Treatment Differences in Primary and Specialty Settings in Veterans with Major Depression

Victor Puac-Polanco; Lucinda B. Leung; Robert M. Bossarte; Corey Bryant; Janelle N. Keusch; Howard Liu; Hannah N. Ziobrowski; Wilfred R. Pigeon; David W. Oslin; Edward P. Post; Ronald C. Kessler

doi:10.3122/jabfm.2021.02.200475

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Appendix 4.
Patients Seen for Incident Depression as Reported in the Veterans Health Administration Electronic Medical Records from December 2018 through June 2020

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Table 1.

Distributions and Associations of Administrative Variables with Survey Completion (n = 55,106)^{^†}

	Prevalence		Univariate		Multivariate
	%	(S.E.)	OR	(95% CI)	OR	(95% CI)
Age
18-34	27.61	(0.19)	0.76^*	(0.69-0.83)	0.75^*	(0.68-0.82)
35-49	26.91	(0.19)	0.95	(0.87-1.03)	0.94	(0.86-1.03)
50-59	17.06	(0.16)	1.15^*	(1.05-1.26)	1.17^*	(1.07-1.29)
60+	28.42	(0.19)	1.00	Ref	1.00	Ref
χ²³			72.65^*		76.83^*
Sex
Male	82.67	(0.16)	0.77^*	(0.72-0.84)	0.69^*	(0.63-0.75)
Race/ethnicity
Non-Hispanic White	60.84	(0.21)	1.00	Ref	1.00	Ref
Non-Hispanic Black	25.12	(0.18)	0.66^*	(0.61-0.71)	0.66^*	(0.60-0.72)
Hispanic	10.30	(0.13)	0.63^*	(0.56-0.72)	0.67^*	(0.59-0.76)
Other	3.74	(0.08)	0.58^*	(0.47-0.71)	0.59^*	(0.48-0.72)
χ ²³			154.23^*		128.88^*
Marital status
Currently married	48.60	(0.21)	1.00	Ref	1.00	Ref
Divorced	21.87	(0.18)	0.83^*	(0.77-0.91)	0.82^*	(0.75-0.89)
Separated	4.70	(0.09)	0.90	(0.77-1.05)	0.99	(0.84-1.15)
Widowed	2.14	(0.06)	0.76^*	(0.60-0.97)	0.69^*	(0.54-0.89)
Never married	22.69	(0.18)	0.78^*	(0.72-0.85)	0.90^*	(0.82-0.98)
χ ²⁴			42.34^*		28.52^*
Census region
Northeast	10.77	(0.13)	1.02	(0.91-1.15)	0.98	(0.86-1.10)
Midwest	17.67	(0.16)	1.10	(0.99-1.21)	1.01	(0.91-1.13)
South	50.64	(0.21)	0.98	(0.90-1.07)	0.97	(0.89-1.06)
West	20.92	(0.17)	1.00	Ref	1.00	Ref
χ ²³			6.65		1.11
Urbanicity
Major metro	85.87	(0.15)	1.00	Ref	1.00	Ref
Urban	12.73	(0.14)	1.19^*	(1.09-1.31)	1.10	(1.00-1.21)
Rural	1.40	(0.05)	1.21	(0.94-1.56)	1.10	(0.85-1.42)
χ ²²			15.83^*		3.73
% of population below 1.5 of poverty line
1st quartile (low % with low income)	25.00	(0.18)	1.00	Ref	1.00	Ref
2nd quartile	25.00	(0.18)	1.10	(1.00-1.20)	1.02	(0.93-1.12)
3rd quartile	25.00	(0.18)	1.15^*	(1.05-1.26)	1.06	(0.96-1.16)
4th quartile (high % with low income)	25.00	(0.18)	1.19^*	(1.08-1.30)	1.10	(1.00-1.21)
χ ²³			14.97^*		4.15
History of previously diagnosed mental disorders
Depression	47.99	(0.21)	0.86^*	(0.81-0.92)	0.89	(0.79-1.01)
Anxiety	28.27	(0.19)	0.92^*	(0.86-0.99)	1.00	(0.83-1.21)
PTSD	24.28	(0.18)	0.83^*	(0.77-0.90)	0.87	(0.71-1.06)
Adjustment disorder	16.10	(0.16)	0.98	(0.89-1.07)	1.11	(0.90-1.37)
Other reactions to stress	6.40	(0.10)	0.98	(0.86-1.12)	1.25	(0.77-2.05)
Substance	17.62	(0.16)	0.77^*	(0.70-0.84)	0.89	(0.70-1.14)
Other disorders	18.84	(0.17)	1.03	(0.95-1.12)	1.08	(0.87-1.33)
Number of previously diagnosed mental disorders
0	30.29	(0.20)	1.00	Ref	1.00	Ref
1	22.00	(0.18)	0.94	(0.86-1.03)	—	—
2	21.34	(0.17)	0.85^*	(0.77-0.93)	0.85^*	(0.78-0.94)
3+	26.38	(0.19)	0.82^*	(0.76-0.90)	0.85^*	(0.78-0.93)
χ ²³			25.46^*
Current depression treatment
Primary	58.16	(0.21)	0.89^*	(0.82-0.96)	0.86	(0.80-0.93)
Secondary with primary physical	16.96	(0.16)	1.11^*	(1.01-1.22)	1.02	(0.91-1.14)
Secondary with primary other mental	24.88	(0.18)	1.00	Ref	1.00	Ref
χ ²²			30.07^*		19.69^*
Treatment location, setting, and type
Seen in community-based clinic	57.15	(0.21)	1.18^*	(1.10-1.26)	1.15^*	(1.07-1.23)
Seen by primary care clinician	39.64	(0.21)	1.09^*	(1.11-1.16)	1.02	(0.94-1.11)
Received psychotherapy^{^‡}	89.29	(0.13)	0.92	(0.83-1.01)	1.10	(0.97-1.25)
Received medication	31.81	(0.20)	1.05	(0.98-1.13)	1.04	(0.96-1.14)
Received PC-MHI treatment	35.95	(0.20)	0.96	(0.89-1.02)	0.99	(0.92-1.07)

CI, confidence interval; OR, odds ratio; PC-MHI, primary care–mental health integration; PTSD, post-traumatic stress disorder; S.E., standard error.
↵* Significant at the 0.05 level, 2-sided test.
↵† Weighted to represent treatment distribution in population.
↵‡ Either saw a mental health specialist or referred to mental health treatment.

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Table 2.

Associations of Administrative Variables with Setting and Type of Treatment (n = 2610)^{^†}

	Target		Primary Care								Specialty Mental Health								F₅	F₁
	Target		Psychotherapy^‡ (n = 290)		ADM (n = 439)		Combined (n = 219)		Total (n = 948)		Psychotherapy^‡ (n = 697)		ADM (n = 373)		Combined (n = 592)		Total (n = 1662)
	Est	(S.E.)	Est	(S.E.)	Est	(S.E.)	Est	(S.E.)	Est	(S.E.)	Est	(S.E.)	Est	(S.E.)	Est	(S.E.)	Est	(S.E.)
Age
18 to 34	27.61	(0.19)	−0.08	(0.06)	−0.03	(0.05)	0.07	(0.07)	−0.03	(0.03)	−0.01	(0.04)	0.06	(0.05)	0.03	(0.04)	0.02	(0.02)	1.2	1.6
35 to 49	26.91	(0.19)	−0.04	(0.06)	−0.02	(0.05)	−0.07	(0.07)	−0.04	(0.03)	−0.07	(0.04)	0.08	(0.05)	0.13	(0.04)	0.02	(0.02)	3.2	2.0
50 to 59	17.06	(0.16)	−0.07	(0.06)	−0.03	(0.05)	0.15	(0.07)	−0.01	(0.03)	0.01	(0.04)	−0.02	(0.05)	0.01	(0.04)	0.00	(0.02)	1.3	0.1
60+	28.42	(0.19)	0.18	(0.06)	0.08	(0.05)	−0.13	(0.06)	0.08	(0.03)	0.07	(0.04)	−0.12	(0.05)	−0.18^*	(0.04)	−0.04	(0.02)	8.6^*	8.7^*
Sex
Male	82.67	(0.16)	0.09	(0.06)	−0.09	(0.05)	−0.03	(0.07)	0.01	(0.03)	0.06	(0.04)	−0.05	(0.05)	−0.09	(0.04)	0.00	(0.02)	2.9	0.1
Race/ethnicity
Non-Hispanic white	60.84	(0.21)	−0.08	(0.06)	0.03	(0.05)	−0.10	(0.07)	−0.05	(0.03)	0.05	(0.04)	−0.02	(0.05)	0.01	(0.04)	0.03	(0.02)	1.6	3.3
Non-Hispanic black	25.12	(0.18)	0.12	(0.06)	−0.05	(0.05)	0.07	(0.07)	0.05	(0.03)	−0.04	(0.04)	−0.01	(0.05)	−0.02	(0.04)	−0.03	(0.02)	1.8	3.9
Hispanic	10.30	(0.13)	−0.05	(0.05)	0.01	(0.05)	0.07	(0.07)	−0.01	(0.03)	−0.02	(0.04)	0.06	(0.06)	0.01	(0.04)	0.00	(0.02)	0.8	0.1
Other	3.74	(0.08)	0.04	(0.06)	0.01	(0.05)	0.00	(0.07)	0.02	(0.03)	−0.02	(0.04)	−0.02	(0.05)	0.00	(0.04)	−0.01	(0.02)	0.2	0.6
Marital status
Currently married	48.60	(0.21)	0.04	(0.06)	0.05	(0.05)	0.00	(0.07)	0.04	(0.03)	−0.03	(0.04)	0.07	(0.05)	−0.06	(0.04)	−0.02	(0.02)	1.1	1.7
Divorced	21.87	(0.18)	−0.04	(0.06)	−0.02	(0.05)	0.00	(0.07)	−0.03	(0.03)	0.02	(0.04)	−0.16^*	(0.04)	0.11	(0.04)	0.01	(0.02)	3.2	1.0
Separated	4.70	(0.09)	−0.07	(0.05)	−0.07	(0.04)	−0.09	(0.05)	−0.07	(0.03)	0.02	(0.04)	0.05	(0.06)	0.06	(0.05)	0.04	(0.03)	1.6	7.6
Widowed	2.14	(0.06)	0.05	(0.07)	0.06	(0.06)	0.02	(0.07)	0.05	(0.04)	0.00	(0.04)	−0.03	(0.05)	−0.06	(0.03)	−0.02	(0.02)	0.8	2.8
Never married	22.69	(0.18)	0.01	(0.06)	−0.01	(0.05)	0.04	(0.07)	0.01	(0.03)	0.00	(0.04)	0.05	(0.05)	−0.05	(0.04)	0.00	(0.02)	0.5	0.1
Census region
Northeast	10.77	(0.13)	−0.09	(0.05)	−0.15^*	(0.04)	−0.20^*	(0.04)	−0.13^*	(0.03)	0.11	(0.04)	0.01	(0.05)	0.02	(0.04)	0.07	(0.03)	5.9^*	23.3^*
Midwest	17.67	(0.16)	−0.07	(0.06)	−0.03	(0.05)	0.00	(0.07)	−0.04	(0.03)	0.06	(0.04)	−0.03	(0.05)	0.00	(0.04)	0.02	(0.02)	1.1	2.4
South	50.64	(0.21)	0.12	(0.06)	0.07	(0.05)	0.14	(0.07)	0.11^*	(0.03)	−0.13^*	(0.04)	0.08	(0.05)	−0.01	(0.04)	−0.06	(0.02)	5.6^*	15.6^*
West	20.92	(0.17)	−0.01	(0.06)	0.05	(0.05)	−0.02	(0.07)	0.01	(0.03)	0.02	(0.04)	−0.07	(0.05)	0.00	(0.04)	0.00	(0.02)	0.5	0.1
Urbanicity
Major metro	85.87	(0.15)	0.13	(0.05)	−0.04	(0.05)	0.18^*	(0.05)	0.09	(0.03)	−0.15^*	(0.04)	0.01	(0.05)	0.10	(0.04)	−0.04	(0.03)	7.7^*	10.0^*
Urban	12.73	(0.14)	−0.14	(0.05)	0.06	(0.05)	−0.18^*	(0.05)	−0.08	(0.03)	0.15^*	(0.04)	−0.01	(0.05)	−0.10	(0.04)	0.04	(0.03)	8.0^*	9.8^*
Rural	1.40	(0.05)	0.01	(0.06)	−0.05	(0.04)	0.00	(0.07)	−0.01	(0.03)	0.02	(0.04)	0.01	(0.05)	−0.01	(0.04)	0.01	(0.03)	0.2	0.3
% of population below 1.5 of poverty line
1st quartile (low % with low income)	25.00	(0.18)	−0.08	(0.06)	−0.06	(0.05)	0.13	(0.07)	−0.03	(0.03)	0.04	(0.04)	−0.06	(0.05)	0.02	(0.04)	0.02	(0.02)	2.0	1.3
2nd quartile	25.00	(0.18)	−0.01	(0.06)	0.07	(0.05)	0.03	(0.07)	0.02	(0.03)	0.00	(0.04)	0.00	(0.05)	−0.05	(0.04)	−0.01	(0.02)	0.5	0.7
3rd quartile	25.00	(0.18)	0.00	(0.06)	0.04	(0.05)	−0.10	(0.06)	−0.01	(0.03)	−0.01	(0.04)	0.06	(0.05)	0.00	(0.04)	0.00	(0.02)	0.7	0.1
4th quartile (high % with low income)	25.00	(0.18)	0.09	(0.06)	−0.05	(0.05)	−0.06	(0.07)	0.01	(0.03)	−0.03	(0.04)	0.00	(0.05)	0.03	(0.04)	−0.01	(0.02)	1.2	0.2
History of previously diagnosed mental disorders
Depression	47.99	(0.21)	0.00	(0.06)	−0.09	(0.05)	−0.09	(0.07)	−0.05	(0.03)	0.02	(0.04)	0.03	(0.05)	0.03	(0.04)	0.03	(0.02)	1.0	3.3
Anxiety	28.27	(0.19)	−0.04	(0.06)	−0.19^*	(0.04)	0.00	(0.07)	−0.08	(0.03)	0.01	(0.04)	0.10	(0.05)	0.06	(0.04)	0.04	(0.03)	3.2	8.8^*
PTSD	24.28	(0.18)	−0.12	(0.05)	−0.24^*	(0.04)	−0.20^*	(0.06)	−0.18^*	(0.03)	0.07	(0.04)	0.09	(0.05)	0.13	(0.04)	0.09^*	(0.03)	9.3^*	43.0^*
Adjustment disorder	16.10	(0.16)	−0.05	(0.06)	−0.20^*	(0.04)	0.00	(0.07)	−0.09	(0.03)	0.05	(0.04)	0.03	(0.05)	0.06	(0.04)	0.05	(0.03)	3.4^*	11.0^*
Other reactions to stress	6.40	(0.10)	−0.04	(0.05)	−0.12	(0.04)	−0.05	(0.06)	−0.07	(0.03)	−0.01	(0.04)	0.09	(0.06)	0.08	(0.05)	0.04	(0.03)	2.2	6.3
Substance	17.62	(0.16)	−0.12	(0.05)	−0.17^*	(0.04)	−0.13	(0.06)	−0.14^*	(0.03)	0.03	(0.04)	0.00	(0.05)	0.18^*	(0.05)	0.07	(0.03)	7.0^*	25.8^*
Other disorders	18.84	(0.17)	−0.12	(0.05)	−0.21^*	(0.04)	−0.01	(0.07)	−0.13^*	(0.03)	0.04	(0.04)	0.07	(0.05)	0.11	(0.04)	0.07	(0.03)	5.8^*	22.6^*
Number of previously diagnosed mental disorders
0	30.29	(0.20)	0.07	(0.06)	0.28^*	(0.05)	0.11	(0.07)	0.15^*	(0.03)	−0.07	(0.04)	−0.09	(0.05)	−0.08	(0.04)	−0.08^*	(0.02)	7.6^*	29.9^*
1	22.00	(0.18)	0.09	(0.06)	0.03	(0.05)	−0.04	(0.07)	0.04	(0.03)	0.00	(0.04)	0.01	(0.05)	−0.09	(0.04)	−0.02	(0.02)	1.7	2.6
2	21.34	(0.17)	−0.06	(0.06)	−0.09	(0.04)	0.10	(0.07)	−0.04	(0.03)	0.02	(0.04)	0.02	(0.05)	0.02	(0.04)	0.02	(0.02)	1.3	1.8
3+	26.38	(0.19)	−0.12	(0.05)	−0.26^*	(0.04)	−0.17	(0.06)	−0.17^*	(0.03)	0.05	(0.04)	0.07	(0.05)	0.16^*	(0.04)	0.09^*	(0.03)	9.9^*	41.7^*
Current depression treatment
Primary	58.16	(0.21)	0.27^*	(0.05)	−0.38^*	(0.05)	0.07	(0.07)	0.02	(0.03)	−0.04	(0.04)	0.04	(0.05)	0.02	(0.04)	−0.01	(0.02)	15.6^*	0.3
Secondary with primary physical	16.96	(0.16)	−0.24^*	(0.04)	0.78^*	(0.06)	0.02	(0.07)	0.14^*	(0.04)	0.06	(0.04)	−0.22^*	(0.04)	−0.22^*	(0.03)	−0.07^*	(0.02)	53.9^*	28.1^*
Secondary with primary other mental	24.88	(0.18)	−0.09	(0.05)	−0.27^*	(0.04)	−0.11	(0.06)	−0.15^*	(0.03)	−0.01	(0.04)	0.16	(0.06)	0.18^*	(0.05)	0.08	(0.03)	10.3^*	31.8^*
Treatment location, setting, and type
Seen in community-based clinic	57.15	(0.21)	0.01	(0.06)	−0.02	(0.05)	−0.04	(0.07)	−0.01	(0.03)	0.13^*	(0.04)	−0.11	(0.05)	−0.14^*	(0.04)	0.00	(0.02)	5.7^*	0.1
Seen by primary care clinician	39.64	(0.21)	−0.35^*	(0.05)	0.78^*	(0.03)	0.35^*	(0.07)	0.16^*	(0.03)	−0.16^*	(0.04)	−0.05	(0.05)	0.03	(0.04)	−0.08^*	(0.02)	60.5^*	34.9^*
Received psychotherapy^{^‡}	89.29	(0.20)	0.34^*	(0.01)	−1.44^*	(0.08)	−0.21	(0.08)	−0.35^*	(0.04)	0.35^*	(0.00)	−0.03	(0.05)	0.02	(0.04)	0.18^*	(0.02)	217.4^*	179.1^*
Received medication	31.81	(0.13)	−0.72^*	(0.02)	1.03^*	(0.03)	0.74^*	(0.06)	0.15^*	(0.03)	−0.74^*	(0.01)	0.79^*	(0.05)	0.53^*	(0.04)	−0.08^*	(0.02)	656.1^*	31.8^*
Received PC-MHI treatment	35.95	(0.20)	1.25^*	(0.03)	−0.23^*	(0.04)	0.87^*	(0.06)	0.70^*	(0.03)	−0.36^*	(0.03)	−0.65^*	(0.02)	−0.19^*	(0.04)	−0.36^*	(0.02)	367.4^*	878.2^*

ADM, antidepressant medication; Est, standardized mean estimates; PC-MHI, primary care–mental health integration; PTSD, post-traumatic stress disorder; S.E., standard error.
↵* Significant at the 0.05 level, 2-sided test, adjusted for false discovery rate.
↵† Weighted to represent treatment distribution in population; estimates in the target column are in true metrics of the scales, whereas estimates in the other columns are based on standardized values of the row variables, with mean of 0 and variables of 1.0.
↵‡ Either saw a mental health specialist or referred to mental health treatment.

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Table 3.

Associations of Depression Severity with Setting and Type of Treatment (n = 2610)^{^†}

	Target		Primary Care								Specialty Mental Health								F₅	F₁
	Target		Psychotherapy^‡ (n = 290)		ADM (n = 439)		Combined (n = 219)		Total (n = 948)		Psychotherapy^‡ (n = 697)		ADM (n = 373)		Combined (n = 592)		Total (n = 1662)
	Est	(S.E.)	Est	(S.E.)	Est	(S.E.)	Est	(S.E.)	Est	(S.E.)	Est	(S.E.)	Est	(S.E.)	Est	(S.E.)	Est	(S.E.)
QIDS-SR	13.12	(0.08)	0.02	(0.06)	−0.18^*	(0.05)	−0.06	(0.07)	−0.06	(0.03)	−0.09	(0.04)	0.06	(0.05)	0.22^*	(0.04)	0.03	(0.02)	8.6^*	4.6
HRSD (%)
Mild	29.54	(0.89)	0.00	(0.06)	0.09	(0.05)	−0.01	(0.07)	0.02	(0.03)	0.08	(0.04)	−0.06	(0.05)	−0.14^*	(0.04)	−0.01	(0.02)	3.8^*	0.8
Moderate	33.80	(0.93)	0.03	(0.06)	0.10	(0.05)	0.03	(0.07)	0.05	(0.03)	−0.02	(0.04)	−0.02	(0.05)	−0.05	(0.04)	−0.03	(0.02)	1.0	3.7
Severe	20.81	(0.79)	−0.10	(0.05)	−0.09	(0.04)	−0.02	(0.07)	−0.08	(0.03)	0.00	(0.04)	0.10	(0.06)	0.06	(0.04)	0.04	(0.03)	2.3	8.3^*
Very severe	15.85	(0.71)	0.07	(0.06)	−0.14^*	(0.04)	0.00	(0.07)	−0.01	(0.03)	−0.08	(0.03)	−0.02	(0.05)	0.17^*	(0.05)	0.01	(0.02)	5.7^*	0.2
Years with depression (mean)	9.74	(0.22)	0.06	(0.07)	−0.07	(0.04)	−0.08	(0.06)	−0.01	(0.03)	0.06	(0.04)	−0.09	(0.05)	−0.03	(0.04)	0.01	(0.02)	2.1	0.2
Depression persistence (%)	50.93	(0.67)	−0.08	(0.06)	−0.12	(0.05)	0.04	(0.07)	−0.06^*	(0.03)	0.01	(0.04)	0.00	(0.05)	0.10	(0.04)	0.03	(0.02)	2.3	5.7
Depression factors
Depression severity	0.00	(0.02)	−0.07	(0.06)	−0.20^*	(0.05)	0.02	(0.07)	−0.09^*	(0.03)	−0.07	(0.04)	0.11	(0.05)	0.22^*	(0.04)	0.05	(0.02)	9.7^*	11.8^*
Positive mental health	0.00	(0.02)	0.11	(0.06)	0.18^*	(0.05)	0.04	(0.06)	0.12	(0.03)	0.04	(0.04)	−0.10	(0.05)	−0.21^*	(0.04)	−0.06	(0.02)	8.8^*	19.1^*
Anhedonia	0.00	(0.02)	−0.12	(0.06)	−0.09	(0.05)	0.04	(0.07)	−0.08	(0.03)	−0.03	(0.04)	0.07	(0.05)	0.14^*	(0.04)	0.04	(0.02)	4.2^*	7.8^*
Cognitive difficulties	0.00	(0.02)	−0.05	(0.06)	−0.16	(0.05)	−0.02	(0.07)	−0.08	(0.03)	−0.03	(0.04)	0.07	(0.05)	0.14	(0.04)	0.04	(0.02)	4.1^*	8.6^*
Rumination	0.00	(0.02)	−0.06	(0.05)	−0.13	(0.05)	−0.09	(0.07)	−0.09	(0.03)	0.00	(0.04)	0.03	(0.05)	0.14	(0.04)	0.05	(0.02)	3.6^*	10.5^*
Dissociation	0.00	(0.02)	−0.08	(0.06)	−0.13	(0.05)	0.02	(0.07)	−0.07	(0.03)	−0.02	(0.04)	0.06	(0.05)	0.13	(0.04)	0.04	(0.02)	3.4^*	7.7^*
Mixed episodes	0.00	(0.02)	−0.01	(0.06)	−0.12	(0.05)	0.14	(0.07)	−0.02	(0.03)	0.00	(0.04)	0.01	(0.05)	0.01	(0.04)	0.01	(0.02)	1.7	0.4

ADM, antidepressant medication; Est, standardized mean estimates; HRSD, Hamilton Rating Scale for Depression; S.E., standard error.; QIDS-SR, Quick Inventory of Depressive Symptomatology Self-Report Scale.
↵* Significant at the 0.05 level, 2-sided test, adjusted for false discovery rate.
↵† Weighted to represent treatment distribution in population; Estimates in the target column are in true metrics of the scales, whereas estimates in the other columns are based on standardized values of the row variables, with mean of 0 and variables of 1.0.
↵‡ Either saw a mental health specialist or referred to mental health treatment.

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Table 4.

Associations of Comorbidity with Setting and Type of Treatment (n = 2610)^{^†}

	Target		Primary Care								Specialty Mental Health								F₅	F₁
	Target		Psychotherapy^a (n = 290)		ADM (n = 439)		Combined (n = 219)		Total (n = 948)		Psychotherapy^a (n = 697)		ADM (n = 373)		Combined (n = 592)		Total (n = 1662)
	Est	(S.E.)	Est	(S.E.)	Est	(S.E.)	Est	(S.E.)	Est	(S.E.)	Est	(S.E.)	Est	(S.E.)	Est	(S.E.)	Est	(S.E.)
Presenting problems (weighted count^{^‡})
PTSD	1.86	(0.02)	−0.10	(0.06)	−0.25^*	(0.05)	−0.11	(0.07)	−0.15^*	(0.03)	0.01	(0.04)	0.15	(0.05)	0.15^*	(0.04)	0.08^*	(0.02)	8.6^*	30.7^*
Other anxiety disorders^{^§}	4.21	(0.04)	−0.13^*	(0.06)	−0.07	(0.05)	−0.05	(0.07)	−0.09	(0.03)	−0.05	(0.04)	0.17^*	(0.05)	0.15^*	(0.04)	0.05	(0.02)	6.4^*	11.7^*
Substance Use Disorder	0.36	(0.02)	−0.04	(0.06)	−0.12	(0.04)	−0.16	(0.05)	−0.09^*	(0.03)	0.00	(0.04)	0.05	(0.05)	0.14^*	(0.05)	0.05	(0.03)	4.1^*	11.7^*
Anger	1.12	(0.02)	0.02	(0.06)	−0.18^*	(0.05)	−0.08	(0.07)	−0.06	(0.03)	0.06	(0.04)	0.03	(0.05)	0.00	(0.04)	0.03	(0.02)	2.7	5.6
Other emotional problems	0.52	(0.02)	0.01	(0.06)	−0.06	(0.05)	−0.18	(0.06)	−0.05	(0.03)	0.02	(0.04)	0.01	(0.05)	0.04	(0.04)	0.03	(0.02)	1.6	3.6
SSD	0.00	(0.02)	0.03	(0.06)	−0.03	(0.05)	0.08	(0.07)	0.02	(0.03)	−0.07	(0.04)	−0.01	(0.05)	0.08^*	(0.04)	−0.01	(0.02)	1.9	0.6
Number of comorbid disorders^{^¶}
0	22.76	(0.82)	0.03	(0.06)	0.24^*	(0.05)	0.23	(0.08)	0.14^*	(0.04)	−0.02	(0.04)	−0.13	(0.05)	−0.14^*	(0.04)	−0.07^*	(0.02)	8.7^*	28.0^*
1	32.17	(0.91)	0.06	(0.06)	−0.07	(0.05)	−0.06	(0.07)	−0.01	(0.03)	0.05	(0.04)	−0.03	(0.05)	−0.05	(0.04)	0.00^*	(0.02)	1.5	0.1
2	24.38	(0.84)	−0.01	(0.06)	−0.11	(0.04)	−0.09	(0.06)	−0.06	(0.03)	0.00	(0.04)	0.08	(0.05)	0.06	(0.04)	0.03	(0.02)	1.8	5.1
3+	20.69	(0.79)	−0.09	(0.05)	−0.05	(0.05)	−0.07	(0.06)	−0.07	(0.03)	−0.03	(0.04)	0.09	(0.05)	0.13	(0.04)	0.04	(0.03)	3.5^*	7.5^*
EMR mental disorders during recruitment
Anxiety disorder	26.79	(0.87)	0.02	(0.06)	−0.05	(0.05)	0.07	(0.07)	0.01	(0.03)	−0.13^*	(0.03)	0.11	(0.05)	0.14^*	(0.04)	0.00	(0.02)	6.3^*	0.1
PTSD	20.12	(0.78)	−0.16^*	(0.05)	−0.12	(0.04)	−0.06	(0.06)	−0.13^*	(0.03)	−0.03	(0.04)	0.15	(0.06)	0.18^*	(0.05)	0.07	(0.03)	8.0^*	22.1^*
Adjustment disorder	4.47	(0.40)	−0.06	(0.05)	−0.10	(0.04)	0.18	(0.09)	−0.02	(0.03)	−0.04	(0.03)	−0.02	(0.05)	0.11^*	(0.05)	0.01	(0.03)	3.6^*	0.5
Other reactions to stress	4.12	(0.39)	0.08	(0.07)	−0.14^*	(0.03)	−0.02	(0.07)	−0.01	(0.03)	0.01	(0.04)	−0.04	(0.05)	0.04	(0.04)	0.01	(0.02)	1.9	0.2
Substance Use Disorder	9.89	(0.58)	−0.12	(0.05)	−0.18^*	(0.03)	−0.19^*	(0.05)	−0.15^*	(0.02)	0.00	(0.04)	0.09	(0.06)	0.21	(0.05)	0.08	(0.03)	9.4^*	32.0^*
Other mental disorders	6.28	(0.48)	−0.07	(0.05)	−0.05	(0.04)	0.07	(0.08)	−0.04	(0.03)	−0.06	(0.03)	0.19	(0.07)	0.06	(0.05)	0.02	(0.03)	4.1^*	1.7
Number of comorbid EMR disorders
0	45.66	(0.98)	0.14	(0.06)	0.27^*	(0.05)	−0.04	(0.07)	0.14^*	(0.03)	0.11	(0.04)	−0.22^*	(0.05)	−0.31^*	(0.04)	−0.07	(0.02)	21.5^*	28.0^*
1	39.28	(0.96)	−0.07	(0.06)	−0.19^*	(0.04)	0.05	(0.07)	−0.09	(0.03)	−0.05	(0.04)	0.13	(0.05)	0.15^*	(0.04)	0.04	(0.02)	6.5^*	10.0^*
2+	15.06	(0.70)	−0.09	(0.05)	−0.11	(0.04)	−0.01	(0.07)	−0.08	(0.03)	−0.09	(0.03)	0.13	(0.06)	0.22^*	(0.05)	0.04	(0.03)	9.1^*	9.2^*

ADM, antidepressant medication; EMR, electronic medical record; Est, standardized mean estimates; PTSD, post-traumatic stress disorder; S.E., standard error; SSD, somatic symptom disorder.
↵* Significant at a 0.05 level, 2-sided test, adjusted for false discovery rate.
↵† Weighted to represent treatment distribution in population; estimates in the target column are in true metrics of the scales, whereas estimates in the other columns are based on standardized values of the row variables, with mean of 0 and variables of 1.0.
↵‡ Presenting problems are scored 3 for any primary problem, 2 for secondary and not primary problem, 1 for screening positive and not a primary or secondary problem, and 0 for none.
↵§ Anxiety disorder scores range from 0 to 9 and include GAD, panic/phobias, and OCD.
‖ Number of comorbid disorders was scored in the range 0-1 as the sum of: (1) PTSD as either a primary or secondary presenting problem or a score in the clinical range of a PTSD Checklist for DSM-5 (PCL-5) screening scale calibrated to the full PCL-5; (2) the quartile of the sample with the highest score of presenting problems for a range of other anxiety disorders as either primary (2 points) or secondary (1) point; (3) substance use disorder as either a primary or secondary presenting problem or a score in the clinical range on the PROMIS Alcohol/Substance Use Short Form-7a scale; (4) anger as either a primary or secondary presenting problem; (5) other emotional disorder as either a primary or secondary presenting problem; and (6) a score in the clinical range for a study-specific screening scale for DSM-5 somatic symptom disorder.
↵¶ Either saw a mental health specialist or referred to mental health treatment.

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Appendix 1.

ICD-9-CM1 and ICD-10-CM2 Mental and Behavioral Health Codes

Disorder	Codes
Major depression	ICD-9-CM codes: 296.2X, 296.3X, 300.4, 311
	ICD-10-CM codes: F32.XX (excluding F32.81 and F32.89), F33.XX
Suicide attempt	ICD-9-CM codes: E950.X, E951.X, E952.X, E953.X, E954, E955.X, E956, E957.X
	ICD-10-CM codes: T14.91, T36.XX2, T37.XX2, T38.XX2, T39.XX2, T40.XX2, T41.XX2, T42.XX2, T43.XX2, T44.XX2, T45.XX, T46.XX2, T47.XX2, T48.XX2, T49.XX2, T50.XX2, T51.XX2, T52.XX2, T53.XX2, T54.XX2, T55.XX2, T56.XX2, T57.XX2, T58.XX2, T59.XX2, T60.XX2, T61.XX2, T62.XX2, T63.XX2, T64.XX2, T65.XX2, T71.1 × 2, T71.2 × 2
Bipolar disorder	ICD-9-CM codes: 296.0X, 296.1X, 296.4X, 296.5X, 296.6X, 296.7, 296.80, 296.81, 296.89, 301.13
	ICD-10-CM codes: F30.X, F31.X, F34.0
Nonaffective psychosis	ICD-9-CM codes: 293.81, 293.82, 293.89, 295.XX, 297.X, 298.X, 301.22
	ICD-10-CM codes: F06.0, F06.1, F20.XX, F21, F22, F23, F24, F25.X, F28, F29, F53
Dementia	ICD-9-CM codes: 290.XX, 294.1X, 294.8
	ICD-10-CM codes: F01.XX, F01.XX, F03.XX
Intellectual disabilities	ICD-9-CM codes: 317, 318, 319
	ICD-10-CM codes: F70, F71, F72, F73, F78, F79
Autism	ICD-9-CM code: 299.XX
	ICD-10-CM code: F84.0
Tourette's disorder	ICD-9-CM code: 307.23
	ICD-10-CM code: F95.2
Stereotyped movement disorders	ICD-9-CM code: 307.3
	ICD-10-CM code: F98.4
Borderline intellectual functioning	ICD-10-CM code: R41.83

ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification¹; ICD-10-CM, International Classification of Diseases, Tenth Revision, Clinical Modification.²

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Appendix 3.

Brief Description of Machine Learning Algorithms Included in the SuperLearner Library

Algorithm	R Package	Description
Regularization²²	glmnet	Penalized regression reduces overfit due to collinear independent variables
Elastic net		Ridge regression shrinks coefficients for collinear independent variables toward zero but does not fully eliminate any independent variable Elastic net regression allows various penalties where coefficients for collinear independent variables are shrunk toward zero (but not to eliminating contributions to the predicted probability) and/or to zero (eliminating their contributions to the predicted probability) Mixing parameter penalty (alpha) is set somewhere between 0.01 and .99 Lasso regression shrinks coefficients for collinear covariate coefficients to zero, eliminating their contributions to the predicted probability
Spline
Adaptive splines²³	earth	Adaptive spline regression flexibly captures interactions and linear and nonlinear associations
Adaptive polynomial splines²⁴		Linear segments (splines) of varying slopes are connected and smoothed to create piecewise curves (basis functions)
	polspline	Final fit is built using a stepwise procedure that selects the optimal combination of basis functions Earth and polymars are generally similar but differ in the order that basis functions (eg, linear vs nonlinear) are added to build the final model
Decision trees
Random forest²⁵	ranger	Decision tree methods capture interactions and nonlinear associations Independent variables are partitioned (based on values) and stacked to build decision trees and assemble an aggregate “forest” Random forest builds numerous trees in bootstrapped samples and generates an aggregate tree by averaging across trees (reducing overfit) Suitable for large data sets but may be unstable and overfitting
Gradient boosting^26,27	xgboost	Extreme gradient boosting decision tree algorithm. Final predictions are formulated by models sequentially built (using gradient descent algorithm to minimize loss) to resolve residual error made by existing models
Neural networks²⁸	nnet	Connections between predictors and the outcome are modeled as a network Predictors affect the outcome through intermediate layers Weights are assigned to connections Capture interactions and nonlinear associations Low interpretability

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Appendix 5.

Factor Analysis (n = 2,169)^{^†}

	Seven-Factor Solution
	I	II	III	IV	V	VI	VII
I. Depression severity
Sad	0.59	-0.23	-0.01	-0.13	0.02	0.06	-0.18
So sad nothing could cheer up	0.62	-0.17	-0.07	-0.10	0.01	0.13	-0.16
Not feeling much better when good things happen	0.54	-0.14	-0.15	-0.10	-0.02	0.18	-0.10
Emotionally numb, empty, unable to feel	0.50	-0.08	-0.19	-0.07	-0.05	0.24	-0.05
Excessively guilty or self-blaming	0.40	-0.27	0.09	-0.10	0.18	0.09	-0.01
Helpless	0.45	-0.40	0.13	-0.10	0.02	0.13	-0.08
Irritable	0.75	0.03	-0.11	0.03	-0.10	-0.15	0.13
Extremely irritable	0.74	0.04	-0.12	0.05	-0.10	-0.09	0.19
Worried and anxious	0.75	-0.06	0.09	0.08	0.05	-0.09	-0.07
Difficulty concentrating because of worry	0.68	-0.02	0.05	0.26	0.06	-0.07	0.00
Keyed up or tense	0.80	0.08	0.00	0.12	0.01	-0.09	0.03
Unusually restless	0.78	0.12	-0.01	0.09	-0.02	-0.07	0.13
Might lose control	0.54	-0.11	0.06	0.06	-0.03	0.12	0.18
Fearing something awful	0.50	-0.17	0.09	0.02	0.07	0.09	0.08
II. Positive mental health
Less worthwhile than other people	0.39	-0.45	0.07	-0.14	0.10	0.08	-0.04
Coped well with normal stresses	-0.07	0.51	-0.02	-0.28	0.02	0.11	0.00
Able to bounce back from stressful situations	-0.05	0.54	-0.02	-0.26	0.03	0.11	0.03
Can keep from feeling depressed	-0.13	0.59	0.05	-0.07	0.06	0.09	0.06
Satisfied with life	0.05	0.83	0.05	0.09	0.05	-0.06	0.03
Felt life was fulfilling	0.09	0.84	0.07	0.12	0.05	-0.05	0.01
Engaged with life rather than hiding from it	0.07	0.72	0.10	-0.07	0.07	-0.06	-0.02
Felt mentally healthy	-0.17	0.54	0.01	-0.23	0.01	0.08	0.11
Felt in control of emotions	-0.17	0.57	-0.05	-0.21	0.06	0.08	-0.06
Had a general sense of well-being	-0.08	0.74	0.00	-0.09	0.08	0.01	0.07
Had a positive outlook on life	0.03	0.85	0.07	0.04	0.07	0.00	0.06
Had the desire to do things	0.00	0.55	0.22	-0.13	0.07	0.01	0.06
Felt confident	-0.04	0.69	0.02	-0.16	0.02	0.04	0.14
Great faith in the future	0.10	0.84	0.08	0.09	0.08	-0.03	0.07
Expect to succeed	0.09	0.81	0.03	-0.01	0.09	0.01	0.09
Future seemed dark	0.09	-0.58	0.03	-0.13	0.04	0.13	0.01
Felt you don't get the breaks	0.04	-0.58	0.03	-0.10	0.03	0.12	0.22
Equally worthwhile/deserving as other people	-0.01	0.49	-0.03	-0.00	-0.15	-0.04	-0.02
Ask “What could I have done to deserve this?”	0.01	-0.41	0.06	-0.03	0.36	-0.01	0.28
III. Anhedonia: unable to experience pleasure when…
having favorite food or drinks	-0.03	0.03	0.74	-0.01	-0.06	0.03	-0.04
spending leisure time with friends	-0.07	0.07	0.78	0.02	-0.03	0.02	-0.06
doing favorite hobbies or pastimes	-0.04	0.05	0.78	-0.03	-0.06	0.05	-0.01
spending quality time with close loved ones	0.01	0.10	0.77	0.03	-0.07	-0.02	-0.01
having big success at work, school, or in finances	0.06	0.06	0.72	-0.08	-0.04	-0.03	-0.02
IV. Cognitive difficulties
Problems with concentration/decision-making	0.15	-0.03	0.03	0.61	0.03	0.03	-0.07
Feeling slowed down	0.01	0.09	0.01	0.62	0.00	0.24	-0.04
Low energy level	0.10	-0.02	-0.05	0.49	0.05	0.07	-0.09
Mind as sharp as usual	-0.01	0.10	0.13	-0.67	0.07	-0.04	0.02
Memory much worse than usual	0.06	0.00	0.05	0.59	0.02	0.11	-0.05
Thinking as fast as usual	0.14	0.10	0.16	-0.66	0.01	-0.03	0.03
Not able to keep track of activities	0.08	0.07	0.06	0.56	0.00	0.08	0.04
V. Rumination
Analyze recent events to understand why depressed	0.02	0.15	-0.05	-0.02	0.80	-0.02	-0.13
Think about why depressed	0.06	0.06	-0.12	-0.04	0.69	0.07	-0.06
Write down your thoughts and analyze them	-0.01	0.27	-0.03	0.05	0.55	0.11	-0.20
Analyze personality to understand why depressed	-0.04	0.19	-0.10	-0.03	0.83	0.01	-0.14
Ask “Why do I always react this way?”	0.00	-0.24	0.01	0.10	0.56	-0.09	0.26
VI. Dissociation
Feeling not real or cut off from the world	0.09	-0.17	-0.05	0.00	0.06	0.64	0.08
Feeling outside of body, watching yourself	-0.01	-0.02	0.05	0.14	0.01	0.80	0.07
Feeling like surroundings detached or unreal	0.00	0.00	0.00	0.18	0.00	0.82	0.06
Feeling surroundings dreamlike, distant, or distorted	-0.02	0.01	0.02	0.19	0.00	0.82	0.08
VII. Mixed episodes
Much better mood, happier, excitable than usual	-0.11	0.15	0.03	-0.06	-0.02	0.04	0.66
Extremely self-confident or optimistic, could do anything	-0.01	0.32	-0.07	-0.11	-0.02	0.05	0.62
Mood changed rapidly: very happy, very sad, very angry	0.29	-0.02	-0.07	0.00	-0.13	0.05	0.60
More talkative than usual	0.01	0.05	0.02	0.00	-0.11	0.10	0.70
Thoughts raced through mind so fast hardly kept track	0.30	0.04	-0.02	0.13	0.00	0.11	0.45
Much more engaged, busy, productive than usual	0.10	0.21	-0.06	-0.13	-0.02	-0.01	0.66

↵† Principal axis factor analysis. The parallel analysis simulation method was used to determine the number of factors to extract.²⁹ Promax rotation was used to improve interpretability.

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Appendix 6.

Correlations Among Factors in Promax Rotated Factor Solution

	Factors
	I	II	III	IV	V	VI	VII
Depression severity	1.00
Positive mental health	-0.53	1.00
Anhedonia	-0.24	0.40	1.00
Cognitive difficulties	0.44	-0.40	-0.28	1.00
Rumination	0.33	-0.17	0.10	0.15	1.00
Dissociation	0.42	-0.23	-0.16	0.16	0.24	1.00
Mixed episodes	0.17	0.16	0.21	0.09	0.27	0.16	1.00

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Appendix 7.

AUC of 10-fold Externally Cross-Validated SuperLearner Models^{^†}

	AUC (95% CI)
I. Primary care
Primary care versus specialty mental health	0.645 (0.623, 0.668)
Psychotherapy versus total sample	0.550 (0.520, 0.580)
Medication versus total sample	0.684 (0.649, 0.718)
Combined versus total sample	0.530 (0.487, 0.572)
Any primary care versus total sample	0.574 (0.552, 0.595)
III. Specialty mental health
Psychotherapy versus total sample	0.534 (0.511, 0.556)
Medication versus total sample	0.572 (0.539, 0.604)
Combined versus total sample	0.602 (0.576, 0.627)
Any specialty mental health versus total sample	0.500 (0.483, 0.518)

AUC, area under the ROC curve; 95% CI, 95% confidence interval.
↵† See Appendix 3 for the list of classifiers.

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Appendix 8.

Comparison of Primary Problems and Diagnoses between Analytic Sample and Those Who Did Not Report Depression as a Problem

	Analytic Sample (n = 2610)		No Self-Reported Depression (n = 471)
	%	(S.E.)	%	(S.E.)
Primary presenting problems
Depression	71.79	(0.88)	0.00	—
Anxiety disorder	49.69	(0.98)	22.17	(1.89)
PTSD	42.45	(0.97)	20.52	(1.84)
Substance use disorder	4.81	(0.42)	2.42	(0.70)
Anger	15.48	(0.71)	7.13	(1.17)
Other emotional problems	11.38	(0.62)	10.45	(1.39)
Primary EMR diagnosis
Depression	60.11	(0.96)	58.40	(2.24)
Anxiety disorder	8.79	(0.55)	9.70	(1.35)
PTSD	11.94	(0.63)	13.83	(1.57)
Adjustment disorder	2.71	(0.32)	1.97	(0.63)
Other reactions to stress	1.96	(0.27)	0.64	(0.36)
Substance use disorder	1.97	(0.27)	4.70	(0.96)
Other mental disorders	2.12	(0.28)	3.51	(0.84)