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.

Functioning and utility for current health of patients with depression or chronic medical conditions in managed, primary care practices.

BACKGROUND: Health utility is the recommended outcome metric for medical cost-effectiveness studies. We compared health utility and quality of life for primary care patients with depression or chronic medical conditions. METHODS: Respondents were outpatients (N = 17 558) of primary care clinicians (N = 181) in 7 managed care organizations. Utility was assessed by time tradeoff, or the years of life that patients would exchange for perfect health, and standard gamble, or the required chance of success to accept a treatment that can cause immediate death or survival in perfect health. Probable 12-month depressive disorder and affective syndromes were assessed through self-report items from a diagnostic interview. Medical conditions were assessed with self-report. Quality of life was assessed by the 12-Item Short-Form Health Survey. Regression models were used to compare quality of life and utility for patients with depression vs chronic medical conditions. RESULTS: Patients with probable 12-month depressive disorder had worse mental health and role-emotional and social functioning and lower utility for their current health than patients with each chronic medical condition (for most comparisons, P<.001). Depressed patients had worse physical functioning than patients with 4 common chronic conditions but better physical functioning than patients with 4 other conditions (each P<.001). Patients with lifetime bipolar illness and 12-month double depression had the poorest quality of life and lowest utility. CONCLUSIONS: Primary care patients with depressive conditions have poorer mental, role-emotional, and social functioning than patients with common chronic medical conditions, and physical functioning in the midrange. The low utility of depressed patients relative to patients with chronic medical conditions suggests that recovery from depression should be a high practice priority.

The quality of care for depressive and anxiety disorders in the United States.

BACKGROUND: Depressive and anxiety disorders are prevalent and cause substantial morbidity. While effective treatments exist, little is known about the quality of care for these disorders nationally. We estimated the rate of appropriate treatment among the US population with these disorders, and the effect of insurance, provider type, and individual characteristics on receipt of appropriate care. METHODS: Data are from a cross-sectional telephone survey conducted during 1997 and 1998 with a national sample. Respondents consisted of 1636 adults with a probable 12-month depressive or anxiety disorder as determined by brief diagnostic interview. Appropriate treatment was defined as present if the respondent had used medication or counseling that was consistent with treatment guidelines. RESULTS: During a 1-year period, 83% of adults with a probable depressive or anxiety disorder saw a health care provider (95% confidence interval [CI], 81%-85%) and 30% received some appropriate treatment (95% CI, 28%-33%). Most visited primary care providers only. Appropriate care was received by 19% in this group (95% CI, 16%-23%) and by 90% of individuals visiting mental health specialists (95% CI, 85%-94%). Appropriate treatment was less likely for men and those who were black, less educated, or younger than 30 or older than 59 years (range, 19-97 years). Insurance and income had no effect on receipt of appropriate care. CONCLUSIONS: It is possible to evaluate mental health care quality on a national basis. Most adults with a probable depressive or anxiety disorder do not receive appropriate care for their disorder. While this holds across diverse groups, appropriate care is less common in certain demographic subgroups.

Mental health problems among homeless mothers: relationship to service use and child mental health problems.

BACKGROUND: The purpose of this study was to describe the prevalence of psychological distress and probable lifetime mental disorders among homeless mothers, their use of services, and the relationship between maternal and child mental health problems. METHOD: The study involved a cross-sectional assessment of 110 mothers and 157 children living in homeless shelters in Los Angeles County. RESULTS: The majority (72%) of sheltered homeless mothers reported high current psychological distress or symptoms of a probable lifetime major mental illness or substance abuse. However, few mothers (15%) in need of services received mental health care, and the main point of contact for those with a mental health problem was the general medical sector. Mothers with a probable mental disorder were also significantly more likely to have children with either depression or behavior problems. CONCLUSIONS: Homeless mothers have a high level of unmet need for mental health services. The relationship between maternal and child problems underscores the need for homeless family interventions that promote access to psychiatric care for both generations.

The effects of insurance generosity on the psychological distress and psychological well-being of a general population.

Reductions in the generosity of fee-for-service insurance lower the use of general medical and mental health services, but do they lead to lower mental health status for the covered population? We addressed this question using data from the RAND Corporation Health Insurance Experiment. Families in six sites in the United States were randomly assigned to one of 14 insurance plans for three- or five-year periods. On average, there were no significant adverse effects of cost-sharing plans, relative to a free-care plan, on either psychological well-being or psychological distress, when the cost-sharing plans included full catastrophic coverage. Those with high mental health status but low income at baseline had significantly more favorable mental health outcomes on the cost-sharing plans than on the free-care plan. We cannot definitively comment on the effects of insurance generosity for the sick poor. Our findings apply in the context of mandated comprehensive mental and general health coverage for a general nonelderly, nondisabled household population.

Outcomes for adult outpatients with depression under prepaid or fee-for-service financing.

OBJECTIVE: To compare change over time in symptoms of depression and limitations in role and physical functioning of patients receiving prepaid or fee-for-service care within and across clinician specialties. METHOD: Observational study of change in outcomes over 2 years for 617 depressed patients of psychiatrists, psychologists, other therapists, and general medical clinicians in three urban sites in the United States. RESULTS: Psychiatrists treated psychologically sicker patients than other clinicians in all payment types. Among psychiatrists' patients, those initially receiving prepaid care acquired new limitations in role/physical functioning over time, while those receiving fee-for-service care did not. This finding was most striking in independent practice associations but varied by site and organization. Patients of psychiatrists were more likely to use antidepressant medication than were patients of other clinicians, but among psychiatrists' patients, there was a sharp decline over time in the use of such medication in prepaid compared with fee-for-service care. Outcomes did not differ by payment type for depressed patients of other specialty groups, or overall. CONCLUSION: Depressed patients of psychiatrists merit policy interest owing to their high levels of psychological sickness. For these patients, functioning outcomes were poorer in some prepaid organizations. The nonexperimental evidence favors (but cannot prove) an explanation based on care received, such as a reduction in medications, rather than on preexisting sickness differences.

Functioning and well-being outcomes of patients with depression compared with chronic general medical illnesses.

BACKGROUND: Cross-sectional studies have found that depression is uniquely associated with limitations in well-being and functioning that were equal to or greater than those of chronic general medical conditions such as diabetes and arthritis. However, whether these relative limitations persist over time is not known. METHODS: We conducted a 2-year observational study of 1790 adult outpatients with depression, diabetes, hypertension, recent myocardial infarction, and/or congestive heart failure. Change in functional status and well-being was compared for depressed patients vs patients with chronic general medical illnesses, controlling statistically for medical comorbidity, sociodemographics, system, and specialty of care. RESULTS: Over 2 years of follow-up, limitations in functioning and well-being improved somewhat for depressed patients; even so, at the end of 2 years, these limitations were similar to or worse than those attributed to chronic medical illnesses. Similar patterns were observed for depressed patients in the mental health specialty sector and those in the general medical sector, but the patients in the mental health specialty sector improved more. More severely depressed patients improved more in functioning, but even initially depressed patients without depressive disorder had substantial persistent limitations. CONCLUSION: Depressed patients have substantial and long-lasting decrements in multiple domains of functioning and well-being that equal or exceed those of patients with chronic medical illnesses.

Quality of care for depressed elderly patients hospitalized in the specialty psychiatric units or general medical wards.

BACKGROUND: Studies to assess quality of care have become increasingly important for research and policy purposes. OBJECTIVE: To evaluate the difference in quality of care between elderly depressed patients hospitalized in specialty psychiatric units and those hospitalized in general medical wards. METHODS: We reviewed retrospectively the medical charts of 2746 patients with depression hospitalized in 297 general medical hospitals in five different states. Quality of care was assessed by clinical review of explicit and implicit information contained in the medical records of patients in specialty psychiatric units (n = 1295) and general medical wards (n = 1451). We also used other secondary data sources to determine postdischarge outcomes. RESULTS: We found that (1) a higher percentage of admissions on the psychiatric units were considered appropriate, (2) overall psychological assessment was better on the psychiatric unit, (3) patients were more likely to receive psychological services on the psychiatric wards but more likely to receive traditional general medical services on medical wards, (4) there were more inpatient general medical complications on the psychiatric wards, and (5) implicit measures of clinical status at discharge were better for those on the psychiatric unit. CONCLUSIONS: Although limited by reliance on medical record abstraction and a retrospective study design, our data indicate that the quality of care for the psychological aspects of the treatment of depression may be better on psychiatric units, while the quality of general medical components of care may be better on general medical wards.

Two-year effects of quality improvement programs on medication management for depression.

BACKGROUND: Significant underuse of evidence-based treatments for depression persists in primary care. We examined the effects of 2 primary care-based quality improvement (QI) programs on medication management for depression. METHODS: A total of 1356 patients with depressive symptoms (60% with depressive disorders and 40% with subthreshold depression) from 46 primary care practices in 6 nonacademic managed care organizations were enrolled in a randomized controlled trial of QI for depression. Clinics were randomized to usual care or to 1 of 2 QI programs that involved training of local experts who worked with patients' regular primary care providers (physicians and nurse practitioners) to improve care for depression. In the QI-medications program, depression nurse specialists provided patient education and assessment and followed up patients taking antidepressants for up to 12 months. In the QI-therapy program, depression nurse specialists provided patient education, assessment, and referral to study-trained psychotherapists. RESULTS: Participants enrolled in both QI programs had significantly higher rates of antidepressant use than those in the usual care group during the initial 6 months of the study (52% in the QI-medications group, 40% in the QI-therapy group, and 33% in the usual care group). Patients in the QI-medications group had higher rates of antidepressant use and a reduction in long-term use of minor tranquilizers for up to 2 years, compared with patients in the QI-therapy or usual care group. CONCLUSIONS: Quality improvement programs for depression in which mental health specialists collaborate with primary care providers can substantially increase rates of antidepressant treatment. Active follow-up by a depression nurse specialist in the QI-medications program was associated with longer-term increases in antidepressant use than in the QI model without such follow-up.

Comorbid anxiety disorder and the functioning and well-being of chronically ill patients of general medical providers.

BACKGROUND: The comorbidity of psychiatric disorders with chronic health conditions has emerged as a topic of considerable clinical and policy interest, in part owing to the evidence that anxiety disorders themselves are associated with morbidity. However, the implications for health-related quality of life that result from anxiety disorders, which are comorbid to chronic medical or psychiatric illness, are not well understood, especially in primary care samples. METHODS: A 2-year observational study of 875 adult patients with hypertension, diabetes, heart disease, and current depressive disorder or subthreshold depression receiving care from general medical providers was conducted. The unique effect of any comorbid anxiety disorder on functioning and well-being (determined with the use of the 36-Item Short-Form Health Survey [SF-36]) was estimated, as well as the differential impact at baseline, 2-year follow-up, and change over time, of any comorbid anxiety disorder for patients with chronic medical conditions or depression. RESULTS: Patients with comorbid anxiety who received general medical care had lower levels of functioning and well-being than those without comorbid anxiety. These differences were most pronounced in mental health-related quality-of-life measures and when anxiety was comorbid with chronic medical conditions rather than with depression. Hypertensive and diabetic patients with comorbid anxiety were as debilitated as patients with depression or heart disease, and this low health-related quality of life persisted over time. Comorbid anxiety had less of an effect on patients with heart disease who already had a low health-related quality of life. CONCLUSION: The finding of substantial differences in the quality of life between hypertensive and diabetic patients with and without comorbid anxiety disorder highlights the clinical and societal importance of identifying comorbid anxiety in these patients.

Counseling typically provided for depression. Role of clinician specialty and payment system.

BACKGROUND: To assess how current policy trends may affect the use of counseling for depression, we examined the variation in the use of counseling and usual clinician counseling style for depression across specialty sectors (psychiatry, psychology, and general medicine) and reimbursement type (fee-for-service or prepaid). METHODS: Three types of observational data from the RAND Medical Outcomes Study: (1) patient-reported demographics, depressive symptoms, clinical status, and perceptions about participation style; (2) clinician reports of counseling during specific patient encounters; and (3) clinician reports of the usual counseling and interpersonal style across patients who were seen in a practice. RESULTS: While almost all depressed patients who were being treated by mental health specialists received brief counseling for at least 3 minutes, less than half of the depressed patients in the general medical sector received such counseling--even for those patients with a current depressive disorder. Counseling rates were lower under prepaid than fee-for-service care in general medical practices. Psychiatrists relied more on psychodynamic approaches, and psychologists relied more on behavioral therapies relative to each other, but both specialty groups provided longer sessions and used more formal psychotherapeutic techniques (e.g., interpretation) than did general medical clinicians. Clinicians who were treating more patients who had prepaid plans reported a lower proclivity for face-to-face counseling, and they spent less time when they were counseling patients compared with clinician who were treating more patients who had fee-for-service plans; however, these differences were not large. CONCLUSION: The use of counseling in the usual care for depression varied by both specialty and payment system, while the usual clinician counseling style differed markedly by specialty, but only slightly by payment system.

The course of depression in adult outpatients. Results from the Medical Outcomes Study.

OBJECTIVE: To compare the course of depression during a 2-year period in adult outpatients (n = 626) with current major depression, dysthymia, and either both current disorders ("double depression") or depressive symptoms with no current depressive disorder. METHODS: Depressed patients visiting 523 clinicians (mental health specialists and general medical providers) were identified using a two-stage screening procedure including the Diagnostic Interview Schedule. The course of depression was assessed in 2 follow-up years with a structured telephone interview based on the format of the Diagnostic Interview Schedule. RESULTS: Baseline severity of depressive symptoms was greatest in patients with double depression, but initial functional status was poor in those with dysthymia with or without concurrent major depression. Patients with dysthymia had the worst outcomes, those with current major depression alone had intermediate outcomes, and those with subthreshold depressive symptoms had the best outcomes. Even the latter group, however, had a high incidence (25%) of major depressive episode over 2 years. Initial depression severity and level of functional status accounted for more explained variance in outcomes than did type of depressive disorder. CONCLUSIONS: The findings emphasize the poor prognosis associated with dysthymia even in the absence of major depression; the prognostic significance of subthreshold depressive symptoms; and the clinical significance of assessing level of severity of symptoms as well as functional status and well-being, regardless of type of depressive disorder.

Long-term effectiveness of disseminating quality improvement for depression in primary care.

BACKGROUND: This article addresses whether dissemination of short-term quality improvement (QI) interventions for depression to primary care practices improves patients' clinical outcomes and health-related quality of life (HRQOL) over 2 years, relative to usual care (UC). METHODS: The sample included 1299 patients with current depressive symptoms and 12-month, lifetime, or no depressive disorder from 46 primary care practices in 6 managed care organizations. Clinics were randomized to UC or 1 of 2 QI programs that included training local experts and nurse specialists to provide clinician and patient education, assessment, and treatment planning, plus either nurse care managers for medication follow-up (QI-meds) or access to trained psychotherapists (QI-therapy). Outcomes were assessed every 6 months for 2 years. RESULTS: For most outcomes, differences between intervention and UC patients were not sustained for the full 2 years. However, QI-therapy reduced overall poor outcomes compared with UC by about 8 percentage points throughout 2 years, and by 10 percentage points compared with QI-meds at 24 months. Both interventions improved patients' clinical and role outcomes, relative to UC, over 12 months (eg, a 10-11 and 6-7 percentage point difference in probable depression at 6 and 12 months, respectively). CONCLUSIONS: While most outcome improvements were not sustained over the full 2 study years, findings suggest that flexible dissemination of short-term, QI programs in managed primary care can improve patient outcomes well after program termination. Models that support integrated psychotherapy and medication-based treatment strategies in primary care have the potential for relatively long-term patient benefits.

Affective disorders in children and adolescents: addressing unmet need in primary care settings.

Affective disorders are common among children and adolescents but may often remain untreated. Primary care providers could help fill this gap because most children have primary care. Yet rates of detection and treatment for mental disorders generally are low in general health settings, owing to multiple child and family, clinician, practice, and healthcare system factors. Potential solutions may involve 1) more systematic implementation of programs that offer coverage for uninsured children; 2) tougher parity laws that offer equity in defined benefits and application of managed care strategies across physical and mental disorders; and 3) widespread implementation of quality improvement programs within primary care settings that enhance specialty/primary care collaboration, support use of care managers to coordinate care, and provide clinician training in clinically and developmentally appropriate principles of care for affective disorders. Research is needed to support development of these solutions and evaluation of their impacts.

Treatment research at the crossroads: the scientific interface of clinical trials and effectiveness research.

OBJECTIVE: Policy and clinical management decisions depend on data on the health and cost impacts of psychiatric treatments under usual care, i.e., effectiveness. Clinical trials, however, provide information on treatment efficacy under best-practice conditions. An understanding of the design, analysis, and conventions of both efficacy and effectiveness studies can lead to research that better informs clinical and societal questions. METHOD: This paper contrasts the strengths and limitations of clinical trials and effectiveness studies for addressing policy and clinical decisions. These research approaches are assessed in terms of outcomes, treatments, service delivery context, implementation conventions, and validity. RESULTS: Clinical trials and effectiveness research share problems of internal and external validity despite more attention to internal validity in clinical trials (e.g., randomization, blinding, standardized protocols) and to external validity in effectiveness studies (e.g., community-based treatments, representative samples). CONCLUSIONS: To develop research at the interface of clinical trials and effectiveness studies, research goals must be redefined, and methods, such as cost-utility and econometric analyses, must be shared and developed. Development of hybrid designs that combine features of efficacy and effectiveness research will require separation of conventions such as frequency of follow-up, intensity of measurement, and sample size from the central scientific issues of aims and validity.

Partial hospitalization (day treatment) for psychiatrically ill elderly patients.

OBJECTIVE: The purpose of this paper is to present initial findings from a retrospective chart review of geriatric day treatment patients in order to focus attention on this potentially important area, add to the limited database in this area, and generate hypotheses for future investigations. METHOD: Data were abstracted from the charts of 100 geriatric day treatment patients over a period of approximately 5 years (1985-1989). Descriptive, univariate, and multiple regression techniques were used to describe the patients and identify variables associated with their outcomes. RESULTS: The typical patient in this program was a widowed white woman in her 70s who suffered from a depressive disorder. During the initial treatment period (usually approximately 3 months), 57% of the patients experienced some clinical improvement. Variables associated with a favorable outcome included diagnosis of a mood disorder rather than a psychotic disorder, better initial functional status, greater initial social support, fewer stressful events during treatment, and longer duration of treatment. CONCLUSIONS: Geriatric day treatment can be effective and merits further study as a mode of treatment for psychiatrically ill elderly patients.

How do HMOs reduce outpatient mental health care costs?

OBJECTIVE: Because previous studies of differences in utilization of mental health care services have had important limitations, it is not clear if their findings that health maintenance organization (HMO) outpatient mental health care costs less than fee-for-service care are due to less access, less intensive care per user, or selective enrollment of healthier people by HMOs. Therefore, the authors used data from the National Institute of Mental Health Epidemiologic Catchment Area (ECA) study to examine differences in the prevalence of psychiatric disorder and differences in the use of outpatient mental health services for adults enrolled in HMO or fee-for-service health insurance plans. METHOD: The subjects were an ECA community sample obtained from East Los Angeles and West Los Angeles. This sample included a large number of Hispanic subjects. The subjects were categorized according to their responses to a 5-item battery on insurance as Medicare enrolles, members of private fee-for-service plans, Medicaid enrollees, members of an HMO, and uninsured. The presence or absence of psychiatric disorders was determined by using the NIMH Diagnostic Interview Schedule. Both users and nonusers of mental health services were studied. RESULTS: The HMO and fee-for-service plans had similar prevalence of psychiatric disorder and similar access to specialty mental health care. However, HMO enrollees had significantly fewer visits per user to providers of specialty care. CONCLUSIONS: The most likely explanation for lower mental health care costs in HMOs is a less intensive style of care for a comparably sick population.

Use of outpatient mental health services over time in a health maintenance organization and fee-for-service plans.

The authors compared the use of outpatient mental health services in a health maintenance organization (HMO) and fee-for-service plans over a 5-year period, using data from a randomized controlled trial. In any given year, enrollees in the HMO and a fee-for-service plan with identical benefits were equally likely to visit a mental health specialist. Over several years, the HMO enrollees were about 50% more likely ever to visit a mental health specialist; fee-for-service enrollees were more likely to receive mental health care in more than 1 study year.

Identifying modifiable risk factors for rehospitalization: a case-control study of seriously mentally ill persons in Mississippi.

OBJECTIVE: The authors sought to identify risk factors for rehospitalization in a seriously mentally ill population, focusing on factors that have the potential to be modified through community-based interventions. METHOD: A case-control design was used in which 101 "case" subjects (recently readmitted psychiatric patients) and a comparison group of 101 subjects living in the community who had been previously hospitalized at the same time as the case subjects, but who in contrast had not been readmitted, were matched on gender, ethnicity, and length of time at risk for rehospitalization. The setting was the Mississippi public mental health system during the first 3 months of 1988, including Mississippi State Hospital and the 10 community mental health regions in its catchment area. The subjects were between the ages of 18 and 55 years, had had at least one previous Mississippi State Hospital admission, and had a primary chart diagnosis of schizophrenia; 197 informants, mostly family members, were also included in the study. Data were collected from structured interviews of subjects and informants, direct observation ratings of subjects, Mississippi State Hospital administrative records, and community mental health center administrative records. RESULTS: Medication noncompliance, comorbid alcohol abuse, and a high level of criticism of subjects by informants were associated with greater risk of rehospitalization, while types and extent of outpatient service use, access to care, quality of life, and demographic variables (other than ethnicity and gender) were not. CONCLUSIONS: These findings imply that interventions aimed at improving medication compliance, reducing alcohol abuse, and helping families cope with their mentally ill relatives could reduce the risk of hospitalization in this population.

Functioning and well-being of patients with panic disorder.

OBJECTIVE: The authors compared the health-related quality of life of patients with panic disorder to that of patients with other major chronic medical and psychiatric conditions. METHOD: The physical and mental health of a group of 433 patients with current panic disorder and 9,839 outpatients with psychiatric or medical disorders were assessed with the 20- and 36-item short-form surveys of the Medical Outcomes Study. After controlling for other disease conditions, demographics, and study site, the authors used multiple regression methods to estimate health-related quality of life levels for panic disorder patients and patients with hypertension, diabetes, heart disease, arthritis, chronic lung problems, and major depression. RESULTS: Patients with panic disorder had levels of mental health and role functioning that were substantially lower than those of patients with other major chronic medical illnesses but were higher than or comparable to those of patients with depression. However, their physical functioning levels and perceptions of current health were more like those of patients with hypertension and were similar to general population norms. CONCLUSIONS: Panic disorder is a serious societal health problem with large consequences, and it affects primarily psychological and role domains.