A Population-Based Cross-Sectional Study Comparing Depression and Health Service Deficits Between Rural and Nonrural U.S. Military Veterans
ABSTRACT With involvement in two wars over the past decade, there has been a documented increase in depression prevalence and suicide incidence among U.S. military veterans. Because higher proportions of veterans come from rural communities, access to care may be an issue when behavioral health care is needed. Although the
INTRODUCTION
In
Presently, there is no definitive diagnostic test for depression- the condition is diagnosed by presenting symptoms. The Patient Health Questionnaire depression scale (PHQ-9, PHQ-8), a screening and diagnostic tool often used in primary care, incorporates the criteria of major depressive disorder (MDD) as defined in the Diagnostic and Statistical Manual, Fourth Edition, Text Revision (DSM-IV-TR).14 Accordingly, the DSM-IV-TR defines the symptoms of depression as: depressed mood, diminished interest or pleasure in activities, changes in appetite or weight, changes in sleep patterns, talking or moving slower or faster than usual, increased fatigue, loss of energy, feelings of worthlessness or guilt, inability to concentrate, and/or suicidal ideation. For a diagnosis of MDD, a person must have either of thefirst2symptomslistedaboveandatotaloffiveormore symptoms present for at least 14 days.14
The purpose of this study was to determine the prevalence of depression, as measured by a validated diagnostic and severity depression instrument (PHQ-8)15 that can be used to identify current depression, in U.S. military veterans.16 Further, the study sought to ascertain the differences, if any, in the prevalence of depression between rural and nonrural veterans. Taking known service utilization issues into account, this article also examined the prevalence of health service deficits (HSDs) for rural versus nonrural military veterans who were currently depressed.
HSDs are an evolving concept and are composed of the following: no routine medical examination, no primary care provider, no health insurance, and/or a deference of medical care because of cost, all within the last 12 months. Having at least one of these constituted having a HSD.17-19 An earlier study,17 analyzing Behavioral Risk Factor Surveillance System (BRFSS) data, examined depression and HSDs in rural compared to nonrural adult populations and found that rural residency was an independent risk factor for greater HSDs in adults with depression.
The study described here sought to fill identified epidemiological gaps in our knowledge regarding rural U.S. military veterans, depression prevalence, and HSDs. Specifically, analyzing nonmedical records or data for both depression and HSDs identifies the population of U.S. military veterans who may have mental health concerns and who may not be receiving health care-related services for them. In our discussion, we emphasize the importance of interprofessional team care, including pharmacists, physicians, and other primary care providers, for those needing and not receiving mental health care for depression.
METHODS
To answer the research question, 2006 BRFSS data were analyzed using bivariate and multivariate techniques. BRFSS is a random digit telephone survey that is a collaborative project of the
The response rate for the BRFSS data is the number of respondents who completed the survey as a proportion of all eligible and likely eligible persons. The median survey response rate for all states and
BRFSS collects information from individuals on healthrisk behaviors, preventive health practices, and health care access primarily related to chronic disease and injury. BRFSS is constituted of core questions that must be asked of every survey participant and optional modules that may be chosen by individual states and asked only of the survey respondents from the participating state(s).
For this analysis, the population of interest was U.S. veterans 3 18 years of age identified as currently depressed using the PHQ-8 criteria (Table I). Current depression as measured by the PHQ-8 was the primary dependent variable for this study. In difference to current depression, lifetime depression was measured by respondents' answer to the following question: has a doctor or other health care provider ever told you that you have a depressive disorder?
For analysis, a number of variables were either recoded or computed. Recoding for the most part entailed collapsing response categories and removing the response categories of "don't know" and "refused." Recoded variables were lifetime depression (yes/no), age (<65/365 years), employment status (employed for wages/unemployed/ not working by choice/ unable to work), marital status (married or living with partner/ not married or living with partner), self-defined health status (good to excellent/fair to poor), and geographic locale (rural/ nonrural). The computed variables were current depression, HSDs, socioeconomic status (SES), and race/ethnicity.
The PHQ-8 screening and diagnostic tool was transformed into survey questions and all BRFSS respondents from the states that chose this optional module were asked those questions. This served to identify currently depressed U.S. veterans regardless of whether or not they had been previously diagnosed by a health care provider and regardless of whether or not they have ever received care for such. The standardized and validated PHQ-8 consists of eight of the nine criteria on which the DSM-IV-TR diagnosis of depressive disorders is based.14 The ninth question in the DSM-IV-TR assesses suicidal or self-injurious thoughts. It was omitted because interviewers/researchers were not able to provide adequate intervention by telephone if a respondent indicated that they were having such thoughts.15 The PHQ-8 response set was standardized to make it similar to other BRFSS questions by asking the number of days in the past 2 weeks the respondent had experienced a particular depressive symptom. Similar to a methodology employed by other researchers,15,21 the modified response set was converted back to the original response set: 0 to 1 day = not at all, 2 to 6 days = several days, 7 to 11 days = more than half the days, and 12 to 14 days = nearly every day, with points (0 to 3) assigned to each category respectively. The scores for each item were summed to produce a total score between 0 and 24 points. A total score of 0 to 4 represents no significant depressive symptoms. A total score of 5 to 9 represents mild depressive symptoms; 10 to 14, moderate; 15 to 19, moderately severe; and 20 to 24, severe. This is summarized in Table I. For our analyses, current depression was defined as a PHQ-8 score of 310, which has 88% sensitivity and 88% specificity for major depression and, regardless of diagnostic status, typically represents clinically significant depression.15,21
HSDs, one of the independent variables in this analysis, were computed from the response categories of four separate variables (health insurance status, personal health care provider, deferment of medical care because of cost, and routine medical examination). The response categories included in the computation of the variable were did not have health insurance, did not have a health care provider, deferred medical care because of cost, and did not have a routine medical examination, all within the last 12 months. Together these 4 issues form a constellation of factors that can and often lead to deficits in care in the U.S. health system. These four issues are interwoven, and since HSDs are an evolving concept, they are given equal weight in this analysis. Having at least one of these constituted having a health service deficit.
SES was also one of the primary independent variables. SES is one of the strongest determinants of health.22 Although it is a commonly used term in analyses across disciplines (e.g., sociology, social epidemiology, social psychology), there is no general consensus about how to either define or measure the construct.23-25
Typically SES refers to a combination of household income and other social measures, such as attained educational level, indexed into a single variable.25 The purpose of SES is to provide some means of comparing relative position with regard to others. Almost always, SES is computed as a three-level variable (i.e., low, mid-range, and high).25 Various measures of SES are typically not interchangeable and reflect the intent and approach of the investigator.25
In our analyses, SES was a computed variable comprised of two categorical variables: attained education and median annual household income. In keeping with convention, data categories from each of these individual variables were coded as one of low, mid-range, or high and numbered 1, 2, or 3, respectively. The variables with numbered factors or categories were then added together to create the composite variable of SES. For education, low was less than high school and was coded as 1, mid-range was high school graduate and was coded as 2, and high was at least some college and was coded as 3. For income, low referred to the category <
The Metropolitan Statistical Area (MSA) variable included in BRFSS was used to define place of residence as either rural or nonrural. Rural residents were defined as persons living either within an MSA that had no city center or outside an MSA. Nonrural residents included all respondents living in a city center of an MSA, outside the city center of an MSA but inside the county containing the city center, or inside a suburban county of the MSA.
Race/ethnicity was calculated from participant responses to two separate survey questions-one regarding race and the other regarding Latino/Hispanic ethnicity. All race/ethnicity categories were computed as mutually exclusive entities. For example, all respondents coded as Caucasian chose white as their racial classification, likewise, black for African-American, etc. If a respondent identified themselves as Hispanic or Latino, they were classified by that ethnic category regardless of any additional racial classification. The category of other/ multiracial was also calculated.
Bivariate and multivariate analyses were performed. Initial bivariate analysis was performed to examine the unadjusted odds for rural (versus nonrural) veterans regarding HSDs, current depression, and lifetime depression. Subsequent bivariate analysis compared the characteristics (using study covariates) of currently depressed U.S. veterans by geographic locale (rural versus nonrural). Initial logistic regression was performed to determine the adjusted odds of U.S. veterans for both current and lifetime depression controlling for SES and race/ethnicity. Multivariate logistic regression analysis was also performed to further ascertain the characteristics (based on factors of the study covariates) of rural U.S. veterans with current depression (as measured by the PHQ-8). All analyses were performed on weighted data as is recommended by the
RESULTS
The study sample included 636,412 currently depressed U.S. veterans, 159,022 (25%) of whom were rural residents. Initial bivariate analysis (Table II) revealed that in comparison to nonrural veterans, rural veterans had greater odds of having at least 1 HSD (unadjusted OR = 1.19, 95% CI = 1.19- 1.19), being currently depressed as measured by the PHQ-8 (unadjusted OR = 1.12, 95% CI = 1.11-1.12), and having lifetime depression (unadjusted OR = 1.13, 95% CI = 1.13- 1.14). Table III, based on contingency table analysis, presents a description of depressed U.S. veterans by geographic locale (rural/nonrural). All results were statistically significant using alpha set at <0.05 and a c2 as the test statistic. Of note, this analysis revealed, higher proportions of rural currently depressed U.S. veterans had at least one HSD, were low SES, were Caucasian, and also had lifetime depression. In this analysis, we also broke out the prevalence of the four variables constituting the computed HSDs variable. This analysis yielded that for all of the variables constituting HSDs, the prevalence was higher for depressed rural veterans, although timing of the most recent medical exam was barely so.
Logistic regression analysis (not shown) yielded that rural veterans had higher odds of both current depression and life-time depression than nonrural veterans when controlling for SES and race/ethnicity. Additional logistic regression sis (Table using current depression (PHQ-8 measure) as the dependent variable, was performed to ascertain the contribution (effect size) each independent covariate made to the dependent variable when controlling for all covariates in relation to one another. This analysis revealed that rural veterans with current depression had higher odds of being Hispanic or Other/Multiracial (OR = 1.09, 95% CI = 1.05-1.13; OR = 1.69, 95% CI = 1.65-1.73) than Caucasian, not employed for wages (as measured by three factors) (unemployed OR = 1.23, 95% CI = 1.19-1.27; not working by choice OR =1.35, 95% CI = 1.33-1.37; unable to work OR =3.39, 95% CI = 3.34-3.45) than employed for wages, younger than 65 years of age (OR = 2.10, 95% CI = 2.07-2.14), and report having at least 1 HSD (OR = 1.70, 95% CI = ,1.68-1.72). In addition, rural veterans with current depression had lesser odds of being middle or high SES (OR = 0.87, 95% CI = 0.86-0.88; OR = 0.48, 95% CI = 0.47-0.49), reporting their health as good to excellent (OR = 0.20, 95% CI = 0.20-0.21), and being married or living with a partner (OR = 0.68, 95% CI = 0.61-0.69).
DISCUSSION
This study sought to fill epidemiological knowledge gaps regarding rural U.S. military veterans, depression prevalence, and HSDs. Our findings indicated that rural veterans had higher odds of being currently depressed when compared to their nonrural counterparts. This was also the case for lifetime depression. Additionally, the prevalence of HSDs was approximately 20% greater for rural veterans. These findings are in line with recent research that has demonstrated that rurality is a fundamental social determinant of health.26 Greater HSDs may occur in rural areas in part because accessing available health services may be exacerbated by geographic isolation, poorer roads, and lack of public transportation, whereas attitudes related to health may make less healthy behaviors more socially acceptable.26
This study further identified the characteristics of currently depressed rural U.S. military veterans. Among the significant characteristics identified were that this vulnerable population had greater odds of being unable to work, being younger than 65 years of age, and having at least one HSD. Additionally, currently depressed veterans had lesser odds of being married or living with a partner and being middle or high SES.
The strong association between current depression and being unable to work for rural veterans is most likely multi-factorial. Although depression in and of itself may lead to an inability to work, other factors may include physical impairment as a result of military service, other mental health issues (e.g., post-traumatic stress disorder), lack of a social support system,27 and/or lack of training for civilian employment.
In regards to physical impairment, a recent report by Bilmes et al28 estimated that 44% of veterans regardless of geographic locale who served during the Gulf War (1990- 1991) filed disability claims with 87% being approved. They estimated that there will be a similar prevalence of claims and approval for those serving in the
Our findings indicated that rural veterans who were currently depressed had lesser odds of being married or living with a partner, suggesting a possible absence of a social support system. Some studies have found that for returning veterans, lower levels of social support are correlated with poorer health.27 Depression is a dimension of poor health. A small study conducted in 2012, which surveyed returning veterans, found that 48% of veterans offered that readjusting to social life was difficult and 36% expressed difficulties reacclimating to family life.30 Findings from yet another study indicated that social isolation was not a significant issue for some veterans.31
Lack of training for civilian employment may be another one of the multifactorial variables possibly contributing to depression in rural veterans. While serving in the military, training is provided for specific duties; however, that training may not always translate to civilian employment. One study yielded that 60% of returning veterans found it difficult to explain to civilian employers how their military skills translated to current employment opportunities.30 Additionally, 46% found it challenging to compete with candidates who had been in the workforce for a longer period of time and 43% reported that they lacked needed training for available jobs.30 According to the
Another significant finding from our study was that rural veterans experiencing current depression had greater odds of being younger than 65 years of age. In some ways, this is not a surprising finding because overall, younger veterans are more likely to have recently served in a conflict. Our finding replicates that of other studies.33-37 Further, as with some of our already discussed findings, the increase in depression in younger veterans could be further exacerbated by economic hardships. For instance, in 2011 Iraq and
We also found that rural U.S. veterans with current depression had higher odds of having at least one HSD. HSDs include no routine medical examination, no primary care provider, no health insurance, and/or a deference of medical care because of cost, all within the last 12 months. There may be a common misperception that combat involved veterans are entitled to receive lifetime medical insurance and care. However, coverage for medical services is not guaranteed for all military veterans regardless of combat status.38 Although it is often cited that accessing services and availability of services may be a difficult issue for rural veterans, the reality may be more complicated than simple access. To receive veteran-related medical insurance and coverage, there is a prioritization system based on medical conditions related to military service.39 Furthermore, there is an income-based adjustment for priority level for eligibility for services.38 For veterans returning from a theater of combat, one must apply for health care coverage within 5 years after honorable or general discharge from active duty or risk losing eligible services.38,39 Moreover, the VA health system is currently distressed, intensifying difficulties with health care service availability and access.40
The findings from this study suggest that mental health care might be improved through community outreach efforts in rural areas. Outreach endeavors are essential to ensure that there are adequate efforts being made to meet the mental health needs of rural currently depressed veterans.41
Study Limitations
Several potential limitations to this study should be noted. First, the survey is based on telephone-derived data. Since some people would not be reachable by phone, the data might lack representation. For instance, some choose to not have telephones (landlines or mobile) and a very small proportion cannot afford phone services. In addition, widespread use of answering machines and caller identification now allow people to filter their phone calls potentially leading to a passive refusal to participate in surveys such as the BRFSS. Nevertheless, call filtering is beyond the control of survey administrators and the vast majority of U.S. residents live in households with telephones, which minimizes the bias of lack of phone access. Study strength is in the use of a national database that included a robust sample of residents weighted to reflect the demographics of the U.S. population.
A second limitation is that the survey used close-ended questions, which limit participants' options to fully explain response choices. Nonetheless, the survey questions were worded such that the answer choices covered a wide range of response possibilities. A third, and related, limitation is that the answers are self-reported, which introduces the possibility of recall bias on the part of the survey participants. Furthermore, this study did not account for seasonal depression or seasonal depressive symptoms, which may have been manifested at the time of the call because of the time of year and been mistaken for MDD. This limitation is beyond the control of the study. A final potential bias resulted from the languages of the survey-English and Spanish. Individuals who did not speak English or Spanish were excluded from this survey. However, since all U.S. military applicants must speak, write, and read English fluently, this should not be a problem for the population studied.
CONCLUSIONS
There is a higher prevalence of current and lifetime depression among rural veterans. Furthermore, rural veterans experience a higher prevalence of health service deficits. This is particularly important given both the ongoing wars
ACKNOWLEDGMENTS
We would like to thank the anonymous reviewers whose reviews helped us to greatly improve the manuscript.
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doi: 10.7205/MILMED-D-14-00101
College of American Pathologists’ Laboratory Standards for Next-Generation Sequencing Clinical Tests
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