Barriers to mental health treatment: results from the National Comorbidity Survey Replication.

BACKGROUND: The aim was to examine barriers to initiation and continuation of treatment among individuals with common mental disorders in the US general population. METHOD: Respondents in the National Comorbidity Survey Replication with common 12-month DSM-IV mood, anxiety, substance, impulse control and childhood disorders were asked about perceived need for treatment, structural barriers and attitudinal/evaluative barriers to initiation and continuation of treatment. RESULTS: Low perceived need was reported by 44.8% of respondents with a disorder who did not seek treatment. Desire to handle the problem on one's own was the most common reason among respondents with perceived need both for not seeking treatment (72.6%) and for dropping out of treatment (42.2%). Attitudinal/evaluative factors were much more important than structural barriers both to initiating (97.4% v. 22.2%) and to continuing (81.9% v. 31.8%) of treatment. Reasons for not seeking treatment varied with illness severity. Low perceived need was a more common reason for not seeking treatment among individuals with mild (57.0%) than moderate (39.3%) or severe (25.9%) disorders, whereas structural and attitudinal/evaluative barriers were more common among respondents with more severe conditions. CONCLUSIONS: Low perceived need and attitudinal/evaluative barriers are the major barriers to treatment seeking and staying in treatment among individuals with common mental disorders. Efforts to increase treatment seeking and reduce treatment drop-out need to take these barriers into consideration as well as to recognize that barriers differ as a function of sociodemographic and clinical characteristics.

Impairment in role functioning in mental and chronic medical disorders in the United States: results from the National Comorbidity Survey Replication.

This study presents national data on the comparative role impairments of common mental and chronic medical disorders in the general population. These data come from the National Comorbidity Survey Replication, a nationally representative household survey. Disorder-specific role impairment was assessed with the Sheehan Disability Scales, a multidimensional instrument that asked respondents to attribute impairment to particular conditions. Overall impairment was significantly higher for mental than chronic medical disorders in 74% of pair-wise comparisons between the two groups of conditions, and severe impairment was reported by a significantly higher portion of persons with mental disorders (42.0%) than chronic medical disorders (24.4%). However, treatment was provided for a significantly lower proportion of mental (21.4%) than chronic medical (58.2%) disorders. Although mental disorders were associated with comparable or higher impairment than chronic medical conditions in all domains of function, they showed different patterns of deficits; whereas chronic medical disorders were most likely to be associated with impairment in domains of work and home functioning, mental disorders were most commonly associated with problems in social and close-relation domains. Comorbidity between chronic medical and mental disorders significantly increased the reported impairment associated with each type of disorder. The results indicate a serious mismatch between a high degree of impairment and a low rate of treatment for mental disorders in the United States. Efforts to reduce disability will need to address the disproportionate burden and distinct patterns of deficits of mental disorders and the potentially synergistic impact of comorbid mental and chronic medical disorders.

Use of practitioner-based complementary therapies by persons reporting mental conditions in the United States.

BACKGROUND: To our knowledge, this study provides the first national estimates for use of practitioner-based complementary treatments by US residents reporting mental conditions. METHODS: A total of 16038 respondents to the 1996 Medical Expenditure Panel Survey were asked about visits for 12 complementary medical services (eg, chiropractic services and herbal remedies). Bivariate and multiple regression models examined use of these therapies in individuals reporting a mental condition (n= 1803), fair or poor mental health status (n=992), and 1 of 4 chronic medical conditions (n = 3262) and in the remainder of the sample (n= 10 793). RESULTS: A total of 9.8% of those reporting a mental condition made a complementary visit, and about half of these (4.5%) made a visit to treat the mental condition. Persons reporting transient stress or adjustment disorders were most likely (odds ratio, 9.1%; 95% confidence interval, 5.5%-12.7%), and those with psychotic (odds ratio, 1.5%; 95% confidence interval, 0.0%-4.2%) and affective (odds ratio, 2.6%; 95% confidence interval, 1.5%-3.8%) conditions least likely, to use complementary therapies to treat their mental condition. In multivariate models controlling for medical comorbidity, fair or poor mental health status, and demographic factors, report of a mental condition predicted a 1.27-fold increase in the odds of a complementary visit (95% confidence interval, 1.04-1.54). CONCLUSIONS: Self-reported mental conditions were associated with increased use of complementary treatments, although use of these treatments was concentrated in respondents with transient distress rather than chronic and serious conditions. More research using structured diagnostic interviews is needed to examine the prevalence, patterns, and clinical implications of use of these treatments by individuals with mental conditions in "real world" community settings.

Integrated medical care for patients with serious psychiatric illness: a randomized trial.

BACKGROUND: This randomized trial evaluated an integrated model of primary medical care for a cohort of patients with serious mental disorders. METHODS: A total of 120 individuals enrolled in a Veterans Affairs (VA) mental health clinic were randomized to receive primary medical care through an integrated care initiative located in the mental health clinic (n = 59) or through the VA general medicine clinic (n = 61). Veterans who obtained care in the integrated care clinic received on-site primary care and case management that emphasized preventive medical care, patient education, and close collaboration with mental health providers to improve access to and continuity of care. Analyses compared health process (use of medical services, quality of care, and satisfaction) and outcomes (health and mental health status and costs) between the groups in the year after randomization. RESULTS: Patients treated in the integrated care clinic were significantly more likely to have made a primary care visit and had a greater mean number of primary care visits than those in the usual care group. They were more likely to have received 15 of the 17 preventive measures outlined in clinical practice guidelines. Patients assigned to the integrated care clinic had a significantly greater improvement in health as measured by the physical component summary score of the 36-Item Short-Form Health Survey than patients assigned to the general medicine clinic (4.7 points vs -0.3 points, P<.001). There were no significant differences between the 2 groups in any of the measures of mental health symptoms or in total health care costs. CONCLUSION: On-site, integrated primary care was associated with improved quality and outcomes of medical care.

Quality of medical care and excess mortality in older patients with mental disorders.

BACKGROUND: This study investigated whether differences in quality of medical care might explain a portion of the excess mortality associated with mental disorders in the year after myocardial infarction. METHODS: This study examined a national cohort of 88 241 Medicare patients 65 years and older who were hospitalized for clinically confirmed acute myocardial infarction. Proportional hazard models compared the association between mental disorders and mortality before and after adjusting 5 established quality indicators: reperfusion, aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, and smoking cessation counseling. All models adjusted for eligibility for each procedure, demographic characteristics, cardiac risk factors and history, admission characteristics, left ventricular function, hospital characteristics, and regional factors. RESULTS: After adjusting for the potential confounding factors, presence of any mental disorder was associated with a 19% increase in 1-year risk of mortality (hazard ratios [HR], 1.19; 95% confidence interval [CI], 1.04-1.36). After adding the 5 quality measures to the model, the association was no longer significant (HR, 1.10; 95% CI, 0.96-1.26). Similarly, while schizophrenia (HR, 1.34; 95% CI, 1.01-1.67) and major affective disorders (HR, 1.11; 95% CI, 1.02-1.20) were each initially associated with increased mortality, after adding the quality variables, neither schizophrenia (HR, 1.23; 95% CI, 0.86-1.60) nor major affective disorder (HR, 1.05; 95% CI, 0.87-1.23) remained a significant predictor. CONCLUSIONS: Deficits in quality of medical care seemed to explain a substantial portion of the excess mortality experienced by patients with mental disorders after myocardial infarction. The study suggests the potential importance of improving these patients' medical care as a step toward reducing their excess mortality.

Suicidal ideation and suicide attempts in general medical illnesses.

BACKGROUND: This study examines the association between the presence of a general medical illness and suicidality in a representative sample of US young adults. METHODS: Between 1988 and 1994, 7589 individuals aged 17 to 39 years were administered the Diagnostic Interview Schedule as part of a national probability survey. The survey collected information about lifetime suicidal ideation and suicide attempts, a checklist of common general medical conditions, and data on major depression, alcohol use, and demographic characteristics. RESULTS: Whereas 16.3% of respondents described suicidal ideation at some point in their lives, 25.2% of individuals with a general medical condition, and 35.0% of those with 2 or more medical illnesses reported life-time suicidal ideation. Similarly, whereas 5.5% of respondents had made a suicide attempt, 8.9% of those with a general medical illness and 16.2% of those with 2 or more medical conditions had attempted suicide. In models controlling for major depression, depressive symptoms, alcohol use, and demographic characteristics, presence of a general medical condition predicted a 1.3 times increase in likelihood of suicidal ideation; more specifically, pulmonary diseases (asthma, bronchitis) were associated with a two-thirds increase in the odds of lifetime suicidal ideation. Cancer and asthma were each associated with a more than 4-fold increase in the likelihood of a suicide attempt. CONCLUSIONS: A significant association was found between medical conditions and suicidality that persisted after adjusting for depressive illness and alcohol use. The findings support the need to screen for suicidality in general medical settings, over and above use of general depression instruments.

Mental disorders and access to medical care in the United States.

OBJECTIVE: The authors examined the barriers to receipt of medical services among people reporting mental disorders in a representative sample of U.S. adults. METHOD: The sample was drawn from adults who responded to the 1994 National Health Interview Survey (N=77,183). The authors studied the association between report of a mental disorder and 1) access to health insurance and a primary provider, and 2) actual receipt of medical care. Multivariate techniques were used to model problems with access as a function of mental disorders, controlling for demographic, insurance, and health variables. RESULTS: While people who reported mental disorders showed no difference from those without mental disorders in likelihood of being uninsured or of having a primary care provider, they were twice as likely to report having been denied insurance because of a preexisting condition or having stayed in their job for fear of losing their health benefits. Among respondents with insurance, those who reported mental illness were no less likely to have a primary care provider but were about two times more likely to report having delayed seeking needed medical care because of cost or having been unable to obtain needed medical care. CONCLUSIONS: People who reported mental disorders experienced significant barriers to receipt of medical care. Efforts to measure and improve access to health care for this population may need to go beyond simply providing insurance benefits or access to general medical providers.

Depressive symptoms and plan switching under managed care.

OBJECTIVE: A central assumption underlying managed care is that plan switching is a viable option for enrollees when they are dissatisfied. The authors used a national employee survey to test the hypothesis that this mechanism is less effective for enrollees with high levels of depressive symptoms than for the remainder of the population. METHOD: The study used data from the Employee Health Care Value Survey, a 1993 survey of 20,283 employees of three major corporations. The authors used the Medical Outcomes Study 36-Item Short-Form Health Survey to identify individuals with the highest decile of depressive and physical symptoms. They examined the relationship between symptoms and dissatisfaction and, for dissatisfied individuals, how symptoms predicted plan switching. Multivariate models were used to control for potential demographic, health, and health coverage confounders. RESULTS: Depressive and physical symptoms were both associated with dissatisfaction with care. Unlike physical symptoms, depressive symptoms were associated with a significantly lower likelihood of actually disenrolling among people who were dissatisfied or who intended to disenroll. This effect was most pronounced for satisfaction with administrative aspects of care (e.g., gatekeeping, utilization review). CONCLUSIONS: People with high levels of depressive symptoms appeared to be less willing or able to act on their dissatisfaction by switching plans. In particular, they were willing to tolerate higher rates of dissatisfaction with the administrative aspects of their health coverage without disenrolling. Plan switching is an essential mechanism underpinning a health care system predicated on competition; it may be less effective for people with depressive disorders.

Depressive symptoms, satisfaction with health care, and 2-year work outcomes in an employed population.

OBJECTIVE: The relationship of depressive symptoms, satisfaction with health care, and 2-year work outcomes was examined in a national cohort of employees. METHOD: A total of 6,239 employees of three corporations completed surveys on health and satisfaction with health care in 1993 and 1995. This study used bivariate and multivariate analyses to examine the relationships of depressive symptoms (a score below 43 on the Medical Outcomes Study Short-Form Health Survey mental component summary), satisfaction with a variety of dimensions of health care in 1993, and work outcomes (sick days and decreased effectiveness in the workplace) in 1995. RESULTS: The odds of missed work due to health problems in 1995 were twice as high for employees with depressive symptoms in both 1993 and 1995 as for those without depressive symptoms in either year. The odds of decreased effectiveness at work in 1995 was seven times as high. Among individuals with depressive symptoms in 1993, a report of one or more problems with clinical care in 1993 predicted a 34% increase in the odds of persistent depressive symptoms and a 66% increased odds of decreased effectiveness at work in 1995. There was a weaker association between problems with plan administration and outcomes. CONCLUSIONS: Depressive disorders in the workplace persist over time and have a major effect on work performance, most notably on "presenteeism," or reduced effectiveness in the workplace. The study's findings suggest a potentially important link between consumers' perceptions of clinical care and work outcomes in this population.

Health and disability costs of depressive illness in a major U.S. corporation.

OBJECTIVE: Employers are playing an increasingly influential role in determining the scope and character of health coverage in the United States. This study compares the health and disability costs of depressive illness with those of four other chronic conditions among employees of a large U.S. corporation. METHOD: Data from the health and employee files of 15,153 employees of a major U.S. corporation who filed health claims in 1995 were examined. Analyses compared the mental health costs, medical costs, sick days, and total health and disability costs associated with depression and four other conditions: heart disease, diabetes, hypertension, and back problems. Regression models were used to control for demographic differences and job characteristics. RESULTS: Employees treated for depression incurred annual per capita health and disability costs of $5,415, significantly more than the cost for hypertension and comparable to the cost for the three other medical conditions. Employees with depressive illness plus any of the other conditions cost 1.7 times more than those with the comparison medical conditions alone. Depressive illness was associated with a mean of 9.86 annual sick days, significantly more than any of the other conditions. Depressed employees under the age of 40 years took 3.5 more annual sick days than those 40 years old or older. CONCLUSIONS: The cost of depression to employers, particularly the cost in lost work days, is as great or greater than the cost of many other common medical illnesses, and the combination of depressive and other common illnesses is particularly costly. The strong association between depressive illness and sick days in younger workers suggests that the impact of depression may increase as these workers age.

Depressive symptoms and health costs in older medical patients.

OBJECTIVE: The authors assessed the association between depressive symptoms and health costs for a national Veterans Administration (VA) sample. METHOD: The Rand Depression Index was administered to 1,316 medical or surgical inpatients over the age of 60 at nine VA hospitals. Scores were merged with utilization, demographic, and hospital data from national VA inpatient and outpatient files. RESULTS: Medical costs for respondents with the highest quartile of symptoms were approximately $3,200-or 50%-greater than medical costs for those in the least symptomatic quartile. Depressive symptoms were not associated with any statistically significant mental health expenditures. CONCLUSIONS: The study extends previous reports of the high medical costs associated with depressive disorders to an older, public sector population. The mechanisms underlying increased medical costs associated with depressive symptoms, while the subject of much speculation in the literature, still remain largely unknown.

Physical health, depressive symptoms, and managed care enrollment.

OBJECTIVE: This study used a national employee survey to test the hypothesis that symptomatic individuals in general, and individuals with depressive symptoms in particular, are disproportionately enrolled in fee-for-service health care plans as compared to health maintenance organizations (HMOs). METHOD: The study analyzed data from the 1993 Employee Health Care Value Survey, a questionnaire distributed to employees of three large corporations. The sample comprised 20,283 employees covering six U.S. geographic regions and 46 health plans. The authors used logistic regression to model the association between HMO enrollment and presence of physical and depressive symptoms, measured by subscales derived from the Medical Outcomes Study 36-item Short-Form Health Survey, adjusting for health, demographic, and insurance variables. RESULTS: In unadjusted models, enrollees in fee-for-service plans had higher rates of both depressive and physical symptoms than HMO enrollees. After adjustment for age alone or for age and other potential confounders, there was no difference in physical symptoms between plan types. However, individuals with high levels of depressive symptoms were 16% less likely to be enrolled in HMOs than in fee-for-service plans after adjustment for age, other demographic variables, physical health status, and insurance characteristics. CONCLUSIONS: This study provides evidence that symptomatic individuals are more likely to be enrolled in fee-for-service plans than in HMOs. While much of the effect for physical symptoms may be explained by differences in demographic variables, particularly age, the difference in depressive symptoms appears to be independent of those variables.

Understanding disability in mental and general medical conditions.

OBJECTIVE: This study characterized the prevalence, characteristics, and impact of mental and general medical disabilities in the United States. METHOD: The 1994-1995 National Health Interview Survey of Disability was the largest disability survey ever conducted in the United States. A national sample was screened for disability, defined as limitation or inability to participate in a major life activity. Analyses compared cohorts who attributed their disability to physical, mental, or combined conditions. RESULTS: Of 106,573 adults, 1.1% reported functional disability from mental conditions, 4.8% from general medical conditions, and 1.2% from combined mental and general medical conditions. Disabilities attributed to a mental condition were predominantly associated with social and cognitive difficulties, those attributed to general medical conditions with physical limitations, and combined disabilities with deficits spanning multiple domains. In multivariate models, comorbid medical and mental conditions were associated with a twofold increase in odds of unemployment and a two-thirds increase in odds of support on disability payments compared to respondents with a single form of disability. More than half the nonworking disabled reported that economic, social, and job-based barriers contributed to their inability to work. One-fourth of working disabled people reported discrimination on the basis of their disability during the past 5 years. CONCLUSIONS: An estimated three million Americans (one-third of disabled people) reported that a mental condition contributes to their disability. Mental, general medical, and combined conditions are associated with unique patterns of functional impairment. Social and economic factors and job discrimination may exacerbate the functional impairments resulting from clinical syndromes.

Day hospital/crisis respite care versus inpatient care, Part I: Clinical outcomes.

OBJECTIVE: The authors investigated the clinical feasibility and the outcome for patients of a program designed as an alternative to acute hospitalization. METHOD: This was a random-design study comparing a conventional inpatient program for urban, poor, severely ill voluntary patients who usually require hospitalization to an alternative experimental program consisting of a day hospital linked to a crisis residence. Patients were assessed with standardized measures of symptoms, functioning, social adjustment, quality of life, and satisfaction with clinical services upon admission to the study, at discharge from the index admission, and at follow-ups 2, 5, and 10 months after discharge. RESULTS: One hundred ninety-seven patients were enrolled in the 2-year research program and followed for 10 months. Of the voluntary patients who would have been admitted to the hospital, 83% were appropriate for the experimental program. The clinical, functional, social adjustment, quality of life, and satisfaction outcome measures were not statistically different for the patients in the two treatment conditions; however, there was a slightly more positive effect of the experimental program on measures of symptoms, overall functioning, and social functioning. CONCLUSIONS: The experimental condition, a combined day hospital/crisis respite community residence, seems to have had the same treatment effectiveness as acute hospital care for urban, poor, acutely ill voluntary patients with severe mental illness.

Droperidol: efficacy and side effects in psychiatric emergencies.

BACKGROUND: As admission criteria to inpatient units become more focused on patient safety and behavioral instability, primary treatment often requires use of medications that need to be quick, safe, and effective for control of agitation. This article reviews the evidence that droperidol may serve as the optimal medication for this task. DATA SOURCES: A comprehensive MEDLINE search of English-language literature was conducted using the search term droperidol concerning the use of droperidol in psychiatric emergencies. Cross-referencing of those articles was conducted to include pertinent articles in the non-psychiatric and European literature regarding safety and early development of the drug. STUDY FINDINGS: As evidenced in the animal and clinical literature, studies demonstrate the efficacy and rapidity of onset of droperidol and its relative safety compared with the most widely used antiagitation drug, haloperidol. Evidence for this use of droperidol is particularly compelling for situations in which intramuscular administration is necessary. CONCLUSION: Droperidol, while not in widespread use, may prove to be the superior typical neuroleptic for psychiatric emergencies. Increased clinical utilization and study of droperidol for this use is warranted.

Underuse of antidepressants in major depression: prevalence and correlates in a national sample of young adults.

BACKGROUND: Epidemiologic studies have reported disturbingly low rates of treatment for major depression in the United States. To better understand this phenomenon, we studied the prevalence and predictors of antidepressant treatment in a national sample of individuals with major depression. METHOD: Between 1988 and 1994, 7589 individuals, aged 17-39 years and drawn from a national probability sample, were administered the Diagnostic Interview Schedule as part of the National Health and Nutrition Examination Survey. Interviewers asked about prescription drug use and checked medication bottles to record the name and type of medications. RESULTS: A total of 312 individuals, or 4.1% of the sample, met DSM-III criteria for current major depression. Only 7.4% of those with current major depression were being treated with an antidepressant. Among individuals with current major depression, being insured and having a primary care provider each predicted a 4-fold increase in odds of antidepressant treatment; telling the primary provider about depressive symptoms predicted a 10-fold increase in treatment. CONCLUSION: The study's findings support the notion that a serious gap exists between the established efficacy of antidepressant medications and rates of treatment for major depression in the "real world." Underreporting of depressive symptoms to providers and problems with access to general medical care appear to be 2 major contributors to this problem.

Chronic illness and plan satisfaction under managed care.

This DataWatch uses data from the 1993 Employee Health Care Value Survey (EHCVS) to compare the experiences of respondents with and without chronic illnesses under managed care. After controlling for potential confounders, we found that chronic illness was associated with increased odds of dissatisfaction in both independent practice association plans and prepaid group practices, but not under fee-for-service coverage. Chronic illness appeared to exacerbate difficulties and to attenuate the benefits experienced by healthy persons under managed care. We conclude that persons with chronic illnesses may be at particular risk under managed care; their experiences may warrant particular attention when health plan performance is being monitored.

Effect of declining mental health service use on employees of a large corporation.

This study examines concurrent changes in use of mental and general health services and in annual sick days among 20,814 employees of a large corporation. From 1993 to 1995 mental health service use and costs declined by more than one-third, more than three times as much as the decline in non-mental health service use. However, employees who used mental health services showed a 37 percent increase in use of non-mental health services and significantly increased sick days, whereas other employees showed no such increases. Savings in mental health services were fully offset by increased use of other services and lost workdays.

Comparing the national economic burden of five chronic conditions.

Using a nationally representative sample of 23,230 U.S. residents, we examine patterns of economic burden across five chronic conditions: mood disorders, diabetes, heart disease, asthma, and hypertension. Almost half of U.S. health care costs in 1996 were borne by persons with one or more of these five conditions; of that spending amount, only about one-quarter was spent on treating the conditions themselves and the remainder on coexistent illnesses. Each condition demonstrated substantial economic burden but also unique characteristics and patterns of service use driving those costs. The findings highlight the differing challenges involved in understanding needs and improving care across particular chronic conditions.