MEDICATION MANAGEMENT OF DEPRESSION IN THE UNITED-STATES AND ONTARIO

OBJECTIVE: To compare rates of contact for mental problems and receipt of appropriate antidepressant medication management for persons in th e general population with major depression in the United States and On tario, Canada. DESIGN: Survey using the U.S. National Comorbidity Surv ey and the Mental Health Supplement of the Ontario Health Survey. PART ICIPANTS: All persons with major depression as described in DSM-III-R in the previous 12 months, from a multistage random sample of persons aged 21 to 54 years living in households in the United States (n = 574 ) and Ontario (n = 250) in 1990. MEASUREMENTS AND MAIN RESULTS: Self-r eported contact with general medical or mental health specialty provid ers for mental problems and appropriate medication management, defined as a combination of antidepressant medication use and four or more vi sits to any provider within the previous 12 months, were the main outc ome measures. The proportion of depressed persons receiving appropriat e management was lower in the United States than in Ontario (7.3% vs 1 4.9% in Ontario, adjusted odds ratio [AOR] 95% CI 0.4; 95% confidence interval [CI] 0.2, 0.8). This difference was largely the result of few er Americans than Canadians having any mental health care from general medical physicians (9.6% in the United States vs 25.8% in Ontario; AO R 0.3; 95% CI 0.1, 0.5) rather than from specialty providers (20.8% in the United States vs 28.9% in Ontario; AOR 0.7; 95% CI 0.4, 1.1). The se between-country differences were much greater for the poor than for those with higher incomes. The Ontario-United States AOR of making co ntact with either type of clinical provider was 7.5 (95% CI 2.7, 20.7) for lowest-income persons but 2.1 (95% CI 0.3, 5.6) for highest-incom e persons. The proportions of depressed recipients of any mental healt h care who received appropriate management were similar between countr ies (23.9% in the United States vs 27.7% in Ontario; AOR 0.8: 95% CI 0 .3, 1.7). CONCLUSIONS: Most persons with depression in the United Stat es and Ontario do not receive appropriate medication management. The r ate of appropriate medication management in the United States relative to Ontario is lower largely because there is less contact with genera l medical physicians for mental problems, especially for the poor. Eco nomic barriers, rather than knowledge and attitudinal factors, appear to explain this difference.