Does treating maternal depression improve child health management? The case of pediatric asthma

https://doi.org/10.1016/j.jhealeco.2007.03.005Get rights and content

Abstract

Past studies have demonstrated an association between maternal depression and poor management of pediatric asthma. Using an instrumental variables strategy to address the endogeneity of depression treatment, I build on this literature to answer the question of whether treating maternal depression leads to an improvement in pediatric asthma management. I show that treatment of mother's depression improves management of child's asthma, resulting in a reduction in asthma costs in the 6-month period following diagnosis of $798 per asthmatic child whose mother is treated for depression.

Introduction

Asthma is the most common chronic disorder in children in the U.S., affecting 9 million children under the age of 18 (Dey and Bloom, 2005). The estimated cost for treating asthma in children is $3.2 billion annually (CDC, 2005). In addition, some of the most costly asthma-related health care expenditures – emergency department use and hospitalizations – can be avoided if the condition is properly controlled, suggesting potentially large cost savings can be realized if management is improved.1 Recent reports from the NIH (2002) and RAND (2001) summarize the recommendations of expert panels for improving asthma outcomes; both stress the role of the child's family in asthma management, and therefore in asthma outcomes. Because a child's caretaker is called upon to carry out the day-to-day elements of an asthma treatment plan, avoiding unnecessary hospitalizations and emergency department visits depends critically on the caretaker's ability to follow the prescribed asthma management plan.

A key determinant of a mother's ability to care for her asthmatic child is her own mental health, specifically whether she is experiencing depression. There are two main reasons to expect a causal relationship between maternal depression and management of pediatric asthma. First, the caretaker is responsible for helping the child adhere to prescribed medical regimens. Previous evidence suggests that depressed individuals have much lower rates of adherence to their own medical treatment regimes (DiMatteo et al., 2000). A complementary strand of literature has found a negative association between maternal depression and adherence to a pediatric asthma regime (Barlett et al., 2004).

Coupled with the fact that lower rates of compliance to an asthma treatment regime have been shown to be associated with higher asthma morbidity (e.g., Bauman et al., 2002, Lieu et al., 1997), these findings suggest that a caretaker's depression can exacerbate a child's asthma morbidity through noncompliance with a prescribed treatment regime. This also suggests that gains in efficiency of health care delivery could be realized if depression is treated.

The second reason we might expect maternal depression to affect child asthma management is that depressed caretakers may be more likely to overreact to a given set of asthma symptoms, rushing to the emergency department when the episode could be managed at home. One study (Barlett et al., 2004) found that mothers with high levels of depressive symptoms were more likely to report “feeling unable to address acute asthma episodes at home.” Another (Bartlett et al., 2001) showed that even after adjusting for asthma morbidity and other factors, mothers with depressive symptoms were 30% more likely to have taken their child to the emergency room than mothers not showing depressive symptoms. Correcting the misperception of the severity of symptoms by treating maternal depression could also lead to a reduction in unnecessary utilization of health care.

Previous studies have used cross-sectional data to compare the asthma outcomes for children of depressed women with those of children of women who are not depressed. In this paper, I use a pre–post empirical design to look at the asthma health care utilization for the same children before and after their mothers are treated for depression. These children are compared to asthmatic children whose mothers are not treated for depression during the same time period. Knowing the effect of depression treatment is important both because it is a variable that can be affected by policy and because there could be other variables (e.g., distance to health care provider, number of children in the household, family structure) causing both depression and poor asthma management that would not change with depression treatment. If these other components are the cause of the correlation that past literature has found between depression and asthma outcomes, a policy that offers depression treatment for mothers would not be expected to improve their children's asthma outcomes.

In the context of my empirical design, it is important to address the potential endogeneity of who is treated for depression. In particular, the likelihood that depressive symptoms will be recognized increases with the amount of contact that a person has with health care professionals (Bertakis et al., 2001). Children whose asthma is not responding to treatment are likely to have more doctor visits, thereby causing their mothers to have more contact with health professionals and increasing the chances that depressive symptoms, if present, will be recognized. Because these children are also less likely to respond to proper asthma management, a direct estimate of the effect of treatment of depression on asthma outcomes could show a spurious positive correlation.

To address this problem, I use an instrumental variables strategy that exploits exogenous variation in the propensity of primary care physicians (PCPs) to treat depression. Past research has found that certain characteristics of a physician, both observable and not observable to the researcher, can predict the physician's propensity to recognize and treat medical conditions generally, and depression specifically, even controlling for the prevalence of those conditions in their patient populations (e.g., Motjabai, 2002, McKinlay et al., 2002, Robbins et al., 1994). I use these physician differences in propensity to diagnose and treat depression to predict whether mothers of asthmatic children are treated for depression.

Applying this empirical design to Florida Medicaid claims data, I find evidence that asthma management improves in the 6-month period following initiation of treatment of mother's depression, resulting in a reduction in asthma spending in the 6 months following the start of mother's depression treatment of $798 dollars per asthmatic child whose mother is treated for depression.

Section snippets

Conceptual model

The relationships between maternal depression and child's asthma health care utilization can be thought of in the following five equation system:HCUt=f(HCUt1AMt,V),AMt=g(AMt1,DEPt,W),DEPt=h(Tt,X),Tt=j(PROP,Q),PROP=k(Y,Z),where HCU is the asthma health care utilization, AM the asthma morbidity, DEP the mother's depression status, V the other factors affecting HCU, including insurance coverage, W the other factors affecting asthma morbidity including age, sex, genetics, race,

Empirical strategy

My empirical strategy is drawn from the relationships described in Eqs. (1), (2), (3), (4), (5) above. To determine whether depression treatment has an effect on asthma management, I estimate a model of the following form:Yc=α+βTreatm+γX+εThe dependent variables are measures of healthcare utilization or costs for child c incurred in the period after mother's depression treatment began. This is a count of inpatient, outpatient, emergency room, or total visits, or inpatient, outpatient,

Data

The data used in this analysis are Florida Medicaid claims data and eligibility files from July, 1994, through June, 2001. Children insured by Medicaid are more likely to have asthma than those in the non-Medicaid population, and rates of latent depression and untreated depression are higher for women in this population than for similar aged women in the non-Medicaid population (Olfson et al., 2000, Adelmann, 2003). False positive diagnoses are rare in this population (Robbins et al., 1994), so

Results

Estimates from Ordinary Least Squares (OLS) regressions do not show a statistically significant effect of treatment of maternal depression on child's asthma-related health care utilization.12 As discussed previously, these results may be tainted because mothers of children whose asthma is not likely to respond to standard asthma treatment may be the most likely to be treated for depression conditional on symptoms.

The central results of the paper are those using an

Conclusion

This paper has shown significant improvements in the management of pediatric asthma when maternal depression is treated. It is important for these findings to be replicated in a study that can measure underlying asthma morbidity, as the main inferences of this paper are based on an assumption that is not testable using claims data. If they are correct, the findings imply that, particularly in populations that are at high risk for maternal depression (such as Medicaid populations), increased

Acknowledgements

I am grateful to Christina Fu for assistance with Florida Medicaid claims data, and to David Autor, Alisa Busch, Richard Frank, Jon Gruber, Tom McGuire, Robin McKnight, Mike Steinberger, Kathy Swartz, Steve Zuckerman, participants in the R.W.J. Seminar and Annual Meeting, MIT Labor Lunch, BU/Harvard/MIT Health Economics Seminar, and two anonymous referees for helpful comments and suggestions. This work was completed while the author was a Robert Wood Johnson Health Policy Scholar at Harvard

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