Decision Making for Depression in Women Veterans: Patient and Physician Factors
Susan M. Frayne MD MPH
VA Palo Alto Health Care System
Palo Alto, CA
Funding Period: July 1998 - June 2001

BACKGROUND/RATIONALE:
Demographic factors, including patient gender, race, and age have been associated with the
diagnostic and therapeutic interventions patients receive for a number of different
conditions. The limited data available suggests that such factors may similarly influence physician decision-making in a specific condition, depression. Our study applies an experimental design to determine the degree to which patient gender, race, and age influence physician decision-making for depressive symptoms, controlling for other patient and physician characteristics.

OBJECTIVE(S):
This study addresses the following major questions about physicians’ management decisions in the care of women veterans compared with male veterans presenting with symptoms of major depression: (1) To what extent do patient gender, race, and age and physician gender and specialty status influence physician decision-making (diagnostic, therapeutic and referral decisions)? (2) What is the cost of management decisions made for female versus male patients presenting with symptoms of depression? (3) How do the decisions of and costs incurred by VA physicians compare with those of non-VA physicians?

METHODS:
This study applies a randomized factorial experimental design to three dichotomized patient factors (gender, race, and age) and two dichotomized physician factors (gender and specialty status). VA physicians (N=115) from the Northeastern United States reviewed videotapes in which actors simulate a patient-physician encounter (a depression scenario and two control scenarios). The depression scenario script is invariant; what varies across videotapes is the gender, race, and age of the actor-"patient." After reviewing the videotapes, physicians are interviewed about their diagnostic impressions and management recommendations. The experimental design permits assessment of whether patient gender, race, and age influence clinical decisions and estimation of costs. Data from a prior private sector study using the same methodology have been linked to data from this study allowing for VA/non-VA comparisons.

FINDINGS/RESULTS:
Regarding diagnosis, 54% of VA versus 73% of non-VA physicians assigned depression a probability of greater than 50% (p<.01). Regarding management, 13% of VA versus 2% of non-VA physicians said they would refer to mental health (p<.01) and 11% versus 13% would start an antidepressant (p >.05).

IMPACT:
VA has recently launched major initiatives aimed at assuring that veterans presenting with major depression in the medical setting receive high quality care. In our study, high rates of identification of depression did not translate into high rates of adherence to depression treatment guidelines. This suggests that VA’s educational efforts should emphasize early intervention with mental health referral and/or antidepressant therapy. Differences in management by VA versus non-VA physicians may point to systems issues, such as the fact that there is greater access to mental health services in VA. Avoiding erosion of access to such services may be an important element in assuring that veterans with depression receive high quality care.

PUBLICATIONS:

Journal Articles

1. Frayne SM, Halanych JH, Miller DR, Wang F, Lin H, Pogach L, Sharkansky EJ, Keane TM, Skinner KM, Rosen CS, Berlowitz DR. Disparities in diabetes care: impact of mental illness. Archives of Internal Medicine. 2005; 165(22): 2631-8.
2. Frayne SM, Skinner KM, Lin H, Ash AS, Freund KM. Effect of patient gender on late-life depression management. Journal of Women's Health (2002). 2004; 13(8): 919-25.
3. Frayne SM, Seaver MR, Loveland S, Christiansen CL, Spiro A, Parker VA, Skinner KM. Burden of medical illness in women with depression and posttraumatic stress disorder. Archives of Internal Medicine. 2004; 164(12): 1306-12.
4. Frayne SM, Freund KM, Skinner KM, Ash AS, Moskowitz MA. Depression management in medical clinics: does healthcare sector make a difference? American Journal of Medical Quality. 2004; 19(1): 28-36.

DRA: Health Services and Systems, Mental Illness, Special (Underserved, High Risk) Populations
DRE: Communication and Decision Making, Resource Use and Cost
Keywords: Depression, Women - or gender differences
MeSH Terms: Depression, Women