Findings Regarding the Provision of Psychotherapy in a National Sample of Depressed Veterans: Implications for Policy and Practice

Background and Purpose: Psychotherapy services for depression have long been used in the VA Healthcare System, the largest employer of social workers in the United States. Evidence suggests that several forms of psychotherapy, when used alone or with medication, can decrease depressive symptoms, remit major depression, and even prevent the recurrence of major depressive episodes. A recent study revealed that in the VA, about half of veterans who were newly diagnosed with depression received some form of psychotherapy services. However, relatively little has been done to identify the specific types of psychotherapy that were used. The present study examined the rates at which individual and group psychotherapy services were used in the VA healthcare system, as well as the sociodemographic and clinical characteristics that were associated with receiving these therapies.

Method: We used data from the VA National Registry for Depression (NARDEP) to examine psychotherapy services in a national sample of depressed veterans enrolled in VA healthcare services. NARDEP data provided sociodemographic and clinical characteristics (e.g. age, gender, race/ethnicity, education; inpatient stays; alcohol, drug, PTSD, anxiety, bipolar, and personality disorders), as well as counts of psychotherapy encounters, for each of the 476,988 Veterans identified with depression in FY2004. First, we assessed overall prevalence rates of several types of psychotherapy (individual psychotherapy with physicians and non-physicians, and group psychotherapy with any provider), and the mean number of psychotherapy visits that occurred within one year of receiving a depression diagnosis. We then examined bivariate differences in the types of psychotherapy utilized by sociodemographic and clinical characteristics. Finally, multivariate count regression models identified the characteristics associated with not receiving psychotherapy, and the characteristics associated with receiving a greater number of sessions for those who did receive psychotherapy.

Results: Approximately 43.9% of veterans attended at least one psychotherapy visit within one year of receiving a diagnosis of depression. Individual psychotherapy with a physician was the most prevalent service at 28.9%, followed by individual psychotherapy with a non-physician (24.6%), then group therapy (11.4%). However, mean visits were highest for group therapy (13.7 visits), followed by individual with non-physicians (4.6 visits), then individual with physicians (2.7 visits). Across psychotherapy types, risk factors for not receiving services included being older or married. Veterans receiving group psychotherapy were mostly likely to be male, African American, or Hispanic, as well as diagnosed with PTSD, drug, and alcohol disorders.

Conclusions and Implications: Just under half of veterans diagnosed with depression initiated psychotherapy. On average, veterans receiving individual psychotherapy attended few visits. Veterans receiving group therapy attended a mean number of visits that is more consistent with treatment guidelines in terms of frequency and number of therapy sessions, and additionally, some vulnerable subgroups attended more group psychotherapy. These findings suggest that increasing the availability of group treatments may provide a way to deliver more frequent psychotherapy and monitoring visits to those in need. Future research is needed to explore whether system barriers (e.g. staffing levels) might contribute to the low use of psychotherapy.