Treatment Differences in Primary and Specialty Settings in Veterans with Major Depression.

INTRODUCTION: The Veterans Health Administration (VHA) supports the nation's largest primary care-mental health integration (PC-MHI) collaborative care model to increase treatment of mild to moderate common mental disorders in primary care (PC) and refer more severe-complex cases to specialty mental health (SMH) settings. It is unclear how this treatment assignment works in practice. METHODS: Patients (n = 2610) who sought incident episode VHA treatment for depression completed a baseline self-report questionnaire about depression severity-complexity. Administrative data were used to determine settings and types of treatment during the next 30 days. RESULTS: Thirty-four percent (34.2%) of depressed patients received treatment in PC settings, 65.8% in SMH settings. PC patients had less severe and fewer comorbid depressive episodes. Patients with lowest severity and/or complexity were most likely to receive PC antidepressant medication treatment; those with highest severity and/or complexity were most likely to receive combined treatment in SMH settings. Assignment of patients across settings and types of treatment was stronger than found in previous civilian studies but less pronounced than expected (cross-validated AUC = 0.50-0.68). DISCUSSION: By expanding access to evidence-based treatments, VHA's PC-MHI increases consistency of treatment assignment. Reasons for assignment being less pronounced than expected and implications for treatment response will require continued study.

Inequality and mental healthcare utilisation among first-year university students in South Africa.

BACKGROUND: Addressing inequalities in mental healthcare utilisation among university students is important for socio-political transformation, particularly in countries with a history of educational exclusion. METHODS: As part of the WHO World Mental Health International College Student Initiative, we investigated inequalities in mental healthcare utilisation among first-year students at two historically "White" universities in South Africa. Data were collected via a web-based survey from first-year university students (n = 1402) to assess 12-month mental healthcare utilisation, common mental disorders, and suicidality. Multivariate logistic regression models were used to estimate associations between sociodemographic variables and mental healthcare utilisation, controlling for common mental disorders and suicidality. RESULTS: A total of 18.1% of students utilised mental healthcare in the past 12 months, with only 28.9% of students with mental disorders receiving treatment (ranging from 28.1% for ADHD to 64.3% for bipolar spectrum disorder). Of those receiving treatment, 52.0% used psychotropic medication, 47.3% received psychotherapy, and 5.4% consulted a traditional healer. Treatment rates for suicidal ideation, plan and attempt were 25.4%, 41.6% and 52.9%, respectively. In multivariate regression models that control for the main effects of mental health variables and all possible joint effects of sociodemographic variables, the likelihood of treatment was lower among males (aOR = 0.57) and Black students (aOR = 0.52). An interaction was observed between sexual orientation and first generation status; among second-generation students, the odds of treatment were higher for students reporting an atypical sexual orientation (aOR = 1.55), while among students with atypical sexual orientations, the likelihood of mental healthcare utilisation was lower for first-generation students (aOR = 0.29). Odds of treatment were significantly elevated among students with major depressive disorder (aOR = 1.88), generalised anxiety disorder (aOR = 2.34), bipolar spectrum disorder (aOR = 4.07), drug use disorder (aOR = 3.45), suicidal ideation (without plan or attempt) (aOR = 2.00), suicide plan (without attempt) (aOR = 3.64) and suicide attempt (aOR = 4.57). Likelihood of treatment increased with level of suicidality, but not number of mental disorders. CONCLUSION: We found very low mental healthcare treatment utilisation among first-year university students in South Africa, with enduring disparities among historically marginalised groups. Campus-based interventions are needed to promote mental healthcare utilisation by first-year students in South Africa, especially among male and Black students and first-generation students with atypical sexual orientations.

Services for adolescents with psychiatric disorders: 12-month data from the National Comorbidity Survey-Adolescent.

OBJECTIVE: This study examined 12-month rates of service use for mental, emotional, and behavioral disorders among adolescents. METHODS: Data were from the National Comorbidity Survey Adolescent Supplement (NCS-A), a survey of DSM-IV mental, emotional, and behavioral disorders and service use. RESULTS: In the past 12 months, 45.0% of adolescents with psychiatric disorders received some form of service. The most likely were those with ADHD (73.8%), conduct disorder (73.4%), or oppositional defiant disorder (71.0%). Least likely were those with specific phobias (40.7%) and any anxiety disorder (41.4%). Among those with any disorder, services were more likely to be received in a school setting (23.6%) or in a specialty mental health setting (22.8%) than in a general medical setting (10.1%). Youths with any disorder also received services in juvenile justice settings (4.5%), complementary and alternative medicine (5.3%), and human services settings (7.9%). Although general medical providers treated a larger proportion of youths with mood disorders than with behavior disorders, they were more likely to treat youths with behavior disorders because of the larger number of the latter (11.5% of 1,465 versus 13.9% of 820). Black youths were significantly less likely than white youths to receive specialty mental health or general medical services for mental disorders. CONCLUSIONS: Findings from this analysis of NCS-A data confirm those of earlier, smaller studies, that only a minority of youths with psychiatric disorders receive treatment of any sort. Much of this treatment was provided in service settings in which few providers were likely to have specialist mental health training.

Comorbidity of common mental disorders with cancer and their treatment gap: findings from the World Mental Health Surveys.

OBJECTIVE: This study aimed to study the comorbidity of common mental disorders (CMDs) and cancer, and the mental health treatment gap among community residents with active cancer, cancer survivors and cancer-free respondents in 13 high-income and 11 low-middle-income countries. METHODS: Data were derived from the World Mental Health Surveys (N = 66,387; n = 357 active cancer, n = 1373 cancer survivors, n = 64,657 cancer-free respondents). The World Health Organization/Composite International Diagnostic Interview was used in all surveys to estimate CMDs prevalence rates. Respondents were also asked about mental health service utilization in the preceding 12 months. Cancer status was ascertained by self-report of physician's diagnosis. RESULTS: Twelve-month prevalence rates of CMDs were higher among active cancer (18.4%, SE = 2.1) than cancer-free respondents (13.3%, SE = 0.2) adjusted for sociodemographic confounders and other lifetime chronic conditions (adjusted odds ratio (AOR) = 1.44, 95% CI 1.05-1.97). CMD rates among cancer survivors (14.6%, SE = 0.9) compared with cancer-free respondents did not differ significantly (AOR = 0.95, 95% CI 0.82-1.11). Similar patterns characterized high-income and low-middle-income countries. Of respondents with active cancer who had CMD in the preceding 12 months, 59% sought services for mental health problems (SE = 5.3). The pattern of service utilization among people with CMDs by cancer status (highest among persons with active cancer, lower among survivors and lowest among cancer-free respondents) was similar in high-income (64.0%, SE = 6.0; 41.2%, SE = 3.0; 35.6%, SE = 0.6) and low-middle-income countries (46.4%, SE = 11.0; 22.5%, SE = 9.1; 17.4%, SE = 0.7). CONCLUSIONS: Community respondents with active cancer have higher CMD rates and high treatment gap. Comprehensive cancer care should consider both factors.

Dropout from outpatient mental health care in the United States.

OBJECTIVE: Although mental health treatment dropout is common, patterns and predictors of dropout are poorly understood. This study explored patterns and predictors of mental health treatment dropout in a nationally representative sample. METHODS: Data were from the National Comorbidity Survey Replication, a nationally representative household survey. Respondents who had received mental health treatment in the 12 months before the interview (N=1,664) were asked about dropout, which was defined as quitting treatment before the provider wanted them to stop. Cross-tabulation and discrete-time survival analyses were used to identify predictors. RESULTS: Approximately one-fifth (22%) of patients quit treatment prematurely. The highest dropout rate was from treatment received in the general medical sector (32%), and the lowest was from treatment received by psychiatrists (15%). Dropout rates were intermediate from treatment in the human services sector (20%) and among patients seen by nonpsychiatrist mental health professionals (19%). Over 70% of all dropout occurred after the first or second visits. Mental health insurance was associated with low odds of dropout (odds ratio=.6, 95% confidence interval=.4-.9). Psychiatric comorbidity was associated with a trend toward dropout. Several patient characteristics differentially predicted dropout across treatment sectors and in early and later phases of treatment. CONCLUSIONS: Roughly one-fifth of adults in mental health treatment dropped out before completing the recommended course of treatment. Dropout was most common in the general medical sector and varied by patient characteristics across treatment sectors. Interventions focused on high-risk patients and sectors that have higher dropout rates will likely be required to reduce the large proportion of patients who prematurely terminate treatment.

The impact of an integrated population health enhancement and disease management program on employee health risk, health conditions, and productivity.

This study evaluated the impact of an integrated population health enhancement program on employee health risks, health conditions, and productivity. Specifically, we analyzed changes in these measures among a cohort of 543 employees who completed a health risk assessment in both 2003 and 2005. We compared these findings with 2 different sets of employees who were not offered health enhancement programming. We found that the DIRECTV cohort showed a significant reduction in health risks after exposure to the program. Relative to a matched comparison group, the proportion of low-risk employees at DIRECTV in 2005 was 8.2 percentage points higher; the proportion of medium-risk employees was 7.1 percentage points lower; and the proportion of high-risk employees was 1.1 percentage points lower (p < 0.001). The most noticeable changes in health risk were a reduction in the proportion of employees with high cholesterol; an improvement in diet; a reduction of heavy drinking; management of high blood pressure; improved stress management; increased exercise; fewer smokers; and a drop in obesity rates. We also found that a majority of employees who improved their risk levels from 2003 to 2005 maintained their gains in 2006. Employees who improved their risks levels also demonstrated relative improvement in absenteeism. Overall, this study provides additional evidence that integrated population health enhancement positively impacts employees' health risk and productivity; it also reinforces the view that "good health is good business."

Understanding mental health treatment in persons without mental diagnoses: results from the National Comorbidity Survey Replication.

CONTEXT: Epidemiologic surveys have consistently found that approximately half of respondents who obtained treatment for mental or substance use disorders in the year before interview did not meet the criteria for any of the disorders assessed in the survey. Concerns have been raised that this pattern might represent evidence of misallocation of treatment resources. OBJECTIVE: To examine patterns and correlates of 12-month treatment of mental health or substance use problems among people who do not have a 12-month DSM-IV disorder. DESIGN AND SETTING: Data are from the National Comorbidity Survey Replication, a nationally representative face-to-face US household survey performed between February 5, 2001, and April 7, 2003, that assessed DSM-IV disorders using a fully structured diagnostic interview, the World Health Organization Composite International Diagnostic Interview (CIDI). PARTICIPANTS: A total of 5692 English-speaking respondents 18 years and older. MAIN OUTCOME MEASURES: Patterns of 12-month service use among respondents without any 12-month DSM-IV CIDI disorders. RESULTS: Of respondents who used 12-month services, 61.2% had a 12-month DSM-IV CIDI diagnosis, 21.1% had a lifetime but not a 12-month diagnosis, and 9.7% had some other indicator of possible need for treatment (subthreshold 12-month disorder, serious 12-month stressor, or lifetime hospitalization). The remaining 8.0% of service users accounted for only 5.6% of all services and even lower proportions of specialty (1.9%-2.4%) and general medical (3.7%) visits compared with higher proportions of human services (18.9%) and complementary and alternative medicine (7.6%) visits. Only 26.5% of the services provided to the 8.0% of presumably low-need patients were delivered in the mental health specialty or general medical sectors. CONCLUSIONS: Most services provided for emotional or substance use problems in the United States go to people with a 12-month diagnosis or other indicators of need. Patients who lack these indicators of need receive care largely outside the formal health care system.

Health and productivity as a business strategy.

OBJECTIVE: The objective of this study is to assess the magnitude of health-related lost productivity relative to medical and pharmacy costs for four employers and assess the business implications of a "full-cost" approach to managing health. METHODS: A database was developed by integrating medical and pharmacy claims data with employee self-report productivity and health information collected through the Health and Work Performance Questionnaire (HPQ). Information collected on employer business measures were combined with this database to model health-related lost productivity. RESULTS: 1) Health-related productivity costs were more than four times greater than medical and pharmacy costs. 2) The full cost of poor health is driven by different health conditions than those driving medical and pharmacy costs alone. CONCLUSIONS: This study demonstrates that Integrated Population Health & Productivity Management should be built on a foundation of Integrated Population Health & Productivity Measurement. Therefore, employers would reveal a blueprint for action for their integrated health and productivity enhancement strategies by measuring the full health and productivity costs related to the burdens of illness and health risk in their population.

The effects of copayments on medication adherence during the first two years of prescription drug treatment.

OBJECTIVE: The aim of this study was to examine effects of initial prescription copayment size and observed increase on adherence by analyzing data from a managed care database. METHODS: Medical-pharmacy claims data were abstracted from the Integrated Health Care Information Services (IHCIS) National Managed Care Benchmark database for primary employer-sponsored subscribers. Incident fills and refills for the 10 most common medication groups between 2001 and 2003 were predicted by size and observed increase in copayment with the use of survival analysis. RESULTS: High copayments and observed copayment increases were associated with termination of medication use. Whereas effects of copayment level were limited to the first few fills, effects of observed increases in copayments were persistent. CONCLUSIONS: The strategy of increasing initially low copayments after the patient has made enough fills to become insensitive to copayment level is contraindicated by observed increases in copayment, predicting termination. However, other financial incentives might nonetheless help reduce early termination of medication use.

The use of complementary and alternative medicine in the general population: results from a longitudinal community study.

BACKGROUND: Many patients with psychological or physical problems are interested in non-medical approaches. The reasons for the growing popularity of complementary and alternative medicine (CAM) are not well understood considering that evidence of the effectiveness of conventional therapies is greater than ever before. We have examined data from the Zurich Study to determine trends and predictors of CAM use in Switzerland. METHOD: The Zurich Study is a longitudinal community study that was started in 1979 with a sample of 591 participants born in 1958 and 1959. In 1999, the last of six interview waves with face-to-face interviews was conducted. CAM use was analyzed with data from interviews in 1993 and 1999. Polytomous logistic regression analysis focused on the personal, demographic and sociocultural background of CAM users. RESULTS: CAM use in the last 12 months was reported by 21.9% of the participants in 1993 and by 29.5% in 1999. CAM use among those exhibiting either physical or psychological problems was in the ratio of two to one. There was a trend from alternative variants of CAM (homeopathy) to complementary ones (massage, osteopathy, acupuncture). The vast majority of CAM use was in addition to conventional therapies. Predictors of CAM use were, among others, attribution of physical complaints to stress and other psychological variables, very low education level in parents, and lacking political interest. CONCLUSIONS: Besides the sociocultural background, characteristics such as the psychological attribution style play an important role in CAM use. CAM use in Switzerland is mainly of a complementary rather than an alternative nature.

Changing profiles of service sectors used for mental health care in the United States.

OBJECTIVE: Redesigning the fragmented U.S. mental health care system requires knowing how service sectors share responsibility for individuals' mental health needs. METHOD: Twelve-month DSM-IV mental disorders and their severity were assessed in respondents ages 15-54 from the National Comorbidity Survey (NCS) in 1990-1992 (N=5,388) and the NCS Replication in 2001-2003 (N=4,319). Six profiles involving potentially multiple service sectors were defined, including those in which pharmacotherapy plus psychotherapy (psychiatry profile, general medical with other mental health specialty profile), single modalities (general medical only profile, other mental health specialty only profile), or neither modality (human services only profile, complementary/alternative medicine only profile) could potentially have been received. The use of profiles was compared between surveys. RESULTS: The general medical only profile experienced the largest proportional increase (153%) between surveys and is now the most common profile. The psychiatry profile also increased (29%), as did the general medical with other mental health specialty profile (72%). The other mental health specialty only (-73%), the complementary/alternative medicine only (-132%), and the human services only (-137%) profiles all decreased in use. The elderly, women, minorities, the less educated, and rural dwellers were less likely to use profiles capable of delivering pharmacotherapies and/or psychotherapies. CONCLUSIONS: How service sectors share responsibility for peoples' mental health care is changing, with more care falling to general medical providers rather than specialists. Efforts are required to ensure that people who would benefit have access to the necessary treatment modalities.

Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication.

BACKGROUND: Dramatic changes have occurred in mental health treatments during the past decade. Data on recent treatment patterns are needed to estimate the unmet need for services. OBJECTIVE: To provide data on patterns and predictors of 12-month mental health treatment in the United States from the recently completed National Comorbidity Survey Replication. DESIGN AND SETTING: Nationally representative face-to-face household survey using a fully structured diagnostic interview, the World Health Organization's World Mental Health Survey Initiative version of the Composite International Diagnostic Interview, carried out between February 5, 2001, and April 7, 2003. PARTICIPANTS: A total of 9282 English-speaking respondents 18 years and older. MAIN OUTCOME MEASURES: Proportions of respondents with 12-month DSM-IV anxiety, mood, impulse control, and substance disorders who received treatment in the 12 months before the interview in any of 4 service sectors (specialty mental health, general medical, human services, and complementary and alternative medicine). Number of visits and proportion of patients who received minimally adequate treatment were also assessed. RESULTS: Of 12-month cases, 41.1% received some treatment in the past 12 months, including 12.3% treated by a psychiatrist, 16.0% treated by a non-psychiatrist mental health specialist, 22.8% treated by a general medical provider, 8.1% treated by a human services provider, and 6.8% treated by a complementary and alternative medical provider (treatment could be received by >1 source). Overall, cases treated in the mental health specialty sector received more visits (median, 7.4) than those treated in the general medical sector (median, 1.7). More patients in specialty than general medical treatment also received treatment that exceeded a minimal threshold of adequacy (48.3% vs 12.7%). Unmet need for treatment is greatest in traditionally underserved groups, including elderly persons, racial-ethnic minorities, those with low incomes, those without insurance, and residents of rural areas. CONCLUSIONS: Most people with mental disorders in the United States remain either untreated or poorly treated. Interventions are needed to enhance treatment initiation and quality.