Rural-Urban Disparities in Access to Interventional Psychiatry Treatments among VA Patients

Abstract

Objective:

While tele-mental health has improved access to standard medication management and psychotherapy for rural Veterans, implementation of interventional psychiatry treatments will require in-person care, potentially leading to the exacerbation of rural-urban disparities in access to mental health care. We studied the availability of interventional psychiatry treatments, delivered clinically or in the context of a research trial, to rural and urban Veterans.

Methods:

We used VA electronic medical record data to measure the use of electroconvulsive therapy (ECT), magnetic seizure therapy (MST), repetitive transcranial magnetic stimulation (rTMS), vagus nerve stimulation (VNS), deep brain stimulation (DBS), ketamine (infusion or nasal spray), stellate ganglion block (SGB), and medication-assisted psychotherapy (AP) protocols including 3,4-methylenedioxy-methamphetamine (MDMA)-AP and psilocybin-AP, as appropriate, for VA patients with major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) from 2017 through 2024. We compared treatment use in rural and micropolitan locations to use in urban locations.

Results:

Few patients received any interventional psychiatry treatment across strata. The most common modalities were rTMS, ECT, SGB, DBS, and ketamine. The numbers receiving MST, VNS, MDMA-AP, and psilocybin-AP were too small to report in the micropolitan or rural cells. Micropolitan and rural patients had lower odds of receiving rTMS, ECT, SGB, DBS, and ketamine than urban patients. The largest disparities were for rTMS and ketamine.

Conclusions:

There appear to be rural-urban disparities in the emerging field of interventional psychiatry, and the disparities are most pronounced for treatments that require repeated in-person visits such as rTMS and ketamine.

Keywords: Psychiatry, Therapeutic Procedures, Major Depressive Disorder, Posttraumatic Stress Disorder, Veterans

INTRODUCTION

While the developing field of interventional psychiatry (Giacobbe et al., 2021; Trapp & Williams, 2021; Vincent et al., 2020; Williams, Taylor, Kerns, et al., 2014; Williams, Taylor, Snipes, et al., 2014) has the potential to improve mental health treatment for veterans, it also has the potential to worsen rural-urban disparities in access to the most effective mental health interventions. Interventional psychiatry is a subspecialty focused on procedure-based psychiatric care that includes both invasive (e.g., implantation or injection) and non-invasive (e.g., external electrical or magnetic stimulation) techniques (Trapp & Williams, 2021). Once limited to electroconvulsive therapy (ECT; Sackeim, 2017), interventional psychiatry has expanded to include other neurostimulation-based treatments such as magnetic seizure therapy (MST; Deng et al., 2024; Kayser et al., 2011), repetitive transcranial magnetic stimulation (rTMS; Gaynes et al., 2014; Karsen et al., 2014), vagus nerve stimulation (VNS; Austelle et al., 2022), and deep brain stimulation (DBS; Figee et al., 2022), which are under study for or are used to treat a variety of diagnoses including major depressive disorder (MDD [ECT, MST, rTMS, VNS, DBS]) and posttraumatic stress disorder (PTSD [rTMS]). Interventional psychiatry also includes parenterally administered preparations of ketamine for MDD (Nikolin et al., 2023; Smith-Apeldoorn et al., 2022), and stellate ganglion block (SGB) for PTSD (Rae Olmsted et al., 2020), which have also shown promising results for these disorders. Finally, there is enormous interest in promising medication-assisted psychotherapy (AP) protocols such as 3,4-methylenedioxy-methamphetamine (MDMA)-AP for PTSD (Mitchell et al., 2023) and psilocybin-AP for MDD (Haikazian et al., 2023), which will require intensive monitoring in collaboration with interventional psychiatrists.

The rapid expansion of tele-mental health during the COVID-19 pandemic added a tool for rural veterans to access standard medication management and psychotherapy (Leung et al., 2023; Rice et al., 2026). However, implementation of interventional psychiatry treatments will require at least some portion of care to be delivered in person. Outside of ECT, which is delivered more commonly in urban settings than rural settings (Patel et al., 2019; Teja et al., 2024), there has not been research on the geographic spread of interventional psychiatry treatments. Thus, our objective was to make a preliminary assessment of the spread of interventional psychiatry treatments, including ECT, MST, rTMS, VNS, DBS, Ketamine, SGB, MDMA-AP, and Psylocibin-AP using national records from the United State Department of Veterans Affairs (VA) healthcare system. Our hope was that this assessment would be of use in the continual refinement of the VA mental health care system for rural veterans, which includes various treatment modalities and treatment settings.

METHOD

Data Sources

We used VA electronic health record (EHR) data from the corporate data warehouse (CDW), purchased medical claims data from the VA Office of Integrated Veteran Care (IVC) database, the VA Program Integrity Tool (PIT) data, and linked Centers for Medicare and Medicaid Services (CMS) to identify study participants, their demographics and to probe for utilization of interventions of interest. Patients whose records were in the CDW but who did not appear in linked files from IVC, PIT, or CMS were assumed to not to have received services through those mechanisms. This study was classified as exempt from human subjects’ review under Part 4 of the 2018 Common Rule by the Veterans Institutional Review Board of Northern New England. As IRB-exempt research, this study was overseen by the White River Junction VA Medical Center Research and Development Committee under protocol 988703, “Mental Health Services and Outcomes Research.” All study procedures were carried out in accordance with the approved protocol, which followed the relevant VA guidelines.

Cohort selection

We identified VA patients with diagnoses of either major depressive disorder (MDD) or posttraumatic stress disorder (PTSD) between January 1, 2017, and December 31, 2023, who lived in a census area or zip code that could be mapped to a rural-urban commuting area (RUCA), and who were between 18 and 85 years of age at the time of first diagnosis. We used international classification of disease (ICD) codes to identify MDD (296.2x, 296.3x, F32.x, F33.x) and PTSD (309.81, F43.1x). Patients were included in the study for one year following their initial diagnosis. We chose MDD and PTSD because these disorders have both been a major focus interventional psychiatry treatment development and are highly prevalent in the VA patient population. For RUCA coding, we gave preference to census tract codes over zip codes when available. For VA patients with more than one apparent residence, we chose the most frequently seen residence for the year they were in the study. Patients whose location did not map to a RUCA code (9%) were excluded from the cohort. Finally, we divided the patients into three broad RUCA categories (urban [1.0, 1.1, 2.0, 2.1, 3.0, 4.1, 5.1, 7.1, 8.1, 10.1], micropolitan [4.0, 4.2, 5.0, 5.2, 6.0, 6.1] and rural [7.0, 7.2, 7.3, 7.4, 8.0, 8.2, 8.3, 8.4, 9.0, 9.1, 9.2, 10.0, 10.2, 10.3, 10.4, 10.5, 10.6]), using the University of Washington Rural Health Resource Center’s Categorization B, which combines small rural town and isolated small rural town into a single rural category (Hart et al., 2005). In the RUCA schema, the number before the decimal indicates an area’s population density and ranges from 1 (metropolitan area core) to 10 (rural areas), with descriptive gradations in between (e.g., micropolitan area core, small town core). The number after the decimal refers to an area’s commuting flow (e.g., 10.1 indicates secondary flow of 30% through 49% from a rural area to an urban area, 10.4 indicates secondary flow of 10% through 29% from a rural area to an urban area).

Independent Variables

Independent variables included age, sex, race, ethnicity, marital status, military service era, military-related sexual trauma, service-connected disability, comorbidity, and year of entry into the cohort. We used unweighted version of the I6 index for mental health comorbidity (Peltzman et al., 2023), and modified Elixhauser scores for physical health comorbidity (Forehand et al., 2022).

Dependent Variables

We used a variety of data sources including current procedural terminology (CPT) codes, healthcare common procedure (HCPCS) codes, and pharmacy records to determine whether patients received any of ten interventional psychiatry treatments: ECT, MST, rTMS, VNS, DBS, Ketamine, SGB, MDMA-AP, and Psylocibin-AP (Table 1). We were able to use CPT codes to identify ECT, rTMS, VNS, DBS, and SGB. There was a single set of codes for psychedelic-assisted psychotherapy, so we combined MDMA-AP and Psylocibin-AP into a single treatment category of psychedelic-AP. We were able to identify the provision of ketamine and related compounds through pharmacy records. We were able to identify MST only through a HCPCS code for clinical trial participation.

Table 1.

Interventional Psychiatry Treatment Coding

Treatment
Definition

Electroconvulsive Therapy
CPT Codes 90870, 90871, 4066F

Magnetic Seizure Therapy
HCPCS Code G2000

Repetitive Transcranial Magnetic Stimulation
CPT Codes 90867, 90868, 90869

Vagus Nerve Stimulation
CPT Codes E0735, K1020

Deep Brain Stimulation
CPT Codes DBS 61885, 61886 (excluded 61880 – electrode removal)

Stellate Ganglion Block
CPT Code 64510

Ketamine
Pharmacy compounds Ketamine and Esketamine

MDMA-Assisted Psychotherapy*

CPT Codes 0820T 0821T 0822T

Psilocybin-Assisted Psychotherapy*

CPT Codes 0820T 0821T 0822T

ANALYSIS

We began by examining the count and percentage distribution of rural, micropolitan and urban location across each of the independent variables in the study. For confidentiality, we suppressed cell sizes of less than eleven. For time-dependent variables, we chose the patient’s status at the time of their entry into the cohort. Following this, we analyzed the initiation of any interventional psychiatry treatment within each of the three rurality categories during the year following their initial diagnosis. We also examined each intervention type individually. Where applicable, we employed stepwise logistic regression to assess the likelihood of initiating any treatment and each treatment for rural or micropolitan veterans compared to their urban counterparts. For the stepwise models, we set an entry threshold of 0.30 and a stay threshold of 0.35. In cases where there were insufficient patients receiving a treatment, we used the full regression model to display the confidence intervals for non-significant results.

RESULTS

Between 2017 and 2023, there were 2,525,547 urban VA patients, 306,462 micropolitan VA patients, and 245,981 rural VA patients with a diagnosis of MDD or PTSD. The largest group of prevalent cases entered the cohort in 2017 (Urban: 41%, n=1,059,457; Micropolitan: 45%, n=137,158; Rural: 46%, n=111,926). In 2018 and 2019, between 12% and 14% of patients entered the cohort each year across rurality strata. This dropped to 6–9% in the latter years from 2020–2023 (Table 2).

Table 2.

VA Patients aged 18–85 with Depression or PTSD Diagnoses from 2017–23, by Rurality

Baseline Characteristic
Urban
N=2,525,547
Micropolitan
N=306,462
Rural
N=245,981

n
%
n
%
n
%

Female Sex
363,198
14%
32,757
11%
23,345
9%

Race

 White
1,685,457
67%
251,559
83%
209,966
86%

 Black
612,690
25%
35,545
12%
21,217
9%

 Asian American or Pacific Islander
77,384
3%
4,614
2%
2,840
1%

 American Indian or Alaskan Native
34,139
1%
5,485
2%
5,933
2%

 Other/Unknown
90,597
4%
6,556
2%
4,240
2%

Hispanic Ethnicity
253,158
10%
13,160
4%
7,200
3%

Married
1,248,331
49%
166,927
54%
137,532
56%

Age Group

 18–40 years
739,601
29%
71,042
23%
48,539
20%

 41–60 years
822,696
33%
91,200
30%
68,590
28%

 61–85 years
963,250
38%
144,220
47%
128,852
52%

Service Era

 Persian Gulf through Present
1,412,160
56%
143,438
47%
102,629
42%

 Post-Vietnam
290,312
12%
35,320
12%
27,369
11%

 Vietnam
762,320
30%
118,557
39%
107,707
44%

Military-Related Sexual Trauma
374,561
15%
40,384
13%
30,748
13%

Service-Connected Disability

 None
477,546
19%
65,127
21%
53,434
22%

 0–60%
1,044,789
41%
179,452
41%
101,401
41%

 70–100%
1,002,590
40%
115,011
38%
91,094
37%

Diagnosis

 Major Depressive Disorder (MDD)
2,059,082
82%
249,062
81%
198,219
81%

 Posttraumatic Stress Disorder (PTSD)
1,502,132
59%
179,452
59%
143,383
58%

 MDD and PTSD
1,036,289
50%
122,142
49%
95,673
48%

Mental Health Comorbidity

 1 Condition
723,742
29%
97,897
32%
83,259
34%

 2 Conditions
1,039,242
41%
123,130
40%
98,222
40%

 3 Conditions
556,636
22%
62,926
21%
48,306
20%

 4 Conditions
144,101
6%
15,926
5%
11,710
5%

 5 Conditions
48,563
2%
5,238
2%
3,627
2%

 6 Conditions
13,263
1%
1,345
<1%
857
<1%

Physical Health Comorbidity

 0 Diagnoses
390,952
16%
36,733
12%
26,654
11%

 1–2 Diagnoses
900,247
36%
100,263
33%
78,139
32%

 >2 Diagnoses
1,233,726
49%
169,376
55%
141,136
57%

Year of Cohort Entry

 2017
1,059,457
41%
137,158
45%
111,926
46%

 2018
361,889
14%
43,429
14%
35,232
14%

 2019
306,938
12%
36,417
12%
28,515
12%

 2020
236,172
9%
26,811
9%
21,144
9%

 2021
169,390
7%
19,752
6%
15,671
6%

 2022
173,920
7%
20,026
7%
15,686
6%

 2023
217,691
9%
22,869
7%
17,807
7%

While rural and micropolitan patients were generally similar, they differed from urban patients in many ways (Table 2). Specifically, compared to the urban population of VA patinets with MDD or PTSD, the micropolitan and rural population of patients with MDD or PTSD had a lower proportion of female sex (Urban: 14%, n=363,198; Micropolitan: 11%, n=32,757; Rural: 9%, n=23,345), a higher proportion of White race (Urban: 67%, n=1,685,457; Micropolitan: 83%, n=251,559; Rural: 86%, n=209,966) and American Indian or Alaskan Native race (Urban: 1%, n=34,139; Micropolitan: 2%, n=5,485; Rural: 2%, n=5,933), a lower proportion of Black race (Urban: 25%, n=612,690; Micropolitan: 12%, n=35,545; Rural: 9%, n=21,217) and Asian American or Pacific Islander race (Urban: 3%, n=77,384; Micropolitan: 2%, n=4,614; Rural: 1%, n=2,840), a lower proportion of Hispanic ethnicity (Urban: 10%, n=253,158; Micropolitan: 4%, n=13,160; Rural: 3%, n=7,200), a higher proportion of married patients (Urban: 49%, n=1,248,331; Micropolitan: 54%, n=166,927; Rural: 56%, n=137,532) and patients in the oldest (61–85 years) age group (Urban: 38%, n=963,250; Micropolitan: 47%, n=144,220; Rural: 52%, n=128,852), as well as a lower propotion of of patients from the Persian Gulf through present military service era (Urban: 56%, n=1,412,160; Micropolitan: 47%, n=143,438; Rural: 42%, n=102,629) and a higher proportion of patients from Vietnam military service era (Urban: 30%, n=762,320; Micropolitan: 39%, n=118,557; Rural: 44%, n=107,707). Across rurality strata, there were similar proportions of patients with service connected disabilities, similar proportions of patients with MDD and PTSD diagnoses, and similar levels of physical health and mental health comorbidities.

As shown in Table 3, approximately half a percent of VA patients with MDD or PTSD received any interventional psychiatry treatment across rurality strata (Urban: 0.52%, n=13,246; Micropolitan: 0.38%, n=1,154; Rural: 0.36%, n=894). The most common modalities were rTMS, ECT, SGB, DBS, and ketamine. Similar proportions of rual, micropolitan, and urban patients received ECT (Urban: 0.16%, n=4,030; Micropolitan: 0.13%, n=404; Rural: 0.12%, n=302), SGB (Urban: 0.07%, n=1,799; Micropolitan: 0.06%, n=173; Rural: 0.07%, n=160), and DBS (Urban: 0.06%, n=1,508; Micropolitan: 0.08%, n=235; Rural: 0.07%, n=178), but a lower proportion of rural and micropolitan patients than urban patients received rTMS (Urban: 0.23%, n=5,759; Micropolitan: 0.10%, n=313; Rural: 0.10%, n=241) and ketamine (Urban: 0.03%, n=672; Micropolitan: 0.02%, n=47; Rural: 0.01%, n=30). Very few patients in any rurality strata received MST, VNS, or psychadelic-AP.

Table 3.

VA Patients aged 18–85 with Depression or PTSD Diagnoses from 2017–23, by Rurality

Treatment Received
Urban
N=2,525,547
Micropolitan
N=306,462
Rural
N=245,981

n
%
n
%
n
%

Any Interventional Psychiatry Treatment
13,246
0.52%
1,154
0.38%
894
0.36%

 Electroconvulsive Therapy
4,030
0.16%
404
0.13%
302
0.12%

 Magnetic Seizure Therapy
NRNZ
–
NRNZ
–
NRZV
–

 Repetitive Transcranial Magnetic Stimulation
5,759
0.23%
313
0.10%
241
0.10%

 Vagus Nerve Stimulation
89
–
NRNZ
–
NRNZ
–

 Deep Brain Stimulation
1,508
0.06%
235
0.08%
178
0.07%

 Stellate Ganglion Block
1,799
0.07%
173
0.06%
160
0.07%

 Ketamine
672
0.03%
47
0.02%
30
0.01%

 Psychedelic-Assisted Psychotherapy
NRNZ
–
NRNZ
–
NRNZ
–

Several of our independent variables including sex, race, ethnicity, marital status, age group, military-related sexual trauma, service-connected disability, comorbid mental health diagnoses and physical health diagnoses, as well as year of entry into the cohort were associated with receipt of any interventional psychiatry treatment (Table 4). The strongest effects were for black race compared to white race (OR=0.34; 95%CI: 0.32–0.36), military-related sexual trauma compared to none (OR=1.47; 95% CI: 1.41–1.53), 70–100% service-connected disablity compared to none (OR=1.54; 95% CI: 1.45–1.60), six mental health diagnoses compared to one (OR=13.02; 95% CI: 11.80–14.37), and more than two physical health diagnoses compared to none (OR=2.07; 95% CI: 1.93–2.21). The odds of receiving interventional psychiatry treatments decreased consistently for patients entering the cohort in successive years. After controlling for these variables (Table 5), we found lower odds of interventional psychiatry treatment for micropolitan and rurual VA patients with MDD or PTSD compared to urban VA patients with MDD or PTSD in general (Micropolitan OR=0.65; 95% CI: 0.62–0.70, Rural OR=0.64; 95% CI: 0.60–0.68) as well for several specific treatments including ECT, rTMS, and Ketamine (both micropolitan and rural), as well as SGB (micropolitan only) and DBS (rural only). The strongest effects were for rTMS (Micropolitan OR=0.43; 95% CI: 0.38–0.48, Rural OR=0.42; 95% CI: 0.37–0.48) and Ketamine (Micropolitan OR=0.55; 95% CI: 0.41–0.74, Rural OR=0.46; 95% CI: 0.32–0.66).

Table 4.

Independent Variables that Significantly Predict Receipt of Any Interventional Psychiatry Treatment

Comparison
Odds Ratio
95% Confidence Interval

Lower Limit
Upper Limit

Male Sex versus Female Sex
0.85
0.81
0.89

Other/Unknown Race versus White Race
0.85
0.80
0.91

Black Race versus White Race
0.34
0.32
0.36

Hispanic Ethnicity versus Not Hispanic Ethnicity
0.82
0.77
0.87

Married versus Not Married
1.09
1.05
1.13

Age Group 41–60 versus Age Group 18–40
1.07
1.02
1.11

Age Group 61–85 versus Age Group 18–40
0.94
0.89
0.98

Military-Related Sexual Trauma versus No Military-Related Sexual Trauma
1.47
1.41
1.53

Service-Connected Disability 0–60% versus None
0.90
0.85
0.94

Service-Connected Disability 70–100% versus None
1.54
1.45
1.60

Two Mental Health Diagnoses versus One
1.61
1.53
1.70

Three Mental Health Diagnoses versus One
2.65
2.50
2.80

Four Mental Health Diagnoses versus One
5.41
5.08
5.76

Five Mental Health Diagnoses versus One
8.64
8.03
9.30

Six Mental Health Diagnoses versus One
13.02
11.80
14.37

One to Two Physical Health Diagnoses versus None
1.69
1.58
1.80

More than Two Physical Health Diagnoses versus None
2.07
1.93
2.21

Entered Cohort 2018 versus 2017
0.79
0.75
0.68

Entered Cohort 2019 versus 2017
0.80
0.76
0.85

Entered Cohort 2020 versus 2017
0.75
0.70
0.80

Entered Cohort 2021 versus 2017
0.73
0.67
0.79

Entered Cohort 2022 versus 2017
0.65
0.59
0.70

Entered Cohort 2023 versus 2017
0.58
0.54
0.63

Table 5.

Odds of Interventional Psychiatry Treatment Receipt for Micropolitan and Rural VA Patients with MDD or PTSD, compared to Urban VA patients with MDD or PTSD*

Treatment Received
Micropolitan
Rural

OR
95% CI
OR
95% CI

Lower
Upper
Lower
Upper

Any Interventional Psychiatry Treatment
0.65
0.62
0.70
0.64
0.60
0.68

 Electroconvulsive Therapy
0.75
0.68
0.83
0.73
0.65
0.82

 Repetitive Transcranial Magnetic Stimulation
0.43
0.38
0.48
0.42
0.37
0.48

 Vagus Nerve Stimulation
0.78
0.36
1.70
0.47
0.15
1.49

 Deep Brain Stimulation
0.94
0.82
1.08
0.80
0.68
0.93

 Stellate Ganglion Block
0.77
0.66
0.90
0.92
0.79
1.09

 Ketamine
0.55
0.41
0.74
0.46
0.32
0.66

 Psychedelic-Assisted Psychotherapy
1.70
0.50
5.84
1.57
0.36
6.91

DISCUSSION

Our study identifies significant disparities in the utilization of interventional psychiatry treatments among VA patients based on rurality. Rural and micropolitan VA patients are less likely to receive these services compared to their urban counterparts, even after controlling for multiple demographic variables that are associated with our outcome of interventional psychiatry treatment receipt. These findings suggest possible barriers to accessing interventional psychiatry treatments for VA patients residing in micropolitan and rural areas. An encouraging finding was that the disparites were less pronounced for treatments that are not typically delivered with frequent repeated outpatient visits such as ECT—which VA patients most commonly inititate during an inpatient psychiatric hospitalization (Peltzman et al., 2020), SGB—where evidence on the frequency and effectiveness of repeat dosing is nascent (Rae Olmsted et al., 2020), and DBS—which can be managed remotely after initial implantation at a specalized center (Sharma et al., 2021). It was more concerning was that two well-established interventional psychiatry treatments that require repeated outpatient visits, rTMS (McClintock et al., 2018) and ketamine (Andrade, 2017), are used about half as frequently in micropolitan and rural areas compared to urban areas. While the emergence of ketamine formulations that can safely be administered with at-home monitoring via telehealth could help close this gap (Hull et al., 2022), we were unable to locate any reports of effective rTMS implementation strategies in rural areas. It is possible that the development of accelerated rTMS protocols (van Rooij et al., 2024), which require fewer visits, may close this gap. Though it was a surpise that there was such little use of VNS in any rurality strata given it’s availablity and FDA approval for treatment-resitant MDD (Bottomley et al., 2019), the very low use of MST and psychedelic-AP reflect their continued experimental status (Deng et al., 2024; Soliman et al., 2024) and limited availablity due to lack of FDA approval for any indication (Marks, 2023).

Several patient factors outside of rurality strongly predicted higher receipt of interventional psychiatry treatment. In our prior research we have found that the same factors, including military sexual trauma (Dufort et al., 2021), highest levels of service connection (Shiner, Leonard Westgate, Harik, et al., 2017), and increasing levels of comorbidity (Peltzman et al., 2023) have all been associated with higher mental health services use. Thus, it is perhaps reassuring that these higher-need patients are also more likely to access interventional psychiatry treatments. It is perplexting, however, that Black race predicts far lower access to interventional psychiatry treatment. We are not aware of any research indicating that Black VA patients are less likely to develop treatment-resistant MDD or PTSD that might be relieved through interventional psychiatry than White VA patients. Similarly, we are aware of no research which suggest differential efffectiveness of these treatments in different racial groups. In prior research, we observed that Black VA patients with comorbid PTSD and opioid use disorder, who tended to live in urban areas, were more likely to receive treatment with methadone while White VA patients, who tended to live in rural areas, were more likely to receive treatment with buprenorphine (Shiner, Leonard Westgate, Bernardy, et al., 2017). This appeared to correspond to the traditionally urban location of methadone clinics and rural location of buprenorphine clinics. The fact that interventional psychiatry treatments tend to be delivered in urban areas, yet Black VA patients tend not to receive them, is inconsisent with this geographic pattern. While no prior studies have examined the availalbity of interventional psychiatry treatments as a group in the VA, our prior work on ECT found a similar disparity for black race (Peltzman et al., 2020). A related and ongong critique of the psychadelic movement has been lack of diversity in study samples despite indications of effectiveness in minority populations (Glynos et al., 2025). Efforts to ensure the availablity of interventional psychiatry treatments for Black VA patients will be as critical as efforts to ensure the availablity of interventional psychiatry treaments for rural VA patients so long as equity is a health system goal (Braganza et al., 2022). Another interesting finding was that patients entering the cohort in successive years were less likely to recieve interventional psychiatry treatment. We previously documented increasing use of ECT in the VA between 2003 and 2019 (Teja et al., 2024). The approximately 20% decrease between 2017 and the pre-pandemic years of 2018 to 2019 could easily be attributed to prevalent cases analyzed in the first year compared to incident cases analysed in subsequent years, rather than a true decrease in treatment access. However, subsequent decreases from 2020 to 2023 indicate that despite a growing number of treatment options, interventional psychiatry access as a whole may have never recovered from the pandemic-era contraction of in-person care (Rice et al., 2026). One strength of this work is that observed rural urban differences are unlikely to be related to insurance coverage or other financial aspects as all patients in this cohort were utilizing their VA health benefits, which provide these treatments without cost to the patient.

There were several limitations to this work. First, we used EHR data to identify the provision of interventional psychiatry treatment. While some treatments such as ECT have been extensively studied using this EHR data (Peltzman et al., 2020; Teja et al., 2024), other treatments such as ketamine infusion are newer and lack specific CPT codes, requiring integration of additional data sources such as pharmacy records. This is one reason it is likely that we have underestimated the receipt of some treatments. Furthermore, even established CPT codes lack the granularity that would be needed to examine important some treatment parameters. For example, both rTMS and deep TMS (which are distinguished by the depth of the magnetic field) use the same CPT codes. Second, data availablity varies across settings where VA patients receive care. The VA increasingly acts as a payor for care in the community, and VA patients frequently have other sources of health insurance coverage such as Medicare (Shiner et al., 2022). While we used linked files, there is less granularity in these records than in VA records. For example, we did not have pharmacy records for care delivered outside of the VA, so would have missed ketamine treatment in those settings. This is another reason it is likely that we have underestimated the receipt of some treatments. Third, we included patients in the cohort for only one year. While this allowed all patients to contribute the same amout of person time, it did result in bunching of observations in the initial year. Thus, the sample is biased towards VA treatment patterns in 2017, and shifts the focus of our observation away from the COVID-19 pandemic era, when in-person VA services were reduced (Rice et al., 2026). Fourth, we did not align specific treatments with effectiveness in MDD versus PTSD. Given the high levels of comorbidity in our population, the rare use and overlap in use of these treatments for both MDD and PTSD, as well as the inability to determine specific indications from EHR data, we opted to use a combined population. It is notable that some treatments, such as DBS, could have been primarily chosen for entirely different indications such as Parkinsonism (Sharma et al., 2021). More broadly our focus on patients with MDD and PTSD may have effected our results by missing interventional psychiatry tretaments for other psychiatric conditions that are rarer in the VA patient population such as obsessive compulsive disorder. Fifth, to detect as many patients as possible receiving these rarely-used treatments, we used any diagnosis of MDD or PTSD during the time period of interest and did not exclude patients with conflicting diagnoses such as bipolar disorder. More restrictive criteria such as requiring repeated diagnoses might have improved the specificity of our case identification strategy (Bauer et al., 2015). Sixth, this work was not designed to understand trends in receipt of interventional psychiatry treatment. Among the most commonly-received treatments (ECT and rTMS), there has already been extensive description of trends in ECT receipt (Teja et al., 2024; Tsai et al., 2021), but there is a need for similar work on trends in rTMS receipt. Finally, we examined the receipt of any exposure to inverventional psychiatry treatment rather than the quality of inteventional psychiatry treatment. For example, ECT for MDD requires a primary treatment series rather than a single treatment and is frequently followed by maintence treatment to maintain effectiveness (Peltzman et al., 2020). Because of the variation in the characteristics of the treatments examined in this study, we examined only exposure to treatment rather than the longitudinally course of treatment that would be required to estimate the quality of care.

CONCLUSION

A growing portfolio of interventional psychiatry treatments are used in the treatment of VA patients with MDD and PTSD. These treatments appear to be accessed less often by rural and micropolitan patients than by urban patients. Future work should attempt a more comprehenisve assessment by improving data sources, examining longitudinal patterns and regional variation, as well as exploring the drivers of disparities. Overcomming rural-urban disparities will require the alighment of the characteristics of these treatments with the characteristics of the rural mental healthcare system.

Acknowledgements:

This is the work of the authors. The views expressed herein represent those of the authors and not necessarily those of the VRHRC-WRJ, ORH, or the VA.

Funding:

This project is part of the Department of Veterans Affairs (VA) Office of Rural Health’s (ORH) Veteran Rural Health Resource Center – White River Junction (VRHRC-WRJ) portfolio of projects.

Footnotes

Related Presentations: This work has not been publicly presented and is not under consideration for publication in any other journal.

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