eAppendix 1
ICD codes for depressive disorders
The International Classification of Diseases codes, Ninth Revision, Clinical Modification (ICD-9-CM) were used for survey years 2004-2015, and the International Classification of Diseases codes, Tenth Revision, Clinical Modification (ICD-10-CM) were used for 2016 and 2017. The ICD-9-CM codes for depressive disorders included 296.20-296.26 for “major depressive disorder, single episode”, 296.30- 296.36 for “major depressive disorder, recurrent episode”, 300.4 for “dysthymic disorder”, and 311 for
“depressive disorder, not elsewhere classified”. ICD-10-CM codes for depressive disorders included F32.0, F32.1, F32.2, F32.3, F32.4, F32.5 and F32.9 for “major depressive disorder, single episode”, F33.0, F33.1, F33.2, F33.3, F33.4 and F33.9 for “major depressive disorder, recurrent episode”, and F34.1 for “dysthymic disorder”.
Multum Lexicon therapeutic classification codes
The level-2 Multum Lexicon therapeutic classification codes of 249, 67, 251 and 64 were used to identify use of antidepressants, anxiolytics/sedatives, antipsychotics and anticonvulsants,
respectively. Prescribed medications not in the above classes were categorized as other medications due to their low frequencies in the study sample.
Sociodemographic characteristics
Race and ethnicity were self-reported by participants. In 2011 and earlier, participants were asked to choose one or more from the race categories, including White, Black/African American, American Indian or Alaska native, Asian, native Hawaiian or other Pacific Islander, and other. Asian and other Pacific Islander have been replaced with specific subcategories since 2012. The race and ethnicity variables generated by the MEPS were used in the present analysis. The unweighted percentages of participants who self-identified as multiracial were less than 4% in samples for each of the survey years, and multiracial participants were not included in the study sample.
Family income levels were defined based on percent of the federal poverty level, with below 200%
defined as low income and below, between 200% and 400% defined as middle income and ≥400%
defined as high income.
eTable 1. Comparison of trends in receiving any outpatient treatment for depression between the stroke population and non-stroke population, Medical Expenditure Panel Survey, United States, 2004-2017
N Adjusted OR (95% Cl) a
Stroke population
Non-stroke population
Stroke population b
Non-stroke population c
P value for Interaction d
Overall 10243 264645 0.90 (0.71, 1.16) 1.15 (1.06, 1.25) 0.170
Age
Age<60 3350 205093 0.70 (0.45, 1.10) 0.99 (0.90, 1.09) 0.328
Age 60-74 3702 41952 1.17 (0.78, 1.76) 1.56 (1.33, 1.82) 0.438
Age ≥75 3191 17600 0.86 (0.56, 1.32) 1.58 (1.26, 1.98) 0.023
Sex
Male 4359 120777 0.92 (0.61, 1.38) 1.12 (0.99, 1.26) 0.597
Female 5884 143868 0.89 (0.65, 1.20) 1.16 (1.06, 1.27) 0.090
Race/ethnicity
Non-Hispanic White 5858 136032 0.89 (0.66, 1.20) 1.18 (1.07, 1.29) 0.158 Non-Hispanic Black 2857 51903 0.90 (0.56, 1.43) 1.13 (0.92, 1.37) 0.354
Hispanic 1528 76710 0.86 (0.46, 1.61) 0.96 (0.82, 1.12) 0.751
Depression screening e
Negative 7404 234444 1.08 (0.78, 1.49) 1.21 (1.10, 1.32) 0.759
Positive 2367 23545 0.90 (0.62, 1.31) 1.38 (1.20, 1.58) 0.025
Abbreviations: CI, confidence interval; OR, odds ratio.
a Odds ratio for period change, adjusted for age, sex, race/ethnicity, family income, health insurance and marital status.
b changes in odds of receiving any outpatient treatment for depression across the whole period from 2004 to 2016 in adults with stroke.
c changes in odds of receiving any outpatient treatment for depression across the whole period from 2004 to 2016 in adults without stroke.
d P value for interaction between the time variable(s) and stroke status in the analytical sample including participants with and without stroke/TIA history.
e Screening negative for depression was defined as scoring less than 3 on the 2-item Patient Health Questionnaire. Screening positive for depression was defined as scoring 3 or above on the 2-item Patient Health Questionnaire.
eTable 2. Trends in receiving no outpatient treatment for depression among survivors of stroke screened positive for depression by the PHQ-2, Medical Expenditure Panel Survey, United States, 2004-2017
N
Weighted %
Adjusted OR (95% Cl) a 2004-
2005
2006- 2007
2008- 2009
2010- 2011
2012- 2013
2014- 2015
2016- 2017
P value for interaction
Overall 2367 64.1 61.7 65.5 65.2 69.0 61.8 66.2 1.11 (0.76, 1.61)
Age 0.647
Age<60 991 57.6 59.3 60.4 54.3 66.7 55.9 60.8 1.04 (0.58, 1.86)
Age 60-74 774 65.6 59.0 57.1 68.2 64.6 59.2 61.1 0.95 (0.51, 1.77)
Age ≥75 602 67.9 67.2 80.1 77.7 76.5 75.4 77.8 1.49 (0.69, 3.23)
Sex 0.669
Male 945 66.0 70.7 73.9 71.9 71.9 70.9 72.3 1.24 (0.64, 2.38)
Female 1422 62.8 54.8 58.8 60.4 66.7 54.9 61.4 1.03 (0.64, 1.67)
Race/ethnicity 0.921
Non-Hispanic White 1267 63.9 59.8 63.3 65.5 67.8 58.3 66.2 1.12 (0.71, 1.77) Non-Hispanic Black 681 63.7 72.4 76.5 72.4 72.6 72.3 69.9 0.98 (0.48, 2.02)
Hispanic 419 66.4 64.4 61.7 55.7 69.0 69.6 59.6 1.22 (0.56, 2.66)
Abbreviations: CI, confidence interval; OR, odds ratio.
a Odds ratio for period change, adjusted for age, sex, race/ethnicity, family income, health insurance and marital status.
eTable 3. Trends in type of treatment and providers among survivors of stroke receiving outpatient treatment for depression, Medical Expenditure Panel Survey, United States, 2004-2017
Weighted % 2004-
2005
2006- 2007
2008- 2009
2010- 2011
2012- 2013
2014- 2015
2016- 2017
Adjusted OR (95% Cl) a
P value for non-linearity Treatment type b
Psychotherapy 13.8 12.3 17.5 15.1 19.7 23.3 24.4 2.26 (1.28, 4.01) 0.535
Any pharmacotherapy 93.5 94.8 94.4 92.0 94.4 95.6 92.0 1.15 (0.47, 2.80) 0.676 Antidepressants 86.9 88.8 86.7 79.1 84.9 84.3 86.5 1.00 (0.57, 1.74) 0.269 Anxiolytics 13.8 14.7 13.7 12.5 15.9 23.5 10.1 1.18 (0.69, 2.02) 0.281
Antipsychotics 12.8 6.5 8.4 12.6 9.7 6.6 6.6 0.54 (0.28, 1.03) 0.622
Anticonvulsants 11.1 9.9 7.7 8.2 12.1 18.0 10.1 1.65 (0.85, 3.23) 0.813 Other medications 7.0 8.4 16.7 10.5 11.7 12.3 14.9 1.61 (0.86, 3.01) 0.468 Psychotherapy & pharmacotherapy 10.3 11.4 15.0 11.6 17.7 20.2 19.7 2.27 (1.25, 4.14) 0.831 Psychotherapy& antidepressants 9.1 9.9 14.2 9.7 14.6 18.1 19.3 2.51 (1.31, 4.78) 0.555 Provider type c
Physician 85.3 91.1 91.4 94.5 90.0 88.9 81.2 0.72 (0.27, 1.88) 0.008
Primary care doctor 37.0 52.4 50.1 50.1 35.8 35.4 42.5 0.69 (0.39, 1.24) 0.367 Psychiatrist 31.9 27.0 33.7 30.2 39.7 46.9 40.4 2.10 (1.06, 4.14) 0.711
Neurologist 3.7 0.3 0.5 1.8 0.0 2.5 0.7 0.56 (0.08, 3.67) 0.480
Psychologist 13.6 9.9 11.5 7.0 6.0 14.7 18.2 1.47 (0.62, 3.48) 0.016
Social worker 11.9 4.1 10.2 2.0 6.4 8.7 7.8 0.81 (0.22, 3.00) 0.186
Abbreviations: CI, confidence interval; OR, odds ratio.
a Odds ratio for period change, adjusted for age, sex, race/ethnicity, family income, health insurance and marital status.
b The sample size was 1764.
c The sample size was 857, i.e. 857 participants with at least one outpatient visit.
eTable 4. Trends in number of treatment visits for among survivors of stroke receiving outpatient treatment for depression, Medical Expenditure Panel Survey, United States, 2004-2017
Weighted % Number of treatment visits 2004-
2005
2006- 2007
2008- 2009
2010- 2011
2012- 2013
2014- 2015
2016- 2017
Adjusted IRR (95% Cl) a
P value for non-linearity Outpatient visits b
0 54.4 56.3 56.1 44.6 55.1 51.4 56.0
1.02 (0.66, 1.57)
1 15.5 17.2 14.0 20.3 18.3 11.4 12.3
2 4.3 5.1 7.9 11.3 6.9 7.9 5.2 0.073
3-6 12.6 14.5 11.5 15.1 15.4 16.7 12.0
≥7 13.2 6.9 10.5 8.7 4.3 12.5 14.4
Psychotherapy visits c
0 86.3 87.7 82.5 84.9 80.3 76.7 75.6
1 4.9 2.3 4.3 6.0 7.1 3.9 5.7
2 1.4 2.9 2.8 2.4 5.1 1.7 2.4 1.84 (0.89, 3.79) 0.130
3-6 3.8 3.1 5.2 2.0 5.7 8.4 8.1
>6 3.7 4.1 5.2 4.7 1.8 9.3 8.3
Abbreviations: CI, confidence interval; IRR, incidence rate ratio.
a Incidence rate ratio for period change, adjusted for age, sex, race/ethnicity, family income, health insurance and marital status. The sample size was 1764.
bThe mean numbers of outpatient visits for depression were 2.64 (95% CI=1.69-3.59) in 2004-2005 and 2.91 (95% CI=1.96-3.85) in 2016-2017.
cThe mean numbers of psychotherapy visits for depression were 0.72 (95% CI=0.30-1.13) in 2004-2005 and 1.71 (95% CI=0.95-2.47) in 2016-2017.
