Episode 14: Pharmacotherapy for Depression in Long‑Term Care - A Real‑World Snapshot

Andie Cartwright

Welcome back. I’m Andie Cartwright, here with Anthony Pero, and today we’re digging into a topic that’s incredibly important in long-term care but can still be easy to miss, and that’s depression. In older adults living in skilled nursing facilities, depression can show up in ways that are subtle and layered and honestly sometimes mistaken for something else entirely. It can affect mood, of course, but also sleep, appetite, engagement, rehab participation, and overall quality of life.

Anthony Pero

Yeah, absolutely. And in long-term care, nothing happens in isolation. When a resident is depressed, that can ripple through functional status, clinical outcomes, and even how they interact with staff, family, and treatment plans. So when we look at depression care in this setting, we’re really talking about a core part of whole-person care, not some side issue.

Andie Cartwright

Right. And what makes this particular paper interesting is that it’s not a tiny sample or a highly controlled trial. It’s a real-world electronic health record study using data from our database. The researchers reviewed records from more than 1.6 million long-term care residents in the U.S. between January and April of 2025, and from that group they identified over 358,000 skilled-nursing facility residents with a documented depression diagnosis.

Anthony Pero

That scale matters. A lot. Because when you have a dataset that large, you can start to see treatment patterns across residents and facilities in a way that feels much closer to day-to-day practice. Not perfect, of course—no observational dataset is—but it does give us a broad view of what’s happening in the field.

Andie Cartwright

And just to put a careful asterisk on this, this is a medRxiv preprint. So it has not been peer reviewed yet, and we should not treat it as something that changes clinical practice on its own. But it is still useful as an early signal, especially because it asks a practical question: among residents in long-term care who have depression documented, how often are they actually receiving pharmacologic treatment?

Anthony Pero

Exactly. The study classified residents as treated or untreated based on whether they had a medication order for depression treatment in medication classes recommended by the American Psychological Association. That’s a pretty straightforward and policy-relevant way to look at access. Because in long-term care, prescribing patterns tell us something about recognition, decision-making, and the broader care environment.

Andie Cartwright

Yeah, and I think that’s the big why behind this episode. Medication isn’t the whole story for depression care, obviously, but access to evidence-informed pharmacotherapy does matter. Especially in older adults, where untreated depression can compound other medical issues and make recovery (or daily functioning) harder. And in LTC, prescribing is also shaped by staffing, documentation, coexisting diagnoses, and local resources.

Anthony Pero

I’d even say medication access is kind of a window into the system. If residents with the same diagnosis are treated differently depending on who they are or where they live, that tells us something meaningful. Maybe about assessment. Maybe about clinical confidence. Maybe about facility-level constraints. So this study is really about treatment rates, but it also opens up a bigger conversation about consistency and equity in care.

Anthony Pero

So let’s get to the headline number. Overall, 81.7% of residents with a documented depression diagnosis had at least one pharmacologic treatment order. On the surface, that suggests most residents in this sample were receiving some form of medication treatment aligned with recommended classes.

Andie Cartwright

Which is a meaningful finding, because the easy assumption might be that depression is broadly undertreated in this setting. And this study says, well, hold on—at least among residents with documented depression in these skilled nursing facilities, most did have a medication order. That doesn’t answer every question, but it does give us a baseline.

Anthony Pero

And when the authors looked at the medication classes, selective serotonin reuptake inhibitors, or SSRIs, were the most frequently used at 59.8%. Miscellaneous antidepressants were next at 42.3%.

Andie Cartwright

I always think category names like “miscellaneous antidepressants” sound a bit like the junk drawer of pharmacology. But the bigger point is that the prescribing pattern wasn’t random. There were certain classes showing up much more often, and SSRIs leading the list makes intuitive sense in a lot of care settings.

Anthony Pero

Right. And another notable point was that treatment rates were similar across depression diagnoses. So the variation wasn’t really being driven by one depression label versus another, at least in the way the study describes it.

Andie Cartwright

Where it gets more interesting is the predictors. The study used multivariable logistic regression to estimate which resident- and facility-level factors were associated with higher or lower odds of treatment. Higher odds of receiving treatment were seen among residents also diagnosed with vascular dementia and among residents with hyperlipidemia medication orders.

Anthony Pero

And lower odds were observed among residents who were Black or African American, residents with diabetes, residents with hyperlipidemia diagnoses, and residents in facilities located in areas with poor socioeconomic status.

Andie Cartwright

That distinction between a hyperlipidemia diagnosis and a hyperlipidemia medication order is interesting, by the way. I don’t wanna over-interpret it, because the paper gives us the association, not the causal why. But it does remind you that comorbidity patterns and medication history can be proxies for all kinds of things—engagement with care, prescribing habits, documentation differences, even just how visible a resident is within the clinical workflow.

Anthony Pero

Exactly. Observational findings like this are useful, but they don’t tell us reasoning or mechanism. We can say these factors were associated with higher or lower odds after adjustment. We cannot say they caused treatment or non-treatment. Still, that pattern matters, because it suggests depression pharmacotherapy in long-term care is influenced by more than the depression diagnosis alone.

Andie Cartwright

And that, to me, is where the operational relevance comes in. If you’re a healthcare leader, a facility operator, a market access team, or really anyone thinking about quality in post-acute and long-term care, this is the kind of data that helps you ask better questions. Not just, are residents being treated, but which residents are less likely to be treated, and under what conditions?

Andie Cartwright

The equity findings are probably the part that lingers the longest after you read the paper. The study found lower odds of treatment among Black or African American residents and among residents in facilities located in more socioeconomically vulnerable areas. And even with all the caution that comes with a preprint, that is hard to ignore.

Anthony Pero

It is. Because those are exactly the kinds of patterns that suggest structural differences in access and delivery. Again, not proof of intent, not proof of a single root cause, but a sign that treatment is not distributed evenly. In a setting like long-term care, where residents are already clinically complex and often highly dependent on the care environment around them, facility context can have a huge effect.

Andie Cartwright

Yeah, and facility context can sound abstract, but it really isn’t. It can mean resource constraints. It can mean staffing limitations. It can mean fewer clinical supports, more strain on assessment workflows, less access to specialized expertise—there are a lot of possibilities. Where was I going with this? Oh right—the point is that depression care doesn’t happen in a vacuum. It happens inside systems.

Anthony Pero

And if the system is under pressure, some conditions may get less attention, especially when symptoms are less visible or can be mistaken for normal aging, cognitive decline, or general frailty. That’s why the authors’ conclusions around improved screening practices are important. Better screening won’t solve everything, but it can reduce the chance that depression goes unrecognized or undertreated.

Andie Cartwright

The paper also points toward more attention to equity in prescribing. I like that framing because it’s practical. It says, let’s not assume treatment patterns are neutral. Let’s examine them. Are similar residents getting similar opportunities for evidence-informed care? If not, what needs to change?

Anthony Pero

And then there’s the call for stronger clinical resources in socially vulnerable settings. That may be one of the most actionable takeaways. If facility-level disadvantage is associated with lower odds of treatment, then quality improvement can’t stop at the resident chart. It has to include the environment around the resident.

Andie Cartwright

Totally. This is one of those studies that gives you both reassurance and urgency. Reassurance because most residents with depression in this analysis did have at least one treatment order. Urgency because the gaps that remain are not random—they appear tied to race, comorbid conditions, and socioeconomic context.

Anthony Pero

So if you zoom out, the implication is pretty clear: improving depression care in long-term care means combining better identification, more consistent evidence-informed prescribing, and a stronger focus on equity across facilities. Not one lever—several.

Andie Cartwright

And we’ll keep saying it carefully: this is an observational preprint, not the final word. But it is a valuable real-world snapshot, and I think it raises exactly the right questions for healthcare leaders and clinicians.

Anthony Pero

Agreed. Andie, this was a good one.

Andie Cartwright

It was. Thanks, Anthony. And thanks to everybody listening—we’ll be back soon with another conversation at the intersection of data, care delivery, and what it all means in practice. Bye for now.

Anthony Pero

Take care, everyone. Bye, Andie.