Understanding depression care in the HMO outpatient setting: what predicts key events on the pathway to care?

Depression is a major public health problem. The distress and functional and social disability it causes are costly to individuals and families, the health care system, and society. The majority of depressed patients are treated by primary care clinicians. Understanding is limited about the factors that affect the pathway to outpatient care for depression in HMO settings. This study describes, among members of a large U.S. health maintenance organization (HMO), the predictors of outcomes that represent progress on the pathway to care for depression, focusing in particular on the relative contribution of depressive symptom levels, gender, age, and other medical and nonmedical factors. The study population is an age/sex stratified sample of HMO members aged 25+ (N=7,844). Data sources include member survey questionnaires, medical charts, and automated utilization databases. Data were collected during a baseline year prior to the members' survey response date (1990-1992) and a follow-up year after that date. The study outcomes measured during the followup year were; study subjects' use of primary medical care; chart notations by a primary care clinician of depression diagnoses, antidepressant prescriptions, and referrals to specialty mental health care; and use of specialty mental health care. Predictor variables included age, gender, level of depressive symptoms, social role functioning, mental health care history, general health status, baseline health care utilization, sociodemographic characteristics, and relation to a personal primary care clinician (and the specialty of that clinician).