Abstract
BackgroundDepression is the second leading cause of death among young adults and a major cause of disability worldwide. Some studies suggest a disparity between rural and urban outcomes for depression. Collaborative Care Management (CCM) is effective in improving recovery from depression, but its effect within rural and urban populations has not been studied.MethodsA retrospective cohort study of 3870 patients diagnosed with depression in a multi-site primary care practice that provided optional, free CCM was conducted. US Census data classified patients as living in an Urban Area, Urban Cluster, or Rural area and the distance they resided from their primary care clinic was calculated. Baseline demographics, clinical data, and standardized psychiatric assessments were collected. Six month Patient Health Questionnaire (PHQ 9) scores were used to judge remission (PHQ9 < 5) or Persistent Depressive Symptoms (PDS) (PHQ9 ≥ 10) in a multivariate model with interaction terms.ResultsRural patients had improved adjusted odds of remission (AOR = 2.8) and PDS (AOR = 0.36) compared to urban area patients. The natural logarithm transformed distance to primary care clinic was significant for rural patients resulting in a lower odds of remission and increased odds of PDS with increasing distance from clinic. The marginal probability of remission or PDS for rural patients equaled that of urban area patients at a distance of 34 or 40 km respectively. Distance did not have an effect for urban cluster or urban area patients nor did distance interact with CCM.ConclusionResiding in a rural area had a beneficial effect on the recovery from depression. However this effect declined with increasing distance from the primary care clinic perhaps related to greater social isolation or difficulty accessing care. This distance effect was not seen for urban area or urban cluster patients. CCM was universally beneficial and did not interact with distance.
Highlights
Depression is the second leading cause of death among young adults and a major cause of disability worldwide
All adult patients diagnosed with major depression (ICD9 codes 296.2 to 296.3) or dysthymia (ICD-9 code 300.4) with an initial Patient Health Questionnaire9 (PHQ-9) [15] score ≥ 10 who were treated at any of five primary care clinics located in Rochester, Minnesota and surrounding communities were eligible for inclusion in the study
Rural patients had the highest incidence of remission and the lowest incidence of Persistent Depressive Symptoms (PDS), whereas urban cluster patients had the lowest incidence of remission and the highest incidence of PDS
Summary
Depression is the second leading cause of death among young adults and a major cause of disability worldwide. Depression affects 8.1% of Americans and is the single largest contributor to non-fatal health loss throughout the world [1, 2]. It has been associated with decreased functional status, quality of life, and income along with substantial societal costs in the form of lost work productivity [3, 4]. Several authors have noted that outcomes including quality of life and treatment effectiveness are worse in rural vs urban settings [8, 9] Possible contributors to this rural-urban disparity include lack of access to medical care, greater
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