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Veterans with depression in primary care: provider preferences, matching, and care satisfaction.

Primary care is often the first point of care for individuals with depression. Depressed patients often have comorbid alcohol use disorder (AUD) and posttraumatic stress disorder (PTSD). Understanding variations in treatment preferences and care satisfaction in this population can improve care planning and outcomes. The design involved a cross-sectional comparison of veterans screening positive for depression. Veterans receiving primary care during the previous year were contacted (n = 10, 929) and were screened for depression using the PHQ-2/PHQ-9. Those with probable depression (n = 761) underwent a comprehensive assessment including screens for AUD and PTSD, treatment provider preferences, treatments received, and satisfaction with care. Treatment provider preferences differed based on specific mental health comorbidities, and satisfaction with care was associated with receipt of preferred care. Depressed veterans with comorbid PTSD were more likely to prefer care from more than one provider type (e.g., a psychiatrist and a primary care provider) and were more likely to receive treatment that matched their preferences than veterans without comorbid PTSD. Veterans receiving full or partial treatment matches affirmed satisfaction with care at higher rates, and veterans with comorbid PTSD were least satisfied when care did not match their preferences. Patient satisfaction with care is an increasingly important focus for health care systems. This study found significant variations in depressed patients' satisfaction with care in terms of treatment matching, particularly among those with comorbid PTSD. Delivery of care that matches patient treatment preferences is likely to improve depressed patient's satisfaction with the care provided.

Keywords: care satisfaction, patient centered care, primary care mental health, treatment matching, treatment preference

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Clients with mental health diagnoses experience better treatment outcomes when they receive care that matches their preferences (Swift, Callahan, & Vollmer, 2011). Treatment preference matching confers improved outcomes for patients with Major Depressive Disorder (MDD; Lin et al., 2005), but many MDD patients have mental health comorbidities (e.g., Kessler, Chiu, Dernier, & Walters, 2005; Yano et al., 2012), and little is known about how treatment preferences differ for patients with and without such comorbidities. Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) frequently coexist with depression in Veterans Affairs (VA) patients (Stecker, Fortney, Owen, McGovern, & Williams, 2010) and are often identified in clinics implementing primary care mental health integration (PC-MHI) (Zivin et al., 2010). In one study, depressed veterans with comorbid PTSD were more likely to prefer combined psychotherapy and pharmacotherapy than veterans without comorbid PTSD, whereas depressed veterans with comorbid AUD did not have distinguishing preferences (Dobscha, Corson, & Gerrity, 2007).

Accommodating patient care preferences and matching preferences to resources is complex and requires planning. In most studies patients indicate their preferences for psychotherapy and/or pharmacotherapy (van Schaik, et al., 2004). This assessment approach (i.e., psychotherapy vs. pharmacotherapy) fails to capture patients' preferences for specific provider types. More than half of individuals receive pharmacotherapy for depression from a general medical practitioner such as a primary care physician (PCP; King & Essick, 2013). Existing literature on patient therapy preferences provides little insight regarding whether the push to increase PCP involvement in depression care through integrated care initiatives reflects patients' provider preferences beyond involvement of PCPs.

The present study takes an exploratory approach to examine primary care (PC) patient provider preferences and assesses the critical association between preference matching and patients' satisfaction with care. It advances three descriptive aims: (a) characterize treatment preferences of veterans with MDD and comorbid mental health conditions in PC for treatment by PCPs, psychiatrists, or other mental health specialists; (b) investigate how often treatment received matched veterans' preferences; and (c) examine satisfaction with care across multiple diagnostic comorbidities: MDD only, MDD and AUD, MDD and PTSD, and MDD with AUD and PTSD.

Method

Cross-sectional data were derived from the Well-being Among Veterans Enhancement Study (WAVES), a group randomized, controlled trial of depression collaborative care management composed of veterans visiting one of 10 VA PC practices in five states (Chaney et al., 2011). Baseline interviews were conducted in 2003 and 2004. Institutional Review Boards at participating VA facilities approved the study.

Participants

The sample included veterans who attended a study clinic in the past 12 months and had an upcoming appointment. Study recruitment details are available elsewhere (Yano et al., 2012). Trained telephone interviewers screened veterans using the Patient Health Questionnaire-2 (PHQ-2), a two-item depression screener (Kroenke, Spitzer, & Williams, 2003). Veterans screening positive for depression were administered the entire Patient Health Questionnaire-9 (PHQ-9). Of the 1,313 veterans with probable MDD, 761 (58%) completed the WAVES baseline assessment (Yano et al., 2012).

Measures

Depression (MDD). The PHQ-9 has high specificity and positive predictive value for MDD (Henkel et al., 2003). Veterans were eligible for WAVES with PHQ-9 scores [greater than or equal to] 10, a cut-score identifying MDD with sensitivity and specificity of .88 (Kroenke, Spitzer, & Williams, 2001). Higher PHQ-9 scores indicate worse depressive symptomology.

Posttraumatic stress disorder. The Primary Care PTSD Screen (PC-PTSD) assesses the presence of four key symptoms of PTSD. A cut-score of [greater than or equal to] 3 identifies PTSD with high sensitivity (0.78) and specificity (0.89) (Prins et al., 2004).

Alcohol use disorder. The Alcohol Use Disorders Identification Test-Consumption questions (AUDIT-C; Bush et al., 1998) identified participants with probable AUD using cut scores of [greater than or equal to] 4 for men and [greater than or equal to] 3 for women (Dawson, Smith, Saha, Rubinsky, & Grant, 2012).

Treatment preference. Veterans' treatment provider preferences were assessed with the following question: "If you were depressed ... and could choose who would help you ... how likely would you be to choose each of the following?" Using a five-point scale, participants indicated their likelihood of choosing a PCP, a psychiatrist or an "other mental health specialist" (OMHS; i.e., psychologist, social worker, counselor, or mental health nurse). Very likely and likely responses designated preferred provider types; uncertain and unlikely/very unlikely responses designated nonpreferred provider types.

Treatment received. Veterans who received outpatient mental health care in the previous six months identified care providers by type. Treatment provided by psychiatrists and OMHSs (psychologists, social workers, counselors, or mental health nurses) was defined as mental health clinician care. Receipt of general practitioner care for an emotional problem in PC was defined as an affirmative response to any questions regarding receipt of medication management during a PC visit and receipt of nonemergency outpatient care or consultation with a nonspecialist (i.e., NOT a psychiatrist or an OMHS).

Treatment satisfaction. Satisfaction with care was reported by answering the following: "How satisfied were you with the overall health care services available to you specifically for emotional problems in the past 6 months?" Very satisfied and satisfied were coded as satisfied, whereas neither satisfied nor dissatisfied, dissatisfied, and very dissatisfied were coded as not satisfied.

Treatment matching. Treatment matching occurred when the care received matched treatment preferences. A full match indicated respondents received care from all preferred provider types (e.g., Preferred: PCP and OMHS; Received: PCP and OMHS), whereas no match indicated respondents received none of the preferred treatments (e.g., Preferred: psychiatrist; Received: PCP). Partial matches were possible when patients preferred multiple provider types (e.g., Preferred: PCP and OMHS; Received: PCP). Treatment matching across respondents was also examined in terms of conditional probabilities. The denominator represented the total number of veterans indicating a particular treatment preference and the numerator represented the number of veterans receiving the preferred treatment.

Treatment precision. Treatment precision was calculated by taking the number of veterans who received their preferred care and dividing by the total number of veterans receiving that treatment, regardless of preference. High precision indicated that treatment delivery was related to preference; low precision suggested that treatment delivery was unrelated to preference.

Data Analysis

Descriptive statistics are presented for all of the included variables, consistent with the exploratory aims of the present study.

Chi-square tests examined whether preference, treatment received, and preference matching differed proportionally across diagnostic groupings. Although statistics were used to highlight differences among groupings, these analyses should be interpreted as exploratory because this study was not designed to specifically investigate differences among the groupings described. Rather than employ conservative multiple comparison adjustments (e.g., Bonferroni or similar corrections), we opted to reduce risk of Type II error by presenting all results, allowing the reader to weigh the results in context (Perneger, 1998; Rothman, 1990; Sato, 1996).

Responses for the treatment provider preference question resulted in a U-shaped distribution; most veterans indicated they were (un)likely or very (un)likely to choose each provider and fewer than 8% indicated uncertainty regarding whether they would choose a particular type of provider. Treatment preference was coded dichotomously, where uncertain indicated failure to specify a preference. Treatment satisfaction responses were dichotomously coded, given the substantial negative skew for these ratings. An active endorsement of satisfaction was required in the dichotomous rating scheme. Finally, the results treat providers with capacity for medication management (i.e., PCP and/or psychiatrist care) as a combined category to facilitate relating the present findings to existing preference literature focusing on modes of treatment (psychotherapy vs. pharmacotherapy).

Results

Reflecting the broader VA patient population, the majority of veterans were male (94.0%), white (85.0%), aged 60.4 years (SD 11.9) and reported at least some college or vocational training beyond high school (51%). Social and health demographic characteristics are available elsewhere (Yano et al., 2012).

Treatment Provider Preferences

More than 90% of the respondents indicated that they wanted care for their emotional problems (see Table 1). Most (68.6%) preferred care from more than one provider type. Overall, 52.8% of all respondents preferred combined treatment involving a psychiatrist and an OMHS. All provider types had similarly high preference rates (i.e., range 63.9% to 66.5%) when considered separately. When we collapsed provider type categories, 85.8% of respondents preferred providers with capacity for medication management (i.e., PCP and/or psychiatrist care), with 23.0% indicating exclusive preference. Nearly 78% of respondents preferred mental health clinicians (i.e., OMHS and/or psychiatrist), with 25.1% indicating exclusive preference.

Of the 761 participants, 358 (47.0%) had MDD only, 109 (14.2%) had MDD + AUD, 222 (29.2%) had MDD + PTSD, and 72 (9.5%) had all three conditions (see Table 2). Compared with those with MDD alone, higher proportions of veterans with MDD + PTSD preferred treatment involving mental health clinicians (i.e., OMHS and/or psychiatrist care). A lower proportion of MDD + PTSD veterans endorsed exclusive preference for PCP care, [chi square](1, n = 761) = 20.1, p < .001. Veterans with MDD + PTSD were less likely to prefer no care than veterans with MDD alone or MDD + AUD, [chi square](1, n = 580) = 14.4, p < .01; [chi square](1, n = 331) = 8.9, p < .03, respectively).

Treatment Received

Approximately half (50.9%) of veterans reported receiving treatment from providers capable of medication management (i.e., PCP and/or psychiatrist care) and 45.9% reported receiving no care at all (see Table 3). Among those reporting care receipt, PCPs were the most common provider (44.5%), followed by psychiatrists (33.0%), and OMHSs (31.1%). Veterans with MDD only or MDD + AUD were significantly more likely to report receiving no care than veterans with MDD + PTSD with or without AUD. Comorbid PTSD groups reported higher rates of accessing nearly all forms of care with significant differences for the all care category (OMHS, PCP, and psychiatrist).

Treatment Provider Preference Matching

Treatment provider preference matching differed substantially across diagnostic comorbidity groupings (see Table 4). Veterans with MDD alone and MDD + AUD were less likely to receive preference-matched treatment than those with comorbid PTSD. Across treatment preference categories, veterans with MDD + PTSD and MDD + AUD + PTSD were significantly more likely to receive a preference match for providers with capacity for medication management (i.e., PCP and/or psychiatrist care; [chi square](1, n = 653) = 93.1, p < .001), and mental health clinicians (i.e., OMHS and/or psychiatrist care; [chi square](1, n = 590) = 45.9, p < .001) compared to veterans without comorbid PTSD.

When the entire sample and all instances of the three provider types were considered, examination of conditional probabilities suggested similar match rates for those preferring care from a PCP, psychiatrist, or OMHS (0.43, 0.45, and 0.40, respectively). Those who preferred PCP care more frequently received no care (0.48) compared with those preferring care from a psychiatrist (0.34) or OMHS (0.38). Treatment precision is the number of individuals receiving a type of treatment as their preference divided by the total number of individuals receiving that specific treatment. No care had low precision (0.15) indicating more veterans received no care than those preferring no care. PCP care had moderate precision (0.63), and mental health clinicians had high precision (OMHS = 0.85 and psychiatrist = 0.87). Treatment precision findings indicate veteran access to active care was more consistent with their mental health clinician preferences than their general care, PCP, preferences.

Treatment Satisfaction

Respondents were more satisfied when a full preference match occurred and less so when no match occurred (see Table 5). Exclusive PCP care preference (row 2, Table 5) represented a significant deviation from this pattern, as respondents receiving care were less satisfied than those who did not, [chi square](1, n = 99) = 6.1, p = .01.

Veterans who received full or partial preference matching were generally more satisfied with care than those who did not receive preference-matched treatment (see Table 6). Similar satisfaction rates were expressed across diagnostic groups, with a notable deviation in the MDD + AUD + PTSD group. Lower satisfaction for these patients may be driven by exceptionally low satisfaction in those whose treatment did not match preferences.

Discussion

Veterans with depression in VA PC equally preferred treatment from PCPs, psychiatrists, and OMHSs. Veterans in this study preferred providers with capacity for medication management (i.e., PCP and/or psychiatrist) at a higher rate than OMHS care (85.8% vs. 66.5%). This finding is surprising given previous studies reporting higher preference rates for psychotherapy than pharmacotherapy, where the type of professional providing pharmacotherapy was unspecified (Dwight-Johnson et al., 2010; Dwight-Johnson, Sherbourne, Liao, & Wells, 2000; Gelhom, Sexton, & Classi, 2011). Al though our use of provider type as a proxy for care type precludes definitive inferences, our data indicate future studies would benefit from assessing preference for provider (e.g., psychiatrist, psychologist, social worker, PCP, physician assistant, mental health nurse, advanced practice registered nurse) and type of service (e.g., psychotherapy, pharmacotherapy, watchful waiting, care management).

Similar to non-veterans with depression (Steidtmann et al., 2012), most VA patients preferred care from two or more types of providers, including PCPs, psychiatrists, and OMHSs. This replicates and expands upon the findings of Dobscha and colleagues (2007) by specifying that preference for pharmacotherapy most frequently involves PCP and psychiatric care in addition to psychotherapy (i.e., OMHS care).

Care preferences varied by clinical comorbidity. Those with MDD and PTSD (with or without AUD) were more likely than those without PTSD to prefer all three provider types concurrently. They also received all forms of treatment more frequently. Individuals with MDD and PTSD tend to have more medical comorbidities, distress, and more complicated depression than those with MDD alone (Campbell et al., 2007; Cohen et al., 2010; Frayne et al., 2011); they may prefer, require, and receive more intensive treatment and may benefit from psychotherapeutic interventions like those typically delivered by OMHSs.

Patients with MDD and comorbid AUD were less likely to prefer and receive treatment from all provider types compared with veterans with comorbid PTSD. These results contradict previous findings that veterans with MDD and AUD had similar care preferences to those without AUD (Dobscha et al., 2007). This may reflect the present study's larger sample size and 23.8% AUD comorbidity, providing more power to detect differences. This suggests the presence of AUD in concert with MDD might be associated with barriers to care engagement.

The observed low precision of no care and high precision for OMHS and psychiatric care suggest that the overall moderate preference-match rates may be driven by the lack of care receipt rather than indiscriminate care. Moderate precision existed for PCP care, indicating that many veterans received depression care from PCPs regardless of their preference. In an environment with limited access to mental health clinicians, PCPs often become default mental health care providers (Kessler & Stafford, 2008). Overall, the treatment precision data suggest that when veterans access care they are likely to receive treatment from preferred provider types. The treatment preference and matching data suggest that for PC-MHI efforts to be successful from a patient-centered perspective, care sites should include adequate access to both OMHSs and psychiatrists. Notably, VA recently launched several initiatives to improve access to preferred provider types (Kehle, Greer, Rutks, & Wit, 2011; Zeiss & Karlin, 2008) via colocation of OMHSs and psychiatrists within PC, incorporating care management models.

Integrated care in VA PC-MHI has been accompanied by high satisfaction ratings (Pomerantz, Cole, Watts, & Weeks, 2008). Patients obtain better outcomes in integrated care than with PCP care alone (Schulberg, Raue, & Rollman, 2002). Strikingly, veterans preferring exclusive PCP care who received matching treatment endorsed satisfaction less frequently than peers preferring PCP care but not receiving PCP care for their emotional problems. This suggests that for depressed veterans, care satisfaction may relate to accessing an integrated mental health provider such as a psychiatrist or OMHS; simply leaving care in the hands of PCPs may not suffice.

Previous researchers found that veterans with MDD and PTSD reported less satisfaction with care than veterans without mental health diagnoses (Desai, Stefanovics, & Rosenheck, 2005). Further, veterans with PTSD who received inpatient care gave the lowest satisfaction ratings among those with mental health diagnoses (Hoff, Rosenheck, Meterko, & Wilson, 1999). We found that veterans with depression and PTSD reported the lowest satisfaction rates of all groups when no treatment match occurred. The presence of comorbid AUD amplified this effect. Satisfaction rates of veterans with depression and PTSD who received full or partial treatment matches were not consistently lower than those without PTSD. These differential satisfaction rates may be explained by the greater likelihood among patients with comorbid PTSD to report a combined preference for PCP, psychiatrist, and OMHS care than veterans with MDD and no PTSD. From a patient-centered perspective, it may be particularly important to accommodate treatment preferences for patients with depression and comorbid PTSD.

Limitations of the present findings fall under three broad categories: methodological, structural variables, and omissions. There are four noteworthy methodological limitations. First, this study utilized a cross-sectional design that does not afford causal inferences regarding relationships among diagnostic groupings, provider preferences, treatment matching, and care satisfaction. The present data may inform future prospective studies focused on comorbid MDD, AUD, and/or PTSD in the context of treatment matching and satisfaction with care. Future studies should investigate how previous experience may influence the relationship between expressed preferences and satisfaction with care received. Second, our sampling approach among VA PC medical clinics may have yielded a sample with particularly poor health (Lee, Yano, Wang, Simon, & Rubenstein, 2002). Thus, these findings may not reflect the preferences and experiences of non-veterans, healthier veterans, those who receive PC outside the VA, or veterans not actively enrolled in PC. However, the present sample accurately reflects VA patients who are most likely to be identified with MDD, AUD, or PTSD in PC visits since VA PC clinics routinely screen for these conditions with the measures used in this study. Third, instead of assessing preferences for treatment modality directly, we employed expressed preferences for provider types as proxies for medication management and psychotherapy. Although informative, it is possible that these proxies were imperfect. The OMHS category included psychologists, counselors, social workers, and psychiatric nurses; it was essentially a 'catch all' category for nonphysician-based mental health specialist care. Although each professional discipline can provide unique contributions to an integrated mental health setting, an appreciation for these contributions cannot be obtained from the present data. Future researchers should distinguish among all provider types and specify the roles each may play in providing psychotherapy, care management, and/or medication monitoring. The current OMHS category as a proxy for psychotherapy may overestimate preference for and access to psychotherapy in this sample. Fourth, treatment matching was based on self-report of treatment received in the past six months. Of the 349 participants reporting no care in the past six months, 57 (16.3%) reported taking medications for emotional problems at some time during that period. Thus, the present results may represent an underestimation of treatment matching, particularly for PCP care involving annual maintenance pharmacotherapy for patients with less complicated presentations.

The second category of limitations is attributable to the unavailability of data involving structural variables related to the care system that may impact outcome variables. Our preferences assessment of outpatient mental health clinicians (psychiatrists and OMHSs) did not specify the location of these services. Researchers have noted that veterans preferred receiving OMHS care at a PC clinic rather than in a specialty clinic (Wittink, Cary, TenHave, Baron, & Gallo, 2010). We believe that preferences expressed in this study are relevant for PC settings. There was no assessment of veteran perception of expediency for accessing each provider type or of actual or perceived costs for accessing each provider type.

The final category of limitations involves variable omissions that should be considered for future studies. We did not assess preference for PC-based nurse practitioners. The treatment received questions were separate for general care providers (PCP, nurse, or other clinician) and mental health clinicians (psychiatrist, psychologist, social worker, mental health nurse, and the open response 'other'). Of the 98 individuals indicating care receipt involving a psychiatric nurse, 12 received this care without co-occurring care from a psychiatrist or other physician. Three of the open response respondents indicated nurse-practitioner as their mental health provider suggesting minimal exclusive nurse practitioner involvement in this sample. As treatment provided by nurse practitioners increases (Iglehart, 2013), future studies should consider explicit assessment of care from these providers. Finally, because the study did not include a preference for watchful waiting (i.e., no active care), it forced participants to choose between treatment and no care. Dobscha and colleagues (2007) reported that 25% of veterans preferred watchful waiting over active treatment for depression. Research in non-VA PC clinics found that 16% of depressed respondents preferred watchful waiting (Johnson, Meredith, Hickey, & Wells, 2006). The preference for watchful waiting in previous studies was higher than that observed for no care (9.5%) in the present study, suggesting that the exclusion of a watchful waiting option in the preference assessment may have had a framing effect that encouraged overreporting of active care preferences. Future research should assess whether a watchful waiting option encourages reporting of active care preferences.

In conclusion, patient-centered care in VA PC-MHI programs needs to include adequate access to specialty mental health care from OMHSs and psychiatrists, because doing so may be associated with care satisfaction and engagement. The present exploratory study found treatment preferences varied by comorbidity, and veterans with depression and comorbid PTSD were more likely to report preferences for multiple treatment providers and to receive treatment matching their preferences. Participants receiving full or partial treatment matches had higher ratings of satisfaction with care and veterans with comorbid PTSD were less likely to affirm satisfaction with care when they did not receive treatments matching their preferences. An understanding of patient preferences will be critical for planning in clinics that aim to provide and improve patient-centered care for patients with depression and comorbid conditions.

http://dx.doi.org/10.1037/fsh0000071

Thomas J. Waltz, PhD, PhD

Eastern Michigan University; and Arkansas Department of Veterans Affairs, North Little Rock, Arkansas

JoAnn E. Kirchner, MD

Arkansas Department of Veterans Affairs, North Little Rock, Arkansas; and University of Arkansas for Medical Sciences

Cory Bolkan, PhD

Washington State University Vancouver

Andrew B. Lanto, MA

Veterans Affairs Greater Los Angeles, Los Angeles, California

Duncan G. Campbell, PhD

University of Montana

Anayansi Lombardero, MA

University of Montana

Kara Zivin, PhD

Veterans Affairs Ann Arbor, Ann Arbor, Michigan; and University of Michigan

Edmund F. Chaney, PhD

University of Washington School of Medicine

Lisa V. Rubenstein, MD, MSPH

Veterans Affairs Greater Los Angeles, Los Angeles, California; and UCLA Schools of Medicine and Public Health

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van Schaik, D. J. F., Klijn, A. F. J., van Hout, H. P. J., van Marwijk, H. W. J., Beekman, A. T. F., de Haan, M., & van Dyck, R. (2004). Patients' preferences in the treatment of depressive disorder in primary care. General Hospital Psychiatry, 26, 184-189.

Wittink, M. N., Cary, M., TenHave, T., Baron, J., & Gallo, J. J. (2010). Towards patient-centered care for depression: Conjoint methods to tailor treatment based on preferences. The Patient: Patient-Centered Outcomes Research, 3, 145-157. doi: 10.2165/11530660-000000000-00000

Yano, E. M., Chaney, E. F., Campbell, D. G., Klap, R., Simon, B. F., Bonner, L. M., ... Rubenstein, L. V. (2012). Yield of practice-based depression screening in VA primary care settings. Journal of General Internal Medicine, 27, 331-338. doi: 10.1007/sl1606-011-1904-5

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Received September 6, 2013

Revision received June 1, 2014

Accepted June 5, 2014

This article was published Online First August 4, 2014. Thomas J. Waltz, PhD, PhD, Department of Psychology, Eastern Michigan University; and Arkansas Department of Veterans Affairs, Mental Health QUERI, HSR&D, North Little Rock, Arkansas; Duncan G. Campbell, PhD, Department of Psychology, University of Montana; JoAnn E. Kirchner, MD, Arkansas Department of Veterans Affairs, Mental Health QUERI, HSR&D; and Department of Psychiatry, University of Arkansas for Medical Sciences; Anayansi Lombardero, MA, Department of Psychology, University of Montana; Cory Bolkan, PhD, Department of Human Development, Washington State University Vancouver; Kara Zivin, PhD, Veterans Affairs Ann Arbor, Center for Clinical Management Research (CCMR), HSR&D, Ann Arbor, Michigan; and Departments of Psychiatry and Health Management and Policy, and Institute of Social Research, University of Michigan; Andrew B. Lanto, MA, Veterans Affairs Greater Los Angeles, HSR&D, Los Angeles, California; Edmund F. Chaney, PhD, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine; Lisa V. Rubenstein, MD, MSPH, Veterans Affairs Greater Los Angeles, HSR&D Center for Implementation Practice and Research Support, Los Angeles, California; and UCLA Schools of Medicine and Public Health.

The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. This project was funded by the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Service and the VA Quality Enhancement Research Initiative (QUERI) (Project nos. MHI 99-375, MNT 01-027, MHQ 10-06) and Department of Veterans Affairs CD2 07-206-1 and HR 10-176-3. Dr. Waltz was funded by a VA Office of Academic Affiliations (OAA) Associated Health Postdoctoral Fellowship Program at the HSR&D Center for Mental Healthcare Outcomes Research (CeMHOR). We thank Valorie Shue for editorial comments on a draft of this article.

Correspondence concerning this article should be addressed to Thomas J. Waltz, PhD, PhD, Psychology Department, 341 Science Complex, Eastern Michigan University, Ypsilanti, MI 48197. E-mail: twaltzl@emich.edu
Table 1
Frequencies of Care Preference

                             Preference by       Exclusive
                             provider type       preference

Care type                     n       (%)       n       (%)

No care                       --       --       72     (9.5)
PCP                          498     (65.4)     99     (13.0)
OMHS                         506     (66.5)     36     (4.7)
Psychiatrist                 486     (63.9)     32     (4.2)
PCP + OMHS                    --       --       68     (8.9)
PCP + Psychiatrist            --       --       52     (6.8)
OMHS + Psychiatrist           --       --      123     (16.1)
PCP + OMHS + Psychiatrist     --       --      279     (36.7)

Note. n = 761. PCP = primary care physician; OMHS = other
mental health specialist (i.e. psychologist, social worker,
counselor, or mental health nurse).

Table 2
Percent of Veterans Preferring Provider Type by Diagnostic Grouping

                                      Diagnostic grouping

                                           MDD +   MDD +     MDD +
       Preference           All     MDD     AUD    PTSD    AUD + PTSD

No care                       9.5   11.2    11.9     5.0      11.1
PCP                          13.0   17.6    16.5     5.9       6.9
OMHS                          4.7    4.6     5.5     3.6       6.9
Psychiatrist                  4.2    4.6     4.6     4.1       1.4
PCP + OMHS                    8.9    9.8    13.8     7.2       2.8
PCP + Psychiatrist            6.8    5.9     9.2     5.4      12.5
OMHS + Psychiatrist          16.2   12.0     9.2    23.9      23.6
PCP + OMHS + Psychiatrist    36.7   34.1    29.4    45.1      34.7
n                           761    358     109     222        72

                             Significance
       Preference               testing

No care                     B, D
PCP                         B **, C, D *
OMHS
Psychiatrist
PCP + OMHS                  E
PCP + Psychiatrist          C, F
OMHS + Psychiatrist         B **, C, D *, E
PCP + OMHS + Psychiatrist   B, D
n

Note. A: MDD differs from MDD + AUD; B: MDD differs from MDD + PTSD;
C: MDD differs from MDD + AUD + PTSD; D: MDD + AUD differs from MDD
+ PTSD; E: MDD + AUD differs from MDD + AUD + PTSD; F: MDD + PTSD
differs from MDD + AUD + PTSD. Significance based on chi-square
tests with one degree of freedom. Comparisons are for supporting
hypothesis generation for future studies. No adjustments for
multiple comparisons were made. Mention of letter p < .05.

* p < .01. ** p < .001.

Table 3
Percent Receiving Treatment by Diagnostic Grouping

                               Diagnostic grouping

   Treatment received       All      MDD     MDD + AUD

No care                     45.9     60.6     61.5
PCP                         10.3      9.8      9.2
OMHS                         3.3      3.4      4.6
Psychiatrist                 3.3      2.5      3.7
PCP + OMHS                   7.6      5.3      3.7
PCP + Psychiatrist           9.5      8.1      5.5
OMHS + Psychiatrist          3.0      2.5      2.6
MHS + PCP + Psychiatrist    17.2      7.8      9.2
n                          761      358      109

                              Diagnostic grouping

                                          MDD +       Significance
   Treatment received      MDD + PTSD   AUD + PTSD       testing

No care                     20.7         26.4      (B, C, D, E) **
PCP                         10.8         12.5
OMHS                         2.7          2.8
Psychiatrist                 4.1          4.2
PCP + OMHS                  13.1          8.3      B *, D
PCP + Psychiatrist          13.1         11.1      D
OMHS + Psychiatrist          4.5          1.4
MHS + PCP + Psychiatrist    31.1         33.3      (B, C, D, E) **
n                          222           72

Note. A: MDD differs from MDD + AUD; B: MDD differs from MDD + PTSD;
C: MDD differs from MDD + AUD + PTSD; D: MDD + AUD differs from MDD
+ PTSD; E: MDD + AUD differs from MDD + AUD + PTSD; F: MDD + PTSD
differs from MDD + AUD + PTSD. Significance based on chi-square
tests with one degree of freedom. Comparisons are for supporting
hypothesis generation for future studies. No adjustments for
multiple comparisons were made. Mention of letter p < .05.

* p < .01. * p < .001.

Table 4
Conditional Probability of Treatment Match by Diagnostic Grouping

                              Diagnostic grouping

Preference                  All   MDD   MDD + AUD

No care                     .71   .78      .77
PCP                         .19   .16      .00
OMHS                        .31   .12      .17
Psychiatrist                .44   .35      .40
PCP + OMHS                  .13   .14      .00
PCP + Psychiatrist          .33   .24      .30
OMHS + Psychiatrist         .37   .26      .40
PCP + OMHS + Psychiatrist   .23   .09      .16

                              Diagnostic grouping

                                         MDD + AUD   Significance
Preference                  MDD + PTSD    + PTSD       testing

No care                        .45          .63         0.188
PCP                            .46          .60         0.001
OMHS                           .50          .80         0.014
Psychiatrist                   .56         1.00         0.509
PCP + OMHS                     .25          .00         0.469
PCP + Psychiatrist             .33          .56         0.149
OMHS + Psychiatrist            .47          .35         0.067
PCP + OMHS + Psychiatrist      .41          .32        <0.001

Note. Significance based on chi-square tests with 3 degrees of
freedom. For conditional probabilities, the denominator was the
total number of veterans indicating a preference and the numerator
was the number of those veterans receiving treatment matching that
preference.

Table 5
Satisfaction With Services by Match Profile

                                         Full    Partial    No
       Preference            n    All    match    match    match

No care                      72   48.6   51.0      --      42.9
PCP                          99   61.6   36.8      --      67.5
OMHS                         36   44.4   36.4      --      48.0
Psychiatrist                 32   53.1   71.4      --      38.9
PCP + OMHS                   68   58.8   77.8     60.9     52.8
PCP + Psychiatrist           52   65.4   64.7     58.8     72.2
OMHS + Psychiatrist         123   55.3   69.6     67.5     24.3
PCP + OMHS + Psychiatrist   279   64.5   80.0     60.2     59.5

                            Significance
       Preference             testing

No care                        0.531
PCP                            0.014
OMHS                           0.517
Psychiatrist                   0.067
PCP + OMHS                     0.383
PCP + Psychiatrist             0.705
OMHS + Psychiatrist           <0.001
PCP + OMHS + Psychiatrist      0.012

Note. Table depicts the percentage of respondents in each category
affirming satisfaction with healthcare services for emotional
problems. Significance based on chi-square tests with two degrees of
freedom for preferences where a partial match was possible, and one
degree of freedom for all others.

Table 6
Satisfaction With Services by Diagnostic Comorbidity

                                Full    Partial    No
Diagnostic group    n    All    match    match    match

All                761   59.3   65.3     61.7     54.8
MDD                358   59.8   61.0     57.7     60.1
MDD + PTSD         222   62.2   68.4     68.1     43.6
MDD + AUD          109   60.6   72.2     63.2     56.9
MDD + AUD + PTSD   72    45.8   60.0     52.4     19.0

                   Significance
Diagnostic group     testing

All
MDD
MDD + PTSD         A **, C **
MDD + AUD          A
MDD + AUD + PTSD   A **, C *

Note. Table depicts the percentage of respondents in each category
affirming satisfaction with healthcare services for emotional
problems. A: Full match differs from No match; B: Full match differs
from Partial match; C: Partial match differs from No match.
Significance based on chi-square tests with two degrees of freedom.
Comparisons are for supporting hypothesis generation for future
studies. No adjustments for multiple comparisons were made. Mention
of letter p < .05.

* p < .01. ** p < .001.
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Author:Waltz, Thomas J.; Kirchner, JoAnn E.; Bolkan, Cory; Lanto, Andrew B.; Campbell, Duncan G.; Lombarder
Publication:Families, Systems & Health
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Date:Dec 1, 2014
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