Treatment Selection for Major Depressive Disorder in Veterans Health Administration Outpatients.

IMPORTANCE: Examination of major depressive disorder (MDD) treatment selection within a large health system allows for evaluation of adherence to guidelines and identification of trends affecting clinical care. OBJECTIVE: To characterize treatment selection patterns among those receiving Veterans Health Administration (VHA) outpatient care for MDD between fiscal year 2011 (FY11) and FY25. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used VHA health records of veterans who received outpatient care for MDD. Outpatient procedure codes and prescription records were used to characterize annual proportions that received different forms of treatment. Veterans younger than 18 years or older than 109 years or who had a documented history of bipolar or schizophrenia spectrum illnesses were excluded. MAIN OUTCOMES AND MEASURES: The proportions of veterans receiving treatment with psychotherapy, specific medications, and medications by class were quantified annually. Psychotherapy engagement was defined based on at least 1 session within a given FY. Veterans were classified as having received a medication based on the presence of at least 1 prescription record within a given FY (excluding prescriptions of fewer than 7 days' duration). RESULTS: A total of 1 583 834 veterans (mean [SD] age, 51.4 [16.6] years; 1 319 301 [83.4%] male; 23 287 [1.5%] Asian, 341 846 [21.6%] Black or African American, and 1 065 904 [67.3%] White) received outpatient treatment between FY11 and FY25. Over time, decreasing proportions received psychotherapy (131 614 of 182 208 [72.2%] to 413 129 of 661 576 [62.4%]), antidepressants (ADs) (156 307 [85.8%] to 512 227 [77.4%]), and combination therapy (ie, psychotherapy with AD: 117 936 [64.7%] to 331 190 [50.1%]), while increasing proportions received psychotherapy without AD (13 678 [7.5%] to 81 939 [12.4%]), AD without psychotherapy (38 371 [21.1%] to 181 037 [27.4%]), and neither psychotherapy nor AD (12 223 [6.7%] to 67 410 [10.2%]). There was decreasing use of selective serotonin reuptake inhibitors (SSRIs) (58.1% to 43.8%) and benzodiazepines (24.7% to 5.4%) and increasing use of serotonin-norepinephrine reuptake inhibitors (SNRIs) (15.6% to 22.3%). Demographic differences in treatment and medication-specific trends were also observed. CONCLUSIONS AND RELEVANCE: In this cohort study of 1 582 834 veterans with MDD, most received recommended treatment, but there was an increasing trend in the proportion who did not (up to 10.2% in 2025). The findings require further investigation into potential undertreatment of VHA outpatients with MDD and underscore the need to examine mental health service availability and other factors that influence treatment selection decisions.