Differences in rural and urban treatment of postpartum depression and anxiety in the United States

Abstract Objective To evaluate pharmacologic and psychotherapy treatment among individuals with postpartum depression or anxiety living in urban and rural areas of the United States. Methods This is a retrospective cohort study of individuals diagnosed with postpartum depression or anxiety within 12 months of delivery from 2011 to 2020 in the MarketScan Commercial Research Database. Individuals with postpartum depression or anxiety were identified using ICD codes. Individuals previously receiving treatment were excluded. The exposure, urban residence, was determined by residence in a metropolitan area. The primary outcome was a composite of pharmacologic and psychotherapy treatment for depression or anxiety. Secondary outcomes included components of the primary outcome and time from delivery to first prescription fill. Multivariable modeling adjusted for clinically relevant confounders including history of depression or anxiety that was untreated. Sensitivity analysis included individuals with prior treatment. Results Of 181,185 individuals included, 159,001 (88%) had urban residence. Individuals with postpartum depression or anxiety residing in urban areas were less likely to receive treatment (aHR 0.90; 95% CI 0.88–0.92) than those residing in rural areas, driven by pharmacologic treatment (aHR 0.79; 95% CI 0.77–0.81). Time from delivery to first prescription fill was longer in urban (mean 134 days, 95% CI 133–134) compared to rural areas (mean 128 days, 95% CI 127–130). Primary results were similar in sensitivity analyses. Conclusion Urban residing individuals with postpartum depression or anxiety were less likely to receive pharmacologic or psychotherapy treatment than rural residing individuals in this insured US cohort. This finding was driven by differences in pharmacologic treatment among groups.