Depression and the Health Care Experiences of Medicare Beneficiaries

Depression is a common disabling condition that exacts a high toll on individuals and society (Rice and Miller 1998; Pincus and Pettit 2001; Kessler et al. 2005). Despite the availability of effective psychotherapeutic and pharmacological treatments (Von Korff et al. 1997; Schulberg et al. 1998), less than one-third of adults with depression in the United States receive appropriate treatment (Wang, Berglund, and Kessler 2000; Young et al. 2001). Patients with depressive symptoms also tend to receive poorer care for their comorbid chronic conditions than do patients without depressive symptoms who have the same chronic conditions (e.g., Ciechanowski, Katon, and Russo 2000; Ciechanowski et al. 2003; Katon et al. 2005). Additional research is needed to understand how the health care experiences of patients with and without depressive symptoms may differ, and to suggest ways in which the health care experience of patients with depression may be improved. This study compared the health care experiences of Medicare beneficiaries with and without symptoms of depression and investigated the role of patient confidence in shaping these experiences. Eighty-three percent of Medicare beneficiaries are aged 65 and older (Kaiser Family Foundation 2010); the rest are primarily younger adults qualified for Medicare via chronic physical disability. The prevalence of depression among the elderly is estimated at 4–25 percent depending on definition (i.e., minor versus major depression), setting (e.g., community-based versus medical inpatient population), and diagnostic criteria (e.g., DSM versus other; McCall et al. 2002). Depression among older adults is a public health concern due to its association with decreased functional ability (Kivela and Pahkala 2001), poorer adherence to medical treatment (DiMatteo, Lepper, and Croghan 2000), and increased risk of mortality (Penninx et al. 1999; Schulz, Drayer, and Rollman 2002; Gallo et al. 2005). People with physical disabilities are also at increased risk for depression (Turner and Noh 1988; Turner and McLean 1989; Geerlings et al. 2000; Yang and George 2005; Schieman and Plickert 2007), partly because of mobility impairment (Briesacher et al. 2002) and partly because of other adversities, such as social stigma (Bruce 1999; Graney 2000; Mickelson 2001). Quality of care for depressed patients is enhanced by good patient–provider communication (Carney et al. 1999; Bultman and Svarstad 2000; Bull et al. 2002; Deveugele, Derese, and De Maeseneer 2002). Depressed patients who report more physician information sharing and more involvement in treatment decisions are more likely to receive guideline-concordant care (Clever et al. 2006). Good patient–provider communication results in a lower symptom burden for patients (Greenfield, Kaplan, and Ware 1985; Little et al. 2001), greater satisfaction with treatment (Stewart 1984; Brody et al. 1989; Little et al. 2001), and improved treatment adherence (Stewart 1984; Lin et al. 1995; Bull et al. 2002). Patients with depressive symptoms often report poor doctor–patient communication. In recent studies of adults with diabetes (Swenson et al. 2008) and chronic coronary disease (Schenker et al. 2009), depressive symptoms were associated with reports of suboptimal clinician–patient communication across multiple domains, particularly patient-centered communication (e.g., elicitation of patient problems, concerns, and expectations; explanation of condition; and responsiveness to patient preferences). The association between depression and poor patient–provider communication may extend to other aspects of care, as depressed patients are often disengaged, unassertive, and poorly informed, and therefore may be unlikely to negotiate care or to expect or demand timely and proper care (Rogers, May, and Oliver 2001; Gask et al. 2003; Savard 2004). However, studies comparing experiences of care reported by depressed and nondepressed patients have so far limited their scope to patient–provider communication, omitting other specific aspects of care and overall evaluations of care. Moreover, little is known about factors that mediate the association between depressive symptoms and poorer experiences of care. One mediating mechanism may be patients' confidence in their ability to actively participate in their health care. To participate, patients must be able to monitor and accurately report on changes in their health condition and feel confident in their ability to do so (Lorig 1996). Confident patients ask more questions, have a greater sense of control over their health, and adhere better to treatment (DiMatteo 1998; Hibbard et al. 1999). Because depression generally entails feelings of pessimism and inefficacy, it is reasonable to assume that patients with depressive symptoms lack confidence in their ability to take an active role in their care. If so, they are likely to also be less satisfied with their care and—according to the chronic care model (Wagner, Austin, and Von Korff 1996)—to actually experience poorer care.