Modeling Adherence to Psychotherapy for Depression

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DESCRIPTION (provided by applicant): Abundant evidence supports the efficacy of psychotherapy for treatment of depression. Consumers often prefer psychotherapy as a first-line treatment. Effective therapy, however, fails to reach the vast majority of people with depressive disorders. Of those who seek therapy for depression, one quarter fail to attend an initial visit and half drop out before the fifth visit. Health services research examining adherence to psychotherapy is remarkably limited. While it is often assumed that provider characteristics influence adherence, this assumption has not been empirically tested. No previous research has examined drop-out prior to the initial visit. The effects of new consumer-directed health plans (Health Savings Accounts and high-deductible plans) on psychotherapy have not been evaluated. Psychotherapy for depression often co- occurs with medication treatment for depression or other medical conditions, but it is not known whether adherence behavior is consistent across different mental health or medical treatments. These gaps must be addressed in order to develop effective and appropriately targeted interventions to improve adherence. The research proposed here is one component of a comprehensive program to understand and increase consumer demand for effective depression treatment. We will use data from a large mixed-model health system to examine patient, provider, and health system factors influencing adherence to psychotherapy. Records from telephone triage calls will be used to identify approximately 40,000 adults and adolescents requesting initial psychotherapy appointments for treatment of depression. Administrative data (insurance claims, insurance coverage, provider performance) and provider survey data will be used to measure key predictors of psychotherapy adherence. The ability to combine these diverse data regarding consumer, provider, and health system characteristics is unique to the proposed study setting. Adherence outcomes include psychotherapy initiation and continuation. Specific aims focus on four issues: 1) How do adherence rates differ between therapists after accounting for chance variation and differences in casemix? Can variation between providers be explained by measurable provider characteristics? 2) Is adherence influenced by level of deductibles and co-payments? How is the effect of cost-sharing moderated by consumers' prior spending on medical and mental health treatment? 3) How does adherence differ between salaried group-model practice and fee-for-service network practice? Can differences be explained by measured provider characteristics? 4) How is adherence to psychotherapy associated with adherence to concomitant antidepressant pharmacotherapy or concomitant treatment for other medical conditions? We propose to use data from a large mixed-model health system to examine patient, provider, and health system factors influencing adherence to psychotherapy. The proposed research is one component of an ongoing comprehensive program to understand and increase consumer demand for effective depression treatment.