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Medication management of depression in the United States and Ontario

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Abstract

OBJECTIVE: To compare rates of contact for mental problems and receipt of appropriate antidepressant medication management for persons in the general population with major depression in the United States and Ontario, Canada.

DESIGN: Survey using the U.S. National Comorbidity Survey and the Mental Health Supplement of the Ontario Health Survey.

PARTICIPANTS: All persons with major depression as described in DSM-III-R in the previous 12 months, from a multistage random sample of persons aged 21 to 54 years living in households in the United States (n=574) and Ontario (n=250) in 1990.

MEASUREMENTS AND MAIN RESULTS: Self-reported contact with general medical or mental health specialty providers for mental problems and appropriate medication management, defined as a combination of antidepressant medication use and four or more visits to any provider within the previous 12 months, were the main outcome measures. The proportion of depressed persons receiving appropriate management was lower in the United States than in Ontario (7.3% vs 14.9% in Ontario, adjusted odds ratio [AOR] 95% CI 0.4; 95% confidence interval [CI] 0.2, 0.8). This difference was largely the result of fewer Americans than Canadians having any mental health care from general medical physicians (9.6% in the United States vs 25.8% in Ontario; AOR 0.3; 95% CI 0.1, 0.5) rather than from specialty providers (20.8% in the United States vs 28.9% in Ontario; AOR 0.7; 95% CI 0.4, 1.1). These between-country differences were much greater for the poor than for those with higher incomes. The Ontario-United States AOR of making contact with either type of clinical provider was 7.5 (95% CI 2.7, 20.7) for lowest-income persons but 2.1 (95% CI 0.3, 5.6) for highest-income persons. The proportions of depressed recipients of any mental health care who received appropriate management were similar between countries (23.9% in the United States vs 27.7% in Ontario; AOR 0.8; 95% CI 0.3, 1.7).

CONCLUSIONS: Most persons with depression in the United States and Ontario do not receive appropriate medication management. The rate of appropriate medication management in the United States relative to Ontario is lower largely because there is less contact with general medical physicians for mental problems, especially for the poor. Economic barriers, rather than knowledge and attitudinal factors, appear to explain this difference.

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Preparation of this report was supported by a Robert Wood Johnson Foundation Generalist Physician Faculty Scholars Award to Dr. Katz and a research scientist award to Dr. Kessler (grant MH00507) and Dr. Wells. The National Comorbidity Study is supported by the National Institute of Mental Health (grants MH46376 and MH49098) with supplemental support from the National Institute of Drug Abuse (through a supplement to MH46376) and the W. T. Grand Foundation (grant 90135190). Ronald C. Kessler is the principal investigator. The Mental Health Supplement to the Ontario Health Surveyor is supported by the Ontario Ministries of Health and Community and Social Services through the Ontario Mental Health Foundation. David R. Offord is the principal investigator.

Collaborating National Comorbidity Study sites and investigatiors are The Addiction Research Foundation (Robin Room), Duke University Medical Center (Dan Blazer, Marvin Swartz), Harvard University (Richard Frank), Johns Hopkins University (James Anthony, William Eaton, Philip Leaf), the Max Planck Institute of Psychiatry—Clinical Institute (Hans-Ulrich Wittchen), the Medical College of Virginia (Kenneth Kendler), the University of Michigan (Lloyd Johnston, Ronald Kessler, Roderick Little), New York University (Patrick Shrout), SUNY Stony Brook (Evelyn Bromet), The University of Toronto (R. Jay Turner), and Washington University School of Medicine (Linda Cottler, Andrew Heath).

Collaborating Mental Health Supplement to the Ontario Health Survey agencies and investigators are The Ontario Mental Health Foundation (Dugal Campbell), The Clarke Institute of Psychiatry (Paula Goering, Elizabeth Lin), McMaster University (Michael Boyle, David Offord), and the Ontario Ministry of Health (Gary Catlin).

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Katz, S.J., Kessler, R.C., Lin, E. et al. Medication management of depression in the United States and Ontario. J GEN INTERN MED 13, 77–85 (1998). https://doi.org/10.1046/j.1525-1497.1998.00022.x

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  • DOI: https://doi.org/10.1046/j.1525-1497.1998.00022.x

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