Are Veterans Getting Their Preferred Depression Treatment? A National Observational Study in the Veterans Health Administration

Background Physician responsiveness to patient preferences for depression treatment may improve treatment adherence and clinical outcomes. Objective To examine associations of patient treatment preferences with types of depression treatment received and treatment adherence among Veterans initiating depression treatment. Design Patient self-report surveys at treatment initiation linked to medical records. Setting Veterans Health Administration (VA) clinics nationally, 2018-2020. Participants A total of 2582 patients (76.7% male, mean age 48.7 years, 62.3% Non-Hispanic White) Main Measures Patient self-reported preferences for medication and psychotherapy on 0-10 self-anchoring visual analog scales (0="completely unwilling"; 10="completely willing"). Treatment receipt and adherence (refilling medications; attending 3+ psychotherapy sessions) over 3 months. Logistic regression models controlled for socio-demographics and geographic variables. Key Results More patients reported strong preferences (10/10) for psychotherapy than medication (51.2% versus 36.7%, McNemar chi(2)(1)=175.3, p<0.001). A total of 32.1% of patients who preferred (7-10/10) medication and 21.8% who preferred psychotherapy did not receive these treatments. Patients who strongly preferred medication were substantially more likely to receive medication than those who had strong negative preferences (odds ratios [OR]=17.5; 95% confidence interval [CI]=12.5-24.5). Compared with patients who had strong negative psychotherapy preferences, those with strong psychotherapy preferences were about twice as likely to receive psychotherapy (OR=1.9; 95% CI=1.0-3.5). Patients who strongly preferred psychotherapy were more likely to adhere to psychotherapy than those with strong negative preferences (OR=3.3; 95% CI=1.4-7.4). Treatment preferences were not associated with medication or combined treatment adherence. Patients in primary care settings had lower odds of receiving (but not adhering to) psychotherapy than patients in specialty mental health settings. Depression severity was not associated with treatment receipt or adherence. Conclusions Mismatches between treatment preferences and treatment type received were common and associated with worse treatment adherence for psychotherapy. Future research could examine ways to decrease mismatch between patient preferences and treatments received and potential effects on patient outcomes.