The Mental Health Parity and Addiction Equity Act Evaluation Study: Impact on Specialty Behavioral Health Care Utilization and Spending Among Carve-In Enrollees

OBJECTIVE

The federal Mental Health Parity and Addiction Equity Act (MHPAEA) sought to eliminate historical disparities between insurance coverage for behavioral health (BH) treatment and coverage for medical treatment. Our objective was to evaluate MHPAEA's impact on BH expenditures and utilization among "carve-in" enrollees.

METHODS

We received specialty BH insurance claims and eligibility data from Optum, sampling 5,987,776 adults enrolled in self-insured plans from large employers. An interrupted time series study design with segmented regression analysis estimated monthly time trends of per-member spending and use before (2008-2009), during (2010), and after (2011-2013) MHPAEA compliance (N=179,506,951 member-month observations). Outcomes included: total, plan, patient out-of-pocket spending; outpatient utilization (assessment/diagnostic evaluation visits, medication management, individual and family psychotherapy); intermediate care utilization (structured outpatient, day treatment, residential); and inpatient utilization.

RESULTS

MHPAEA was associated with increases in monthly per-member total spending, plan spending, assessment/diagnostic evaluation visits [respective immediate increases of: $1.05 (P=0.02); $0.88 (P=0.04); 0.00045 visits (P=0.00)], and individual psychotherapy visits [immediate increase of 0.00578 visits (P=0.00) and additional increases of 0.00017 visits/mo (P=0.03)].

CONCLUSIONS

MHPAEA was associated with modest increases in total and plan spending and outpatient utilization; for example, in July 2012 predicted per-enrollee plan spending was $4.92 without MHPAEA and $6.14 with MHPAEA. Efforts should focus on understanding how other barriers to BH care unaddressed by MHPAEA may affect access/utilization. Future research should evaluate effects produced by the Affordable Care Act's inclusion of BH care as an essential health benefit and expansion of MHPAEA protections to the individual and small group markets.

The Mental Health Parity and Addiction Equity Act evaluation study: Impact on specialty behavioral health utilization and expenditures among "carve-out" enrollees

Interrupted time series with and without controls was used to evaluate whether the federal Mental Health Parity and Addiction Equity Act (MHPAEA) and its Interim Final Rule increased the probability of specialty behavioral health treatment and levels of utilization and expenditures among patients receiving treatment. Linked insurance claims, eligibility, plan and employer data from 2008 to 2013 were used to estimate segmented regression analyses, allowing for level and slope changes during the transition (2010) and post-MHPAEA (2011-2013) periods. The sample included 1,812,541 individuals ages 27-64 (49,968,367 person-months) in 10,010 Optum "carve-out" plans. Two-part regression models with Generalized Estimating Equations were used to estimate expenditures by payer and outpatient, intermediate and inpatient service use. We found little evidence that MHPAEA increased utilization significantly, but somewhat more robust evidence that costs shifted from patients to plans. Thus the primary impact of MHPAEA among carve-out enrollees may have been a reduction in patient financial burden.

The Fracture of Relational Space in Depression: Predicaments in Primary Care Help Seeking

Primary care clinicians treat the majority of cases of depression in the United States. The primary care clinic is also a site for enactment of a disease-oriented concept of depression that locates disorder within an individual body. Drawing on theories of the self and stigma, this article highlights problematics of primary care depression treatment by examining the lived experience of depression. The data come from individuals who screened positive for depressive symptoms in primary care settings and were followed over ten years. After iterative mixed-methodological exploration of a large dataset, we analyzed interviews from a purposive sample of 46 individuals using grounded and phenomenological approaches. We describe two major results. First, we note that depression is experienced as located within and inextricable from relational space and that the self is experienced as relational, rather than autonomous, in depression. Second, we describe the ways in which the experience of depression contradicts a disease-oriented concept such that help-seeking intensifies rather than alleviates the relational problem of depression. We conclude by highlighting that an understanding of illness experience may be essential to improving primary care depression treatment and by questioning the bracketing of relational concerns in depression within the construct of stigma.

Consumer-Involved Participatory Research to Address General Medical Health and Wellness in a Community Mental Health Setting

Barriers to sustainably implementing general medical interventions in community mental health (CMH) settings include role uncertainty, consumer engagement, workforce limitations, and sustainable reimbursement. To address these barriers, this project used a community-partnered participatory research framework to create a stakeholder-based general medical and wellness intervention in a large CMH organization, with consumers involved in all decision-making processes. Consumers faced practical barriers to participating in organizational decision making, but their narratives were critical in establishing priorities and ensuring sustainability. Addressing baseline knowledge and readiness of stakeholders and functional challenges to consumer involvement can aid stakeholder-based approaches to implementing general medical interventions in CMH settings.

Comorbid depression and substance abuse among safety-net clients in Los Angeles: a community participatory study

OBJECTIVE

Depression and substance abuse are common among low-income adults from racial-ethnic minority groups who receive services in safety-net settings, although little is known about how clients differ by service setting. This study examined characteristics and service use among depressed, low-income persons from minority groups in underresourced communities who did and did not have a substance abuse history.

METHODS

The study used cross-sectional baseline client data (N=957) from Community Partners in Care, an initiative to improve depression services in Los Angeles County. Clients with probable depression (eight-item Patient Health Questionnaire) from substance abuse programs were compared with depressed clients with and without a history of substance abuse from primary care, mental health, and social and community programs. Sociodemographic, health status, and services utilization variables were examined.

RESULTS

Of the 957 depressed clients, 217 (23%) were from substance abuse programs; 269 (28%) clients from other sectors had a substance abuse history, and 471 (49%) did not. Most clients from substance abuse programs or with a substance abuse history were unemployed and impoverished, lacked health insurance, and had high rates of arrests and homelessness. They were also more likely than clients without a substance abuse history to have depression or anxiety disorders, psychosis, and mania and to use emergency rooms.

CONCLUSIONS

Clients with depression and a substance abuse history had significant psychosocial stressors and high rates of service use, which suggests that communitywide approaches may be needed to address both depression and substance abuse in this safety-net population.

12-month outcomes of community engagement versus technical assistance to implement depression collaborative care: a partnered, cluster, randomized, comparative effectiveness trial

BACKGROUND

Depression collaborative care implementation using community engagement and planning (CEP) across programs improves 6-month client outcomes in minority communities, compared with technical assistance to individual programs (resources for services [RS]). However, 12-month outcomes are unknown.

OBJECTIVE

To compare effects of CEP and RS on mental health-related quality of life (MHRQL) and use of services among depressed clients at 12 months.

DESIGN

Matched health and community programs (n = 93) in 2 communities randomly assigned to receive CEP or RS. (ClinicalTrials.gov: NCT01699789).

MEASUREMENTS

Self-reported MHRQL and services use at baseline, 6 months, and 12 months.

SETTING

Los Angeles, California.

PATIENTS

1018 adults with depressive symptoms (8-item Patient Health Questionnaire score ≥10), 88% of whom were an ethnic minority.

INTERVENTION

CEP and RS to implement depression collaborative care.

MEASUREMENTS

The primary outcome was poor MHRQL (12-item mental health composite score ≤40) at baseline, 6 months, and 12 months; the secondary outcome was use of services at 12 months.

RESULTS

At 6 months, the finding that CEP outperformed RS to reduce poor MHRQL was significant but sensitive to underlying statistical assumptions. At 12 months, some analyses suggested that CEP was advantageous to MHRQL, whereas others did not confirm a significant difference favoring CEP. The finding that CEP reduced behavioral health hospitalizations at 6 months was less evident at 12 months and was sensitive to underlying statistical assumptions. Other services use did not significantly differ between interventions at 12 months.

LIMITATION

Data are self-reported, and findings are sensitive to modeling assumptions.

CONCLUSION

In contrast to 6-month results, no consistent effects of CEP on reducing the likelihood of poor MHRQL and behavioral health hospitalizations were found at 12 months. Still, given the needs of underresourced communities, the favorable profile of CEP, and the lack of evidence-based alternatives, CEP remains a viable strategy for policymakers and communities to consider.

PRIMARY FUNDING SOURCE

National Institute of Mental Health, Robert Wood Johnson Foundation, California Community Foundation, National Library of Medicine, and National Institutes of Health/National Center for Advancing Translational Science for the UCLA Clinical and Translational Science Institute.

The anatomy of primary care and mental health clinician communication: a quality improvement case study

BACKGROUND

The high prevalence of comorbid physical and mental illnesses among veterans is well known. Therefore, ensuring effective communication between primary care (PC) and mental health (MH) clinicians in the Veterans Affairs (VA) health care system is essential. The VA's Patient Aligned Care Teams (PACT) initiative has further raised awareness of the need for communication between PC and MH. Improving such communication, however, has proven challenging.

OBJECTIVE

To qualitatively understand barriers to PC-MH communication in an academic community-based clinic by using continuous quality improvement (CQI) tools and then initiate a change strategy.

DESIGN, PARTICIPANTS, AND APPROACH

An interdisciplinary quality improvement (QI) work group composed of 11 on-site PC and MH providers, administrators, and researchers identified communication barriers and facilitators using fishbone diagrams and process flow maps. The work group then verified and provided context for the diagram and flow maps through medical record review (32 patients who received both PC and MH care), interviews (6 stakeholders), and reports from four previously completed focus groups. Based on these findings and a previous systematic review of interventions to improve interspecialty communication, the team initiated plans for improvement.

KEY RESULTS

Key communication barriers included lack of effective standardized communication processes, practice style differences, and inadequate PC training in MH. Clinicians often accessed advice or formal consultation based on pre-existing across-discipline personal relationships. The work group identified collocated collaborative care, joint care planning, and joint case conferences as feasible, evidence-based interventions for improving communication.

CONCLUSIONS

CQI tools enabled providers to systematically assess local communication barriers and facilitators and engaged stakeholders in developing possible solutions. A locally tailored CQI process focusing on communication helped initiate change strategies and ongoing improvement efforts.

Older depressed Latinos' experiences with primary care visits for personal, emotional and/or mental health problems: a qualitative analysis

OBJECTIVE

To describe salient experiences with a primary care visit (eg, the context leading up to the visit, the experience and/or outcomes of that visit) for emotional, personal and/or mental health problems older Latinos with a history of depression and recent depressive symptoms and/or antidepressant medication use reported 10 years after enrollment into a randomized controlled trial of quality-improvement for depression in primary care.

DESIGN

Secondary analysis of existing qualitative data from the second stage of the continuation study of Partners in Care (PIC).

PARTICIPANTS

Latino ethnicity, aged > or =50 years, recent depressive symptoms and/or antidepressant medication use, and a recent primary care visit for mental health problems. Of 280 second-stage participants, 47 were eligible. Both stages of the continuation study included participants from the PIC parent study control and 2 intervention groups, and all had a history of depression.

METHODS

Data analyzed by a multidisciplinary team using grounded theory methodology.

RESULTS

Five themes were identified: beliefs about the nature of depression; prior experiences with mental health disorders/treatments; sociocultural context (eg, social relationships, caregiving, the media); clinic-related features (eg, accessibility of providers, staff continuity, amount of visit time); and provider attributes (eg, interpersonal skills, holistic care approach).

CONCLUSIONS

Findings emphasize the importance of key features for shaping the context leading up to primary care visits for help-seeking for mental health problems, and the experience and/or outcomes of those visits, among older depressed Latinos at long-term follow-up, and may help tailor chronic depression care for the clinical management of this vulnerable population.

Community-partnered cluster-randomized comparative effectiveness trial of community engagement and planning or resources for services to address depression disparities

BACKGROUND

Depression contributes to disability and there are ethnic/racial disparities in access and outcomes of care. Quality improvement (QI) programs for depression in primary care improve outcomes relative to usual care, but health, social and other community-based service sectors also support clients in under-resourced communities. Little is known about effects on client outcomes of strategies to implement depression QI across diverse sectors.

OBJECTIVE

To compare the effectiveness of Community Engagement and Planning (CEP) and Resources for Services (RS) to implement depression QI on clients' mental health-related quality of life (HRQL) and services use.

DESIGN

Matched programs from health, social and other service sectors were randomized to community engagement and planning (promoting inter-agency collaboration) or resources for services (individual program technical assistance plus outreach) to implement depression QI toolkits in Hollywood-Metro and South Los Angeles.

PARTICIPANTS

From 93 randomized programs, 4,440 clients were screened and of 1,322 depressed by the 8-item Patient Health Questionnaire (PHQ-8) and providing contact information, 1,246 enrolled and 1,018 in 90 programs completed baseline or 6-month follow-up.

MEASURES

Self-reported mental HRQL and probable depression (primary), physical activity, employment, homelessness risk factors (secondary) and services use.

RESULTS

CEP was more effective than RS at improving mental HRQL, increasing physical activity and reducing homelessness risk factors, rate of behavioral health hospitalization and medication visits among specialty care users (i.e. psychiatrists, mental health providers) while increasing depression visits among users of primary care/public health for depression and users of faith-based and park programs (each p < 0.05). Employment, use of antidepressants, and total contacts were not significantly affected (each p > 0.05).

CONCLUSION

Community engagement to build a collaborative approach to implementing depression QI across diverse programs was more effective than resources for services for individual programs in improving mental HRQL, physical activity and homelessness risk factors, and shifted utilization away from hospitalizations and specialty medication visits toward primary care and other sectors, offering an expanded health-home model to address multiple disparities for depressed safety-net clients.

Community-partnered evaluation of depression services for clients of community-based agencies in under-resourced communities in Los Angeles

BACKGROUND

As medical homes are developing under health reform, little is known regarding depression services need and use by diverse safety-net populations in under-resourced communities. For chronic conditions like depression, primary care services may face new opportunities to partner with diverse community service providers, such as those in social service and substance abuse centers, to support a collaborative care model of treating depression.

OBJECTIVE

To understand the distribution of need and current burden of services for depression in under-resourced, diverse communities in Los Angeles.

DESIGN

Baseline phase of a participatory trial to improve depression services with data from client screening and follow-up surveys.

PARTICIPANTS

Of 4,440 clients screened from 93 programs (primary care, mental health, substance abuse, homeless, social and other community services) in 50 agencies, 1,322 were depressed according to an eight-item Patient Health Questionnaire (PHQ-8) and gave contact information; 1,246 enrolled and 981 completed surveys. Ninety-three programs, including 17 primary care/public health, 18 mental health, 20 substance abuse, ten homeless services, and 28 social/other community services, participated.

MAIN MEASURES

Comparisons by setting in 6-month retrospective recall of depression services use.

KEY RESULTS

Depression prevalence ranged from 51.9 % in mental health to 17.2 % in social-community programs. Depressed clients used two settings on average to receive depression services; 82 % used any setting. More clients preferred counseling over medication for depression treatment.

CONCLUSIONS

Need for depression care was high, and a broad range of agencies provide depression care. Although most participants had contact with primary care, most depression services occurred outside of primary care settings, emphasizing the need to coordinate and support the quality of community-based services across diverse community settings.

Community engagement in disaster preparedness and recovery: a tale of two cities--Los Angeles and New Orleans

Awareness of the impact of disasters globally on mental health is increasing. Known difficulties in preparing communities for disasters and a lack of focus on relationship building and organizational capacity in preparedness and response have led to a greater policy focus on community resiliency as a key public health approach to disaster response. In this article, the authors describe how an approach to community engagement for improving mental health services, disaster recovery, and preparedness from a community resiliency perspective emerged from their work in applying a partnered, participatory research framework, iteratively, in Los Angeles County and the City of New Orleans.

Getting actionable about community resilience: the Los Angeles County Community Disaster Resilience project

Community resilience (CR)--ability to withstand and recover from a disaster--is a national policy expectation that challenges health departments to merge disaster preparedness and community health promotion and to build stronger partnerships with organizations outside government, yet guidance is limited. A baseline survey documented community resilience-building barriers and facilitators for health department and community-based organization (CBO) staff. Questions focused on CBO engagement, government-CBO partnerships, and community education. Most health department staff and CBO members devoted minimal time to community disaster preparedness though many serve populations that would benefit. Respondents observed limited CR activities to activate in a disaster. The findings highlighted opportunities for engaging communities in disaster preparedness and informed the development of a community action plan and toolkit.

Building community disaster resilience: perspectives from a large urban county department of public health

An emerging approach to public health emergency preparedness and response, community resilience encompasses individual preparedness as well as establishing a supportive social context in communities to withstand and recover from disasters. We examine why building community resilience has become a key component of national policy across multiple federal agencies and discuss the core principles embodied in community resilience theory-specifically, the focus on incorporating equity and social justice considerations in preparedness planning and response. We also examine the challenges of integrating community resilience with traditional public health practices and the importance of developing metrics for evaluation and strategic planning purposes. Using the example of the Los Angeles County Community Disaster Resilience Project, we discuss our experience and perspective from a large urban county to better understand how to implement a community resilience framework in public health practice.

Applying community engagement to disaster planning: developing the vision and design for the Los Angeles County Community Disaster Resilience initiative

Community resilience (CR) is a priority for preparedness, but few models exist. A steering council used community-partnered participatory research to support workgroups in developing CR action plans and hosted forums for input to design a pilot demonstration of implementing CR versus enhanced individual preparedness toolkits. Qualitative data describe how stakeholders viewed CR, how toolkits were developed, and demonstration design evolution. Stakeholders viewed community engagement as facilitating partnerships to implement CR programs when appropriately supported by policy and CR resources. Community engagement exercises clarified motivations and informed action plans (e.g., including vulnerable populations). Community input identified barriers (e.g., trust in government) and CR-building strategies. A CR toolkit and demonstration comparing its implementation with individual preparedness were codeveloped. Community-partnered participatory research was a useful framework to plan a CR initiative through knowledge exchange.

Determinants of readiness for primary care-mental health integration (PC-MHI) in the VA Health Care System

BACKGROUND

Depression management can be challenging for primary care (PC) settings. While several evidence-based models exist for depression care, little is known about the relationships between PC practice characteristics, model characteristics, and the practice's choices regarding model adoption.

OBJECTIVE

We examined three Veterans Affairs (VA)-endorsed depression care models and tested the relationships between theoretically-anchored measures of organizational readiness and implementation of the models in VA PC clinics.

DESIGN

1) Qualitative assessment of the three VA-endorsed depression care models, 2) Cross-sectional survey of leaders from 225 VA medium-to-large PC practices, both in 2007.

MAIN MEASURES

We assessed PC readiness factors related to resource adequacy, motivation for change, staff attributes, and organizational climate. As outcomes, we measured implementation of one of the VA-endorsed models: collocation, Translating Initiatives in Depression into Effective Solutions (TIDES), and Behavioral Health Lab (BHL). We performed bivariate and, when possible, multivariate analyses of readiness factors for each model.

KEY RESULTS

Collocation is a relatively simple arrangement with a mental health specialist physically located in PC. TIDES and BHL are more complex; they use standardized assessments and care management based on evidence-based collaborative care principles, but with different organizational requirements. By 2007, 107 (47.5 %) clinics had implemented collocation, 39 (17.3 %) TIDES, and 17 (7.6 %) BHL. Having established quality improvement processes (OR 2.30, [1.36, 3.87], p = 0.002) or a depression clinician champion (OR 2.36, [1.14, 4.88], p = 0.02) was associated with collocation. Being located in a VA regional network that endorsed TIDES (OR 8.42, [3.69, 19.26], p < 0.001) was associated with TIDES implementation. The presence of psychologists or psychiatrists on PC staff, greater financial sufficiency, or greater spatial sufficiency was associated with BHL implementation.

CONCLUSIONS

Both readiness factors and characteristics of depression care models influence model adoption. Greater model simplicity may make collocation attractive within local quality improvement efforts. Dissemination through regional networks may be effective for more complex models such as TIDES.

Treatment of youth depression in primary care under usual practice conditions: observational findings from Youth Partners in Care

OBJECTIVES

The effectiveness of treatments for youth depression in primary care, under usual practice conditions, is largely unstudied. This study aims at estimating the effect of "appropriate treatment," defined as treatment that approximates guideline standards, on clinical outcomes for depressed primary care youth patients by using observational analyses from a randomized trial.

METHODS

Participants were 344 youths aged 13-21 enrolled in the Youth Partners in Care trial. Youths screening positive for depression from six primary care practices in five different health care organizations were randomly assigned to either (1) usual care enhanced by provider education on depression evaluation and management, or (2) a quality improvement (QI) intervention designed to improve access to antidepressant medications and/or cognitive behavior therapy for depression; usual practice conditions otherwise applied. Observational analysis was conducted on the effects of appropriate treatment (antidepressant medication use by algorithms or 6 or more psychotherapy visits) on severe depression (Center for Epidemiologic Studies-Depression score ≥ 24) at 6 months. Selection into treatment is accounted for by using instrumental variables analysis, with randomized QI intervention status as the instrument.

RESULTS

At 6 months, youths receiving "appropriate treatment," compared with others, were significantly less likely to have severe depression (10.9% vs. 45.2%, p<0.0001). Similar findings were observed among youths with depressive disorders and sub-syndromal depressive symptoms, and among Latino and other youths.

CONCLUSIONS

Among depressed primary care youths, care that approximates guideline standards but retains leniency substantially reduces the likelihood of severe depression at 6 months. Such findings apply to youths with or without depressive disorder, and among Latino youth.

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.

Community-based participatory development of a community health worker mental health outreach role to extend collaborative care in post-Katrina New Orleans

OBJECTIVES

The REACH NOLA Mental Health Infrastructure and Training Project (MHIT) aimed to reduce disparities in access to and quality of services for depression and posttraumatic stress disorder (PTSD) in post-Katrina New Orleans by developing a mental health outreach role for community health workers (CHWs) and case managers as a complement to the collaborative care model for depression treatment.

INTERVENTION

Community agency leaders, academics, healthcare organizations, and CHWs engaged in a community participatory process to develop a CHW training program.

DESIGN

A review of qualitative data including semi-structured interviews, project team conference calls, email strings, and meeting minutes was conducted to document CHW input into training and responses to implementation.

RESULTS

CHW contributions resulted in a training program focused on community engagement, depression screening, education, referral assistance, collaboration with clinical teams, and self-care. CHWs reported use of screening tools, early client successes in spite of challenges with client engagement, increase in networking and collaboration with other community agencies and providers, and ongoing community hurricane recovery issues.

CONCLUSIONS

This intervention development approach and model may be used to address post-disaster mental health disparities and as a complement to traditional implementation of collaborative care.

Project overview of the Restoration Center Los Angeles: steps to wholeness--mind, body, and spirit

OBJECTIVES

Unmet needs for depression and substance abuse services are a concern in urban communities. This article summarizes the design and recommendations of the Restoration Center Planning Project to better address depression and substance abuse while promoting resiliency and wellness for persons of African descent in South Los Angeles.

DESIGN

A partnered participatory planning process during 18 months involving community members, faith-based and service agency leaders, and investigators from academic organizations was implemented. Leaders formulated a set of principles to address diversity of the group, hosted community conferences and working groups, while developing recommendations.

RESULTS

The community-academic partnership recommended the establishment of restoration centers in Los Angeles (RCLAs) that would serve as a one-stop shop for holistic services addressing depression, substance abuse, related social and spiritual needs, and coordinated care with a network of existing community-based services. Specific recommendations included that the RCs would aim to: 1) support community resilience and improve outcomes for depression and substance abuse; 2) be one-stop shops; 3) promote cultural competency; 4) facilitate ongoing community input and quality review; 5) assure standards of quality within centers and across the broader network; and 6) support the enterprise through a multi-stakeholder community-based board dedicated to RCLA goals.

CONCLUSION

A community-academic partnered planning process acknowledged the importance of respect for diversity and formulated plans for the Restoration Center network including the integration of health, social, cultural, and faith-based approaches to services with a multi-agency network and community leadership board. The feasibility of the plan will depend on the subsequent implementation phase.

Community-based partnered research: new directions in mental health services research

OBJECTIVE

Community-based participatory research has the potential to improve implementation of best practices to reduce disparities but has seldom been applied in mental health services research. This article presents the content and lessons learned from a national conference designed to stimulate such an application.

DESIGN

Mental health program developers collaborated in hosting a two-day conference that included plenary and break-out sessions, sharing approaches to community-academic partnership development, and preliminary findings from partnered research studies. Sessions were audiotaped, transcribed and analyzed by teams of academic and community conference participants to identify themes about best practices, challenges faced in partnered research, and recommendations for development of the field. Themes were illustrated with selections from project descriptions at the conference.

SETTING AND PARTICIPANTS

Participants, representing 9 academic institutions and 12 community-based agencies from four US census regions, were academic and community partners from five research centers funded by the National Institute of Mental Health, and also included staff from federal and non-profit funding agencies.

RESULTS

Five themes emerged: 1) Partnership Building; 2) Implementing and Supporting Partnered Research; 3) Developing Creative Dissemination Strategies; 4) Evaluating Impact; and 5) Training.

CONCLUSIONS

Emerging knowledge of the factors in the partnership process can enhance uptake of new interventions in mental health services. Conference proceedings suggested that further development of this field may hold promise for improved approaches to address the mental health services quality chasm and service disparities.

Addressing unmet mental health and substance abuse needs: a partnered planning effort between grassroots community agencies, faith-based organizations, service providers, and academic institutions

OBJECTIVE

To conduct a process evaluation of the Restoration Center Los Angeles, a community-academic partnered planning effort aimed at holistically addressing the unmet mental health and substance abuse needs of the Los Angeles African American community.

DESIGN

Semi-structured interviews with open-ended questions on key domains of partnership effectiveness were conducted with a random stratified sample of participants varying by level of involvement.

PARTICIPANTS

Eleven partners representing grassroots community agencies, faith-based organizations, service providers, and academic institutions.

MEASURES

Common themes identified by an evaluation consultant and partners relating to partnership effectiveness, perceived benefits and costs, and future expectations.

RESULTS

Findings underscore the importance of considering the potential issues that may arise with the increasing diversity of partners and perspectives. Many of the challenges and facilitating factors that arise within academic-community partnerships were similarly experienced between the diverse set of community partners. Challenges that affected partnership development between community-to-community partners included differences in expectations regarding the final goal of the project, trust-building, and the distribution of funds. Despite such challenges, partners were able to jointly develop a final set of recommendations for the creation of restoration centers, which was viewed as a major accomplishment.

CONCLUSIONS

Limited guidance exists on how to navigate differences that arise between community members who have shared identities on some dimensions (eg, African American ethnicity, Los Angeles residence) but divergent identities on other dimensions (eg, formal church affiliation). With increasing diversity of community representation, careful attention needs to be dedicated to not only the development of academic-community partnerships but also community-community partnerships.

Building community resilience through mental health infrastructure and training in post-Katrina New Orleans

OBJECTIVE

To describe a disaster recovery model focused on developing mental health services and capacity-building within a disparities-focused, community-academic participatory partnership framework.

DESIGN

Community-based participatory, partnered training and services delivery intervention in a post-disaster setting.

SETTING

Post-Katrina Greater New Orleans community.

PARTICIPANTS

More than 400 community providers from more than 70 health and social services agencies participated in the trainings.

INTERVENTION

Partnered development of a training and services delivery program involving physicians, therapists, community health workers, and other clinical and non-clinical personnel to improve access and quality of care for mental health services in a post-disaster setting.

MAIN OUTCOME MEASURE

Services delivery (outreach, education, screening, referral, direct treatment); training delivery; satisfaction and feedback related to training; partnered development of training products.

RESULTS

Clinical services in the form of outreach, education, screening, referral and treatment were provided in excess of 110,000 service units. More than 400 trainees participated in training, and provided feedback that led to evolution of training curricula and training products, to meet evolving community needs over time. Participant satisfaction with training generally scored very highly.

CONCLUSION

This paper describes a participatory, health-focused model of community recovery that began with addressing emerging, unmet mental health needs using a disparities-conscious partnership framework as one of the principle mechanisms for intervention. Population mental health needs were addressed by investment in infrastructure and services capacity among small and medium sized non-profit organizations working in disaster-impacted, low resource settings.

The Partnered Research Center for Quality Care: developing infrastructure to support community-partnered participatory research in mental health

Evidence-based programs have been shown to improve functioning and mental health outcomes, especially for vulnerable populations. However, these populations face numerous barriers to accessing care including lack of resources and stigma surrounding mental health issues. In order to improve mental health outcomes and reduce health disparities, it is essential to identify methods for reaching such populations with unmet need. A promising strategy for reducing barriers and improving access to care is Community Partnered Participatory Research (CPPR). Given the power of this methodology to transform the impact of research in resource-poor communities, we developed an NIMH-funded Center, the Partnered Research Center for Quality Care, to support partnerships in developing, implementing, and evaluating mental health services research and programs. Guided by a CPPR framework, center investigators, both community and academic, collaborate in all phases of research with the goal of establishing trust, building capacity, increasing buy-in, and improving the sustainability of interventions and programs. We engage in two-way capacity-building, which affords the opportunity for practical problems to be raised and innovative solutions to be developed. This article discusses the development and design of the Partnered Research Center for Quality Care and provides examples of partnerships that have been formed and the work that has been conducted as a result.

The Teen Photovoice Project: a pilot study to promote health through advocacy

BACKGROUND

Clinicians, public health practitioners, and policymakers would like to understand how youth perceive health issues and how they can become advocates for health promotion in their communities. Traditional research methods can be used to capture these perceptions, but are limited in their ability to activate (excite and engage) youth to participate in health promotion activities.

OBJECTIVES

To pilot the use of an adapted version of photovoice as a starting point to engage youth in identifying influences on their health behaviors in a process that encourages the development of health advocacy projects.

METHODS

Application of qualitative and quantitative methods to a participatory research project that teaches youth the photovoice method to identify and address health promotion issues relevant to their lives. Participants included 13 students serving on a Youth Advisory Board (YAB) of the UCLA/RAND Center for Adolescent Health Promotion working in four small groups of two to five participants. Students were from the Los Angeles, California, metropolitan area.

RESULTS

Results were derived from photograph sorting activities, analysis of photograph narratives, and development of advocacy projects. Youth frequently discussed a variety of topics reflected in their pictures that included unhealthy food choices, inducers of stress, friends, emotions, environment, health, and positive aspects of family. The advocacy projects used social marketing strategies, focusing on unhealthy dietary practices and inducers of stress. The youths' focus on obesity-related issues have contributed to the center's success in partnering with the Los Angeles Unified School District on a new community-based participatory research (CBPR) project.

CONCLUSION

Youth can engage in a process of identifying community-level health influences, leading to health promotion through advocacy. Participants focused their advocacy work on selected issues addressing the types of unhealthy food available in their communities and stress. This process appears to provide meaningful insight into the youths' perspective on what influences their health behaviors.

Rapid community participatory assessment of health care in post-storm New Orleans

BACKGROUND

Hurricane Katrina and levee failures disrupted healthcare access for hundreds of thousands of New Orleans residents. Few models exist to explain community stakeholders' priorities for post-disaster recovery while building capacity for response. This project engaged community stakeholders in a rapid, participatory assessment of health priorities 1 year post-disaster, to inform the policy process and build capacity for recovery planning among community members.

METHODS

This project combined community-based participatory research methods and rapid assessment procedures to engage diverse community members in design, conduct, data interpretation, and dissemination of results. Thirty stakeholders in the health and healthcare fields were interviewed in Summer 2006, and four grassroots community discussion groups were held in New Orleans neighborhoods to assess perceptions of the disaster's impacts on healthcare access. Interview transcripts were reviewed in Summer 2006, and themes were elicited using methods rooted in grounded theory. Findings were shared at a public community feedback conference, and recovery-relevant community action steps were set in motion.

RESULTS

Three main themes emerged from the data: (1) healthcare access challenges; (2) unmet needs of specific vulnerable populations; (3) opportunities, resources, and community adaptations to improve healthcare access.

CONCLUSIONS

This rapid, community-based participatory assessment provided new information on diverse community members' concerns and priorities, and it produced a sustainable community-academic partnership dedicated to improving both access to care and the public's health following this major disaster.

The content of substance abuse and mental health counseling reported by patients in a national survey

This study examined counseling content reported by a national sample of persons receiving care for alcohol, drug or mental health (ADM) problems in a year. The sample included 2,722 individuals over 18 who reported past year mental health or substance abuse care or assessments in a nationally representative survey conducted in 2000-2001. Counseling domains approximating commonly practiced or evidence-based approaches for depression, anxiety, or substance abuse were assessed. Patient self-report may be one useful way of tracking whether components of standard therapies are implemented in practice.

Long-term benefits of short-term quality improvement interventions for depressed youths in primary care

OBJECTIVE

Quality improvement programs for depressed youths in primary care settings have been shown to improve 6-month clinical outcomes, but longer-term outcomes are unknown. The authors examined 6-, 12-, and 18-month outcomes of a primary care quality improvement intervention.

METHOD

Primary care patients 13-21 years of age with current depressive symptoms were randomly assigned to a 6-month quality improvement intervention (N=211) or to treatment as usual enhanced with provider training (N=207). The quality improvement intervention featured expert leader teams to oversee implementation of the intervention; clinical care managers trained in cognitive-behavioral therapy for depression to support patient evaluation and treatment; and support for patient and provider choice of treatments.

RESULTS

The quality improvement intervention, relative to enhanced treatment as usual, lowered the likelihood of severe depression (Center for Epidemiological Studies Depression Scale score > or =24) at 6 months; a similar trend at 18 months was not statistically significant. Path analyses revealed a significant indirect intervention effect on long-term depression due to the initial intervention improvement at 6 months.

CONCLUSIONS

In this randomized effectiveness trial of a primary care quality improvement intervention for depressed youths, the main effect of the intervention on outcomes was to decrease the likelihood of severe depression at the 6-month outcome assessment. These early intervention-related improvements conferred additional long-term protection through a favorable shift in illness course through 12 and 18 months.

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.

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.

Persistent depression and anxiety in the United States: prevalence and quality of care

OBJECTIVE

Although effective treatments exist, individuals with depressive and anxiety disorders can remain ill for years. Little is known regarding mental health status and treatment use in this population. This study provided national estimates of the prevalence of persistent depression and anxiety, as well as estimates of illness severity, treatment use, and quality of care in this population.

METHODS

Data were from a prospective, community-based cohort study of 1,642 adults with probable major depression, dysthymia, panic disorder, or generalized anxiety disorder who were part of a U.S. probability sample. Telephone surveys were conducted during 1997-1998 and again an average of 32 months later. Surveys assessed diagnosis, quality of life, treatment satisfaction, medical conditions, suicidal ideation, insurance, medications, and treatment use.

RESULTS

At follow-up, 59% no longer met criteria for a disorder. The estimated national prevalence of a persistent depressive or anxiety disorder was 4.7%. In this subgroup, 87% had a chronic comorbid medical disorder. During the past year, 88% had seen a primary care practitioner, and 22% had seen a mental health specialist. Between baseline and follow-up, the percentage using appropriate medication increased (21% to 29%), but there was no significant change in use of appropriate counseling (23% to 19%). Only 12% were receiving both appropriate medication and counseling at follow-up. Treatment was less likely for men and people with less education. Suicidal ideation was present in 51% at follow-up.

CONCLUSIONS

Strategies are needed to increase treatment use and intensity for people with persistent depressive and anxiety disorders. This may require improved access to mental health specialists.

Using community arts events to enhance collective efficacy and community engagement to address depression in an African American community

OBJECTIVES

We used community-partnered participatory research (CPPR) to measure collective efficacy and its role as a precursor of community engagement to improve depression care in the African American community of South Los Angeles.

METHODS

We collected survey data from participants at arts events sponsored by a CPPR workgroup. Both exploratory (photography exhibit; n = 747) and confirmatory (spoken word presentations; n = 104) structural equation models were developed to examine how knowledge and attitudes toward depression influenced community engagement.

RESULTS

In all models, collective efficacy to improve depression care independently predicted community engagement in terms of addressing depression (B = 0.64-0.97; P < .001). Social stigma was not significantly associated with collective efficacy or community engagement. In confirmatory analyses, exposure to spoken word presentations and previous exposure to CPPR initiatives increased perceived collective efficacy to improve depression care (B = 0.19-0.24; P < .05).

CONCLUSIONS

Enhancing collective efficacy to improve depression care may be a key component of increasing community engagement to address depression. CPPR events may also increase collective efficacy. Both collective efficacy and community engagement are relevant constructs in the South Los Angeles African American community.

Persistent depression and anxiety in the United States: prevalence and quality of care

OBJECTIVE

Although effective treatments exist, individuals with depressive and anxiety disorders can remain ill for years. Little is known regarding mental health status and treatment use in this population. This study provided national estimates of the prevalence of persistent depression and anxiety, as well as estimates of illness severity, treatment use, and quality of care in this population.

METHODS

Data were from a prospective, community-based cohort study of 1,642 adults with probable major depression, dysthymia, panic disorder, or generalized anxiety disorder who were part of a U.S. probability sample. Telephone surveys were conducted during 1997-1998 and again an average of 32 months later. Surveys assessed diagnosis, quality of life, treatment satisfaction, medical conditions, suicidal ideation, insurance, medications, and treatment use.

RESULTS

At follow-up, 59% no longer met criteria for a disorder. The estimated national prevalence of a persistent depressive or anxiety disorder was 4.7%. In this subgroup, 87% had a chronic comorbid medical disorder. During the past year, 88% had seen a primary care practitioner, and 22% had seen a mental health specialist. Between baseline and follow-up, the percentage using appropriate medication increased (21% to 29%), but there was no significant change in use of appropriate counseling (23% to 19%). Only 12% were receiving both appropriate medication and counseling at follow-up. Treatment was less likely for men and people with less education. Suicidal ideation was present in 51% at follow-up.

CONCLUSIONS

Strategies are needed to increase treatment use and intensity for people with persistent depressive and anxiety disorders. This may require improved access to mental health specialists.

The effects of quality improvement for depression in primary care at nine years: results from a randomized, controlled group-level trial

OBJECTIVE

To examine 9-year outcomes of implementation of short-term quality improvement (QI) programs for depression in primary care.

DATA SOURCES

Depressed primary care patients from six U.S. health care organizations.

STUDY DESIGN

Group-level, randomized controlled trial.

DATA COLLECTION

Patients were randomly assigned to short-term QI programs supporting education and resources for medication management (QI-Meds) or access to evidence-based psychotherapy (QI-Therapy); and usual care (UC). Of 1,088 eligible patients, 805 (74 percent) completed 9-year follow-up; results were extrapolated to 1,269 initially enrolled and living. Outcomes were psychological well-being (Mental Health Inventory, five-item version [MHI5]), unmet need, services use, and intermediate outcomes.

PRINCIPAL FINDINGS

At 9 years, there were no overall intervention status effects on MHI5 or unmet need (largest F (2,41)=2.34, p=.11), but relative to UC, QI-Meds worsened MHI5, reduced effectiveness of coping and among whites lowered tangible social support (smallest t(42)=2.02, p=.05). The interventions reduced outpatient visits and increased perceived barriers to care among whites, but reduced attitudinal barriers due to racial discrimination and other factors among minorities (smallest F (2,41)=3.89, p=.03).

CONCLUSIONS

Main intervention effects were over but the results suggest some unintended negative consequences at 9 years particularly for the medication-resource intervention and shifts to greater perceived barriers among whites yet reduced attitudinal barriers among minorities.

Interventions in organizational and community context: a framework for building evidence on dissemination and implementation in health services research

The effective dissemination and implementation of evidence-based health interventions within community settings is an important cornerstone to expanding the availability of quality health and mental health services. Yet it has proven a challenging task for both research and community stakeholders. This paper presents the current framework developed by the UCLA/RAND NIMH Center to address this research-to-practice gap by: (1) providing a theoretically-grounded understanding of the multi-layered nature of community and healthcare contexts and the mechanisms by which new practices and programs diffuse within these settings; (2) distinguishing among key components of the diffusion process-including contextual factors, adoption, implementation, and sustainment of interventions-showing how evaluation of each is necessary to explain the course of dissemination and outcomes for individual and organizational stakeholders; (3) facilitating the identification of new strategies for adapting, disseminating, and implementing relatively complex, evidence-based healthcare and improvement interventions, particularly using a community-based, participatory approach; and (4) enhancing the ability to meaningfully generalize findings across varied interventions and settings to build an evidence base on successful dissemination and implementation strategies.

Mental health service use among hurricane Katrina survivors in the eight months after the disaster

OBJECTIVE

This study examined use of mental health services among adult survivors of Hurricane Katrina in order to improve understanding of the impact of disasters on persons with mental disorders.

METHODS

A geographically representative telephone survey was conducted between January 19 and March 31, 2006, with 1,043 displaced and nondisplaced English-speaking Katrina survivors aged 18 and older. Survivors who reported serious and mild-moderate mood and anxiety disorders in the past 30 days and those with no such disorders were identified by using the K6 scale of nonspecific psychological distress. Use of services, system sectors, and treatments and reasons for not seeking treatment or dropping out were recorded. Correlates of using services and dropping out were examined.

RESULTS

An estimated 31% of respondents (N=319) had evidence of a mood or anxiety disorder at the time of the interview. Among these only 32% had used any mental health services since the disaster, including 46% of those with serious disorders. Of those who used services, 60% had stopped using them. The general medical sector and pharmacotherapy were most commonly used, although the mental health specialty sector and psychotherapy played important roles, especially for respondents with serious disorders. Many treatments were of low intensity and frequency. Undertreatment was greatest among respondents who were younger, older, never married, members of racial or ethnic minority groups, uninsured, and of moderate means. Structural, financial, and attitudinal barriers were frequent reasons for not obtaining care.

CONCLUSIONS

Few Katrina survivors with mental disorders received adequate care; future disaster responses will require timely provision of services to address the barriers faced by survivors.

Do users of regularly prescribed opioids have higher rates of substance use problems than nonusers?

OBJECTIVE

To determine whether individuals who use prescribed opioids for chronic noncancer pain have higher rates of any opioid misuse, any problem opioid misuse, nonopioid illicit drug use, nonopioid problem drug use, or any problem alcohol use, compared with those who do not use prescribed opioids.

METHODS

Respondents were from a nationally representative survey (N = 9,279), which contained measures of regular use of prescribed opioids, substance use problems, mental health disorders, physical health, pain, and sociodemographics.

RESULTS

In unadjusted models, compared with nonusers of prescription opioids, users of prescription opioids had significantly higher rates of any opioid misuse (odds ratio [OR] = 5.48, P < 0.001), problem opioid misuse (OR = 14.76, P < 0.001), nonopioid illicit drug use (OR = 1.73, P < 0.01), nonopioid problem drug use (OR = 4.48, P < 0.001), and problem alcohol use (OR = 1.89, P = 0.04). In adjusted models, users of prescribed opioids had significantly higher rates of any opioid misuse (OR = 3.07, P < 0.001) and problem opioid misuse (OR = 6.11, P < 0.001) but did not have significantly higher rates of the other outcomes.

CONCLUSIONS

Users of prescribed opioids had higher rates of opioid and nonopioid abuse problems compared with nonusers of prescribed opioids, but these higher rates appear to be partially mediated by depressive and anxiety disorders. It is not possible to assign causal priority based on our cross-sectional data, but our findings are more compatible with mental disorders leading to substance abuse among prescription opioid users than prescription opioids themselves prompting substance abuse iatrogenically. In patients receiving prescribed opioids, clinicians need to be alert to drug abuse problems and potentially mediating mental health disorders.

Disruption of existing mental health treatments and failure to initiate new treatment after Hurricane Katrina

OBJECTIVE

The authors examined the disruption of ongoing treatments among individuals with preexisting mental disorders and the failure to initiate treatment among individuals with new-onset mental disorders in the aftermath of Hurricane Katrina.

METHODS

English-speaking adult Katrina survivors (N=1,043) responded to a telephone survey administered between January and March of 2006. The survey assessed posthurricane treatment of emotional problems and barriers to treatment among respondents with preexisting mental disorders as well as those with new-onset disorders posthurricane.

RESULTS

Among respondents with preexisting mental disorders who reported using mental health services in the year before the hurricane, 22.9% experienced reduction in or termination of treatment after Katrina. Among those respondents without preexisting mental disorders who developed new-onset disorders after the hurricane, 18.5% received some form of treatment for emotional problems. Reasons for failing to continue treatment among preexisting cases primarily involved structural barriers to treatment, while reasons for failing to seek treatment among new-onset cases primarily involved low perceived need for treatment. The majority (64.5%) of respondents receiving treatment post-Katrina were treated by general medical providers and received medication but no psychotherapy. Treatment of new-onset cases was positively related to age and income, while continued treatment of preexisting cases was positively related to race/ethnicity (non-Hispanic whites) and having health insurance.

CONCLUSIONS

Many Hurricane Katrina survivors with mental disorders experienced unmet treatment needs, including frequent disruptions of existing care and widespread failure to initiate treatment for new-onset disorders. Future disaster management plans should anticipate both types of treatment needs.

Mental health service use among hurricane Katrina survivors in the eight months after the disaster

OBJECTIVE

This study examined use of mental health services among adult survivors of Hurricane Katrina in order to improve understanding of the impact of disasters on persons with mental disorders.

METHODS

A geographically representative telephone survey was conducted between January 19 and March 31, 2006, with 1,043 displaced and nondisplaced English-speaking Katrina survivors aged 18 and older. Survivors who reported serious and mild-moderate mood and anxiety disorders in the past 30 days and those with no such disorders were identified by using the K6 scale of nonspecific psychological distress. Use of services, system sectors, and treatments and reasons for not seeking treatment or dropping out were recorded. Correlates of using services and dropping out were examined.

RESULTS

An estimated 31% of respondents (N=319) had evidence of a mood or anxiety disorder at the time of the interview. Among these only 32% had used any mental health services since the disaster, including 46% of those with serious disorders. Of those who used services, 60% had stopped using them. The general medical sector and pharmacotherapy were most commonly used, although the mental health specialty sector and psychotherapy played important roles, especially for respondents with serious disorders. Many treatments were of low intensity and frequency. Undertreatment was greatest among respondents who were younger, older, never married, members of racial or ethnic minority groups, uninsured, and of moderate means. Structural, financial, and attitudinal barriers were frequent reasons for not obtaining care.

CONCLUSIONS

Few Katrina survivors with mental disorders received adequate care; future disaster responses will require timely provision of services to address the barriers faced by survivors.

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.

Cost-effectiveness of quality improvement programs for patients with subthreshold depression or depressive disorder

OBJECTIVE

This study explored the cost-effectiveness of quality-improvement interventions for depression in primary care, relative to usual care, among patients with subthreshold depression or depressive disorder.

METHODS

A total of 746 primary care patients in managed care organizations with 12-month depressive disorder and 502 with current depressive symptoms but no disorder (subthreshold depression) participated in a group-level randomized controlled trial initiated between June 1996 and March 1997. Matched clinics were randomly assigned to enhanced usual care or one of two quality improvement interventions that provided education to manage depression over time and resources to facilitate access to medication management or psychotherapy for six to 12 months.

RESULTS

The cost-effectiveness ratio for the pooled intervention groups versus usual care was $2,028 for patients with subthreshold depression (95% confidence interval [CI]=-$17,225 to $21,282) and $53,716 for those with depressive disorder (CI=$14,194 to $93,238), by using a measure of quality-adjusted life years (QALY) based on the 12-Item Short Form Health Survey. Similar results were obtained when alternative QALY measures were used.

CONCLUSIONS

Although precision was limited, even the upper limit of the 95% CIs suggests that such interventions are as cost-effective for patients with subthreshold depression as are many widely used medical therapies. Despite lack of evidence for efficacy of treatments for subthreshold depression, disease management programs that support clinical care decisions over time for patients with subthreshold depression or depressive disorder can yield cost-effectiveness ratios comparable to those of widely adopted medical therapies. Achieving greater certainty about average cost-effectiveness would require a much larger study.

The importance of social context: neighborhood stressors, stress-buffering mechanisms, and alcohol, drug, and mental health disorders

This study examines the relationship among neighborhood stressors, stress-buffering mechanisms, and likelihood of alcohol, drug, and mental health (ADM) disorders in adults from 60 US communities (n=12,716). Research shows that larger support structures may interact with individual support factors to affect mental health, but few studies have explored buffering effects of these neighborhood characteristics. We test a conceptual model that explores effects of neighborhood stressors and stress-buffering mechanisms on ADM disorders. Using Health Care for Communities with census and other data, we found a lower likelihood of disorders in neighborhoods with a greater presence of stress-buffering mechanisms. Higher neighborhood average household occupancy and churches per capita were associated with a lower likelihood of disorders. Cross-level interactions revealed that violence-exposed individuals in high crime neighborhoods are vulnerable to depressive/anxiety disorders. Likewise, individuals with low social support in neighborhoods with high social isolation (i.e., low-average household occupancy) had a higher likelihood of disorders. If replicated by future studies using longitudinal data, our results have implications for policies and programs targeting neighborhoods to reduce ADM disorders.

The effects of health sector market factors and vulnerable group membership on access to alcohol, drug, and mental health care

OBJECTIVE

This study adapts Andersen's Behavioral Model to determine if health sector market conditions affect vulnerable subgroups' use of alcohol, drug, and mental health services (ADM) differently than the general population, focusing specifically on community-level predisposing and enabling characteristics.

DATA SOURCES

Wave 2 data (2000-2001) from the Health Care for Communities study, supplemented with cases from wave 1 (1997-1998), were merged with area characteristics taken from Census, Area Resource File (ARF), and other data sources.

STUDY DESIGN

The study used four-level hierarchical logistic regression to examine access to ADM care from any provider and specialty ADM access. Interactions between community-level predisposing and enabling vulnerability characteristics with individual race/ethnicity, age, income category, and insurance type were explored.

PRINCIPAL FINDINGS

Nonwhites, the poor, uninsured, and elderly had lower likelihoods of service use, but interactions between race/ethnicity, income, age and insurance status with community-level vulnerability factors were not statistically significant for any service use. For ADM specialty care, those with Medicare, Medicaid, private fully managed, and private partially managed insurance, the likelihood of utilization was higher in areas with higher HMO penetration. However, for those with other insurance or no insurance plan, the likelihood of utilization was lower in areas with higher HMO penetration.

CONCLUSIONS

Community-level enabling factors explain part of the effect of disadvantaged status but, with the exception of the effect of HMO penetration on the relationship between insurance and specialty care use, do not modify any of the residual individual-level effects of disadvantage. Interventions targeting both structural and individual levels may be necessary to address the problem of health disparities. More research with longitudinal data is necessary to sort out the causal direction of social context and ADM access outcomes, and whether policy interventions to change health sector market conditions can shift ADM treatment utilization.