The impact of nonclinical factors on care use for patients with depression: A STAR*D report

Introduction: This article presents baseline findings that describe how nonclinical factors were associated with patient use of psychiatric and general medical care and how those relationships changed after patients enrolled in the 41-site Sequenced Treatment Alternatives to Relieve Depression study (STAR*D). Aims: STAR*D offered adult outpatients with major depression diligently delivered, measurement-based care. To achieve full remission within a tolerable medication dose, recommendations for treatment based on routine symptom and side-effect measurements were discussed with patients by clinical research coordinators and offered to clinicians who could flexibly tailor that guidance to accommodate individual patient needs. Medications were provided gratis. Pre- and post-enrollment data came from provider records and from patient face-to-face, telephone, and computer-assisted surveys. Two-part nested mixed models assessed patient likelihood and volume of mental and general medical care services. Results: Prior to enrollment, predisposing (gender, race, education, and care attitude), affordability (private insurance), and clinical factors (depressive symptoms and mental and physical functioning) were found to be important drivers of patient use of psychiatric and general medical care. After STAR*D enrollment, however, predisposing factors were less important drivers of psychiatric service use but remained important drivers of general medical care. Conclusions: Data suggest diligent, measurement-based mental health programs may reduce race, gender, and education disparities in the use of needed mental health care.