Do Gender Minority Medicare Beneficiaries with Depression Receive Adequate Mental Health Care?

Background: Only approximately 1 in 5 people receive adequate mental health treatment, with documented disparities by race/ethnicity, income, insurance, and other sociodemographic factors. Gender minority individuals (transgender and gender non-binary people) have higher rates of depression diagnoses than the general population. However documenting depression care for gender minorities is difficult because gender identity is not routinely collected in administrative data.

Objective: This analysis compares adequate mental health care among Medicare beneficiaries with diagnosed depression by gender identity status (gender minorities vs. other beneficiaries) and reason for Medicare eligibility (age vs. disability).

Study Design: We fit logistic regression models for adequate mental health care, clustered at the beneficiary level, adjusted for age, and number of mental and chronic physical health conditions. We defined adequate mental health care as a binary indicator of 8 outpatient mental health visits or 4 outpatient visits plus a psychotropic medication. We reported covariate-adjusted marginal means of adequate mental health care in gender minority and non-gender-minority beneficiaries, stratified by original eligibility reason (disabled vs. aged).

Population Studied: We identified gender minority beneficiaries using a diagnosis-code-based algorithm developed by the Centers for Medicare and Medicaid Services. We compared these to a random 5% random sample of beneficiaries with at least 1 claim in each year identified who were not identified as gender minority. We included only beneficiaries with a depression chronic condition flag from 2009-2014 who were continuously enrolled in Parts A and B (and never Part C) in each year. We excluded beneficiaries with End-Stage Renal Disease.

Principal Findings: Among beneficiaries originally qualifying due to age, adjusted margins for adequate care were higher for gender minorities (17%) than others (7%; p<0.0001). Among beneficiaries originally qualifying due to disability, adjusted margins for were also higher for gender minorities (39%) than others (25%; p<0.0001). Each additional year of age was associated with a 0.03-0.07 reduction in odds of adequate care. Each additional mental health condition was associated with a 0.33-0.36 increased odds of adequate care. Each physical health condition was associated with a 0.06-0.09 reduced odds of adequate care.

Conclusions: Gender minority Medicare beneficiaries identified via treatment for medical transitions and gender dysphoria and with a diagnosis of depression are more likely to receive adequate mental health treatment than other Medicare beneficiaries with depression diagnoses. One reason for observing this pattern may be that mental health evaluations are required prior to receiving transition-related hormones or surgery. The adjusted proportion of beneficiaries receiving adequate mental health care is low overall, and decreases with age and number of physical health conditions. This study adds to our nascent understanding of mental health needs and disparities for gender minorities. It is unclear how mental health treatment compares for other gender minority beneficiaries not identified using this algorithm, such as those not seeking medical treatment related to their gender identity, or those who are seeking treatment but encounter barriers related to discrimination or insurance coverage. Future research is needed to further elucidate areas for improved treatment for gender minority Medicare beneficiaries with depression.