Quality of Outpatient Depression Treatment in Patients With Comorbid Substance Use Disorder

OBJECTIVE: To investigate the provision of guideline-concordant depression treatment to those with and without substance use disorders in a large, integrated healthcare system. Rationale: Clinical practice guidelines recommend concurrent treatment of co-occurring depression and substance use disorders; however, the degree to which those with substance use disorders receive guideline-concordant treatment for depression is unknown. DESIGN: In this retrospective cohort study of patients diagnosed with a depressive disorder in Fiscal Year 2017 in the United States Veterans Health Administration, we assessed the association of comorbid substance use disorders with guideline-concordant depression treatment, including both medication and psychotherapy, while adjusting for patient demographics and clinical conditions. SETTING: United States Veterans Health Administration PARTICIPANTS: 53,034 Veterans Health Administration patients with a new depression diagnosis in Fiscal Year 2017 RESULTS: Guideline-concordant depression treatment was lower across metrics for those with co-occurring depression and substance use disorders compared to those without substance use disorders. Consistent findings emerged in covariate-adjusted models of antidepressant treatment, such that patients with substance use disorders had 21% lower odds of guideline-concordant acute treatment (adjusted odds ratio=0.79, 95% confidence interval (CI)=0.73–0.84) and 26% lower odds of continuation of treatment (adjusted odds ratio=0.74, 95% CI=0.69–0.79). With regard to psychotherapy, patients with co-occurring depression and substance use disorders had 13% lower odds (adjusted odds ratio=0.87, 95% CI=0.82–0.91) of adequate acute phase treatment and 19% lower odds (adjusted odds ratio=0.81; 95% CI=0.73–0.89) of psychotherapy continuation. CONCLUSIONS: Despite the availability of effective treatments for depression, those with co-occurring substance use disorders are less likely to receive guideline-concordant depression treatment. Efforts to improve the provision of care to those with co-occurring substance use disorders should focus on clinician-based interventions and use of integrated care models to improve the quality of depression treatment.