Impact of rural address and distance from clinic on depression outcomes within a primary care medical home practice

Background: Depression is the second leading cause of death among young adults and a major cause of disability worldwide. Some studies suggest a disparity between rural and urban outcomes for depression. Collaborative Care Management (CCM) is effective in improving recovery from depression, but its effect within rural and urban populations has not been studied.

Methods: A retrospective cohort study of 3870 patients diagnosed with depression in a multi-site primary care practice that provided optional, free CCM was conducted. US Census data classified patients as living in an Urban Area, Urban Cluster, or Rural area and the distance they resided from their primary care clinic was calculated. Baseline demographics, clinical data, and standardized psychiatric assessments were collected. Six month Patient Health Questionnaire (PHQ 9) scores were used to judge remission (PHQ9 < 5) or Persistent Depressive Symptoms (PDS) (PHQ9 ≥ 10) in a multivariate model with interaction terms.

Results: Rural patients had improved adjusted odds of remission (AOR = 2.8) and PDS (AOR = 0.36) compared to urban area patients. The natural logarithm transformed distance to primary care clinic was significant for rural patients resulting in a lower odds of remission and increased odds of PDS with increasing distance from clinic. The marginal probability of remission or PDS for rural patients equaled that of urban area patients at a distance of 34 or 40 km respectively. Distance did not have an effect for urban cluster or urban area patients nor did distance interact with CCM.

Conclusion: Residing in a rural area had a beneficial effect on the recovery from depression. However this effect declined with increasing distance from the primary care clinic perhaps related to greater social isolation or difficulty accessing care. This distance effect was not seen for urban area or urban cluster patients. CCM was universally beneficial and did not interact with distance.