorder diagnosis and met the inclusion criteria of the study between July 1st, 2013 and June 31st, 2016. Of these, 3472 patients received at least one treatment (antidepressants or psychotherapy) for MDD within 2 months of the index diagnosis. Fig. 2 presents the attrition of the study population based on the inclusion criteria. Table 1 describes the social demographics and the receipt of treatment of the study cohort. Most of the
Discussion
Our study found that 66% of the study cohort traveled less than 15 miles to the providers who initiated their MDD treatment. Probably due to the relatively high access to providers within the geographic region investigated, the depression treatment initiation (86%) and engagement (70%) rates found in our study were much higher than 58% treatment rate reported in a similar claim-based study (Soria-Saucedo et al., 2016b). Despite the high treatment engagement rate, only 14% of those who engaged
Conclusion
The study found that 70% of the pediatric patients with newly diagnosed MDD engaged in treatment however, only 11% of those who engaged in treatment met the minimum adequacy of treatment recommended by the guidelines. Increased specialist density had a positive association with treatment engagement in Blacks but among Hispanics, travel distance to the provider who initiated the treatment had a statistically significant negative association with the treatment engagement. Regarding the
Funding source
The project was done without funding.
Conflict of interest
The authors have no conflicts of interest relevant to this article to disclose.
Acknowledgements
Authors would like to acknowledge Texas Children's Health Plan for providing the data for the study.
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