Treatment of depression in rural Arkansas: Policy implications for improving care

Policy-makers have long suspected that greater barriers to care result in d epressed rural residents being less likely to receive high-qualify treatmen t. This study recruited 470 depressed community residents in a 1992 telepho ne survey, followed 95 percent of them through one year, and abstracted add itional data on their health care utilization from insurance claims, medica l and pharmacy records. Bivariate and multivariate models demonstrated that during the year following the baseline there were no significant rural-urb an differences in the rate (probability of any outpatient depression treatm ent), type (probability of receiving general medical depression care only), or quality (completion of guideline-concordant acute-stage care) of outpat ient depression treatment. Annual expenditures for outpatient depression tr eatment were lower for rural subjects compared with their urban counterpart s. Rural subjects had 3.05 times the odds of being admitted to a hospital f or physical problems and 3.06 times the odds of being admitted to a hospita l for mental health problems during the year following baseline compared wi th urban subjects. Cost-offset analyses demonstrate that every dollar inves ted in depression treatment was associated with a $2.61 decrease in the cos t of treating physical problems in depressed rural residents. Limited insur ance coverage and limited availability of services were the most significan t barriers to speciality and general medical outpatient treatment for depre ssion in both rural and urban residents. More than 80 percent of depressed residents in both rural and urban areas visited a primary care provider dur ing the year following baseline. The potential cost offset of depression tr eatment in rural populations plus the improvement in productivity observed in both rural and urban populations indicate that it may be economically po ssible to improve quality of care for depression without bankrupting an alr eady strained health care budget.