Problematic substance use, depressive symptoms, and gender in primary care

This study determined the frequency of problematic substance use and of counseling about drug and alcohol use among 867 women and 320 men who reported symptoms of depression in managed primary care clinics. Seventy-two (8.3 percent) of the women and 61 (19 percent) of the men reported hazardous drinking; 228 (26.3 percent) of the women and 94 (29.4 percent) of the men reported problematic drug use, including use of illicit drugs and misuse of prescription drugs. Only 17 (13.9 percent) of the patients who reported hazardous drinking and 18 (6.6 percent) of those who reported problematic drug use received counseling about drug or alcohol use during their last primary care visit. Men were significantly more likely than women to have received counseling about drug or alcohol use from their primary care practitioner.

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

BACKGROUND

This article addresses whether dissemination of short-term quality improvement (QI) interventions for depression to primary care practices improves patients' clinical outcomes and health-related quality of life (HRQOL) over 2 years, relative to usual care (UC).

METHODS

The sample included 1299 patients with current depressive symptoms and 12-month, lifetime, or no depressive disorder from 46 primary care practices in 6 managed care organizations. Clinics were randomized to UC or 1 of 2 QI programs that included training local experts and nurse specialists to provide clinician and patient education, assessment, and treatment planning, plus either nurse care managers for medication follow-up (QI-meds) or access to trained psychotherapists (QI-therapy). Outcomes were assessed every 6 months for 2 years.

RESULTS

For most outcomes, differences between intervention and UC patients were not sustained for the full 2 years. However, QI-therapy reduced overall poor outcomes compared with UC by about 8 percentage points throughout 2 years, and by 10 percentage points compared with QI-meds at 24 months. Both interventions improved patients' clinical and role outcomes, relative to UC, over 12 months (eg, a 10-11 and 6-7 percentage point difference in probable depression at 6 and 12 months, respectively).

CONCLUSIONS

While most outcome improvements were not sustained over the full 2 study years, findings suggest that flexible dissemination of short-term, QI programs in managed primary care can improve patient outcomes well after program termination. Models that support integrated psychotherapy and medication-based treatment strategies in primary care have the potential for relatively long-term patient benefits.

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

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

Does obesity contribute as much to morbidity as poverty or smoking?

The prevalence of obesity is increasing in America, but its impact on morbidity relative to other health risks is unclear. This paper compares the effects of overweight, poverty, smoking and problem drinking on occurrence of chronic conditions and health-related quality of life. The data were collected from a nationally representative household telephone survey of 9585 adults fielded in 1998, using self-reported measures of height and weight, poverty, smoking status, problem drinking, chronic conditions and SF-12 global scales. Regression analyses were used to estimate effects of health risk factors on morbidity. Thirty-six percent of adults are overweight but not obese (25< or =BMI<30) and another 23% are obese (BMI> or =30). Controlling for demographics, obesity is associated with more chronic conditions and worse physical health-related quality of life (P<0.01). Smoking history and poverty predict having chronic conditions, but their effect sizes are significantly smaller. Even after controlling for chronic conditions, obesity predicts physical health-related quality of life, in that case with an effect size similar to poverty. The effect of problem drinking is always smaller. Obesity is highly prevalent and associated with at least as much morbidity as are poverty, smoking and problem drinking. Nevertheless, the latter have achieved more consistent attention in recent decades in clinical practice and public health policy.

General medical and specialty mental health service use for major depression

OBJECTIVE

While major depression is common, many depressed persons receive, at best, inadequate treatment. A first step in remedying inadequate detection and treatment of major depression requires understanding the pathways into treatment-from situations of no care, to disease recognition, to referral and appropriate treatment-as well as identifying factors associated with movement between these several stages.

METHODS

Using the Epidemiologic Catchment Area sample, we identified factors associated with treatment in the general medical or mental health specialist section, or no treatment in a subsample of individuals with current major depression.

RESULTS

Strikingly, one-fourth of the sample received no services, over half received care in the general medical sector, and only one-fifth accessed a mental health specialist. Among those receiving any health services (general or mental), men and respondents reporting suicidal symptoms were at risk of receiving no care, while perceived poor health and a cluster of core depressive symptoms were associated with increased odds of service use (general or mental). Among respondents receiving general medical services, perceived poor health, core depressive symptoms, a history of depression, and comorbid mental conditions increased the odds of treatment in the specialty mental health sector.

CONCLUSIONS

The findings emphasize the need for public health initiatives to 1) improve detection and movement into treatment among those at risk of receiving no care; and 2) insure that, once within the health care system, the processes of primary care treatment and specialty referrals conform to evidence-based treatment guidelines.

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

BACKGROUND

Depressive and anxiety disorders are prevalent and cause substantial morbidity. While effective treatments exist, little is known about the quality of care for these disorders nationally. We estimated the rate of appropriate treatment among the US population with these disorders, and the effect of insurance, provider type, and individual characteristics on receipt of appropriate care.

METHODS

Data are from a cross-sectional telephone survey conducted during 1997 and 1998 with a national sample. Respondents consisted of 1636 adults with a probable 12-month depressive or anxiety disorder as determined by brief diagnostic interview. Appropriate treatment was defined as present if the respondent had used medication or counseling that was consistent with treatment guidelines.

RESULTS

During a 1-year period, 83% of adults with a probable depressive or anxiety disorder saw a health care provider (95% confidence interval [CI], 81%-85%) and 30% received some appropriate treatment (95% CI, 28%-33%). Most visited primary care providers only. Appropriate care was received by 19% in this group (95% CI, 16%-23%) and by 90% of individuals visiting mental health specialists (95% CI, 85%-94%). Appropriate treatment was less likely for men and those who were black, less educated, or younger than 30 or older than 59 years (range, 19-97 years). Insurance and income had no effect on receipt of appropriate care.

CONCLUSIONS

It is possible to evaluate mental health care quality on a national basis. Most adults with a probable depressive or anxiety disorder do not receive appropriate care for their disorder. While this holds across diverse groups, appropriate care is less common in certain demographic subgroups.

Quality improvement for depression enhances long-term treatment knowledge for primary care clinicians

OBJECTIVE

We evaluated the effect of implementing quality improvement (QI) programs for depression, relative to usual care, on primary care clinicians' knowledge about treatment.

DESIGN AND METHODS

Matched primary care clinics (46) from seven managed care organizations were randomized to usual care (mailed written guidelines only) versus one of two QI interventions. Self-report surveys assessed clinicians' knowledge of depression treatments prior to full implementation (June 1996 to March 1997) and 18 months later. We used an intent-to-treat analysis to examine intervention effects on change in knowledge, controlling for clinician and practice characteristics, and the nested design.

PARTICIPANTS

One hundred eighty-one primary care clinicians.

INTERVENTIONS

The interventions included institutional commitment to QI, training local experts, clinician education, and training nurses for patient assessment and education. One intervention had resources for nurse follow-up on medication use (QI-meds) and the other had reduced copayment for therapy from trained, local therapists (QI-therapy).

RESULTS

Clinicians in the intervention group had greater increases compared with clinicians in the usual care group over 18 months in knowledge of psychotherapy (by 20% for QI-meds, P =.04 and by 33% for QI-therapy, P =.004), but there were no significant increases in medication knowledge. Significant increases in knowledge scores (P =.01) were demonstrated by QI-therapy clinicians but not clinicians in the QI-meds group. Clinicians were exposed to multiple intervention components.

CONCLUSIONS

Dissemination of QI programs for depression in managed, primary care practices improved clinicians' treatment knowledge over 18 months, but breadth of learning was somewhat greater for a program that also included active collaboration with local therapists.

Mental disorders and the use of alternative medicine: results from a national survey

OBJECTIVE

The study examined the relationship between mental disorders and the use of complementary and alternative medicine.

METHOD

Data from a national household telephone survey conducted in 1997-1998 (N=9,585) were used to examine the relationships between use of complementary and alternative medicine during the past 12 months and several demographic variables and indicators of mental disorders. Structured diagnostic screening interviews were used to establish diagnoses of probable mental disorders.

RESULTS

Use of complementary and alternative medicine during the past 12 months was reported by 16.5% of the respondents. Of those respondents, 21.3% met diagnostic criteria for one or more mental disorders, compared to 12.8% of respondents who did not report use of alternative medicine. Individuals with panic disorder and major depression were significantly more likely to use alternative medicine than those without those disorders. Respondents with mental disorders who reported use of alternative medicine were as likely to use conventional mental health services as respondents with mental disorders who did not use alternative medicine.

CONCLUSIONS

We found relatively high rates of use of complementary and alternative medicine among respondents who met criteria for common mental disorders. Practitioners of alternative medicine should look for these disorders in their patients, and conventional medical providers should ask their depressed and anxious patients about the use of alternative medicine. More research is needed to determine if individuals with mental disorders use alternative medicine because conventional medical care does not meet their health care needs.

Treatment preferences among depressed primary care patients

OBJECTIVE

To understand patient factors that may affect the probability of receiving appropriate depression treatment, we examined treatment preferences and their predictors among depressed primary care patients.

DESIGN

Patient questionnaires and interviews.

SETTING

Forty-six primary care clinics in 7 geographic regions of the United States.

PARTICIPANTS

One thousand one hundred eighty-seven English- and Spanish-speaking primary care patients with current depressive symptoms.

MEASUREMENTS AND MAIN RESULTS

Depressive symptoms and diagnoses were determined by the Composite International Diagnostic Interview (CIDI) and the Center for Epidemiological Studies Depression Scale (CES-D). Treatment preferences and characteristics were assessed using a self-administered questionnaire and a telephone interview. Nine hundred eight-one (83%) patients desired treatment for depression. Those who preferred treatment were wealthier (odds ratio [OR], 3.7; 95% confidence interval [95% CI], 1.8 to 7.9; P =.001) and had greater knowledge about antidepressant medication ( OR, 2.6; 95% CI, 1.6 to 4.4; P

CONCLUSIONS

Despite low rates of treatment for depression, most depressed primary care patients desire treatment, especially counseling. Preferences for depression treatment vary by ethnicity, gender, income, and knowledge about treatments.

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Key Words

• depression
• primary care
• patient preferences
• treatment preferences

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MESH Headings

• Adolescent
• Adult
• Depression/classification
• Depression/diagnosis
• Depression/therapy
• Female
• Humans
• Interviews as Topic
• Male
• Middle Aged
• Patient Acceptance of Health Care
• Patient Satisfaction
• Primary Health Care
• Socioeconomic Factors
• Surveys and Questionnaires

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Grants

• R01 HS008349 AHRQ HHS
• K12 MH00990-01-01 NIMH NIH HHS
• HS08349-02 AHRQ HHS

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Affiliation(s)

M Dwight-Johnson Department of Psychiatry, University of Southern California, Los Angeles, Calif, USA.
C D Sherbourne
D Liao
K B Wells

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Estimation of utilities for the effects of depression from the SF-12

BACKGROUND

Utilities for health conditions, including major depressive disorder, have a theoretical relationship to health-related quality of life (HRQOL). Because of the complexity of utility measurement and the existence of large numbers of completed studies with HRQOL data but not utility data, it would be desirable to be able to estimate utilities from measurements of HRQOL.

OBJECTIVE

The objective of this study was to estimate utility for remission in major depression by use of information on associated variation in Short Form 12 (SF-12) scores.

DESIGN

A mapping function for SF-12 scores (based on a 6-health-state model with patient-weighted preferences) was applied to longitudinal data from a large naturalistic study to estimate changes in utilities.

SUBJECTS

Preference ratings for states were performed in a convenience sample of depressed primary care patients (n = 140). Outcomes were evaluated in patients in the Course of Depression Study (n = 295) with a DSM III diagnosis of depression at the onset of the study.

MEASURES

From clinical interview data, differences in utilities and global physical and mental health-related quality of life at 1- and 2-year follow-up were compared for patients who did and did not experience remission as determined by the Course of Depression Interview.

RESULTS

Remission of depression resulted in health status improvement, as measured by the SF-12, equivalent to a gain of 0.11 quality-adjusted life-years over 2 years.

CONCLUSIONS

Utilities for changes in health status, associated with a clinical change in depression, can be modeled from the SF-12 scales, which results in utilities within the range of estimates described in the literature.

Who is at risk of nondetection of mental health problems in primary care?

OBJECTIVE

To determine patient and provider characteristics associated with increased risk of nondetection of mental health problems by primary care physicians.

DESIGN

Cross-sectional patient and physician surveys conducted as part of the Medical Outcomes Study.

PARTICIPANTS

We studied 19,309 patients and 349 internists and family physicians.

MEASUREMENTS AND MAIN RESULTS

We counted "detection" of a mental health problem whenever physicians reported, in a postvisit survey, that they thought the patient had a mental health problem or that they had counseled or referred the patient for mental health. Key independent variables included patient self-reported demographic characteristics, health-related quality of life (HRQOL), depression diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders, and physician demographics and proclivity to provide counseling for depression. Logistic regression analysis, adjusted for HRQOL, revealed physicians were less likely to detect mental health problems in African Americans (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.46 to 0.86), men (OR, 0.64; 95% CI, 0.54 to 0.75), and patients younger than 35 years (OR, 0.61; 95% CI, 0.44 to 0.84), and more likely to detect them in patients with diabetes (OR, 1.4; 95% CI, 1.0 to 1.8) or hypertension (OR, 1.3; 95% CI, 1.1 to 1.6). In a model that included DSM-III diagnoses, odds of detection remained reduced for African Americans as well as for Hispanics (OR, 0.29; 95% CI, 0.11 to 0.71), and patients with more-severe DSM-III diagnoses were more likely to be detected. Physician proclivity toward providing counseling for depression influenced the likelihood of detection.

CONCLUSIONS

Patients' race, gender, and coexisting medical conditions affected physician awareness of mental health problems. Strategies to improve detection of mental health problems among African Americans, Hispanics, and men should be explored and evaluated.

Depression and health-related quality of life in ethnic minorities seeking care in general medical settings

BACKGROUND

To examine ethnic groups differences in (a) prevalence of depressive disorders and (b) health related quality of life in fee-for-service and managed care patients (n=21504) seeking care in general medical settings.

METHODS

Data are from the Medical Outcomes Study, a multi-site observational study of outpatient practices. The study screened patients of clinicians (family practice, internal medicine, cardiology, diabetology and endocrinology) for four chronic medical conditions; depression, coronary heart disease, hypertension and diabetes. A brief eight-item depression screener followed by the Diagnostic Interview Schedule-Depression Section (DIS) for screener positives identified depressed patients (n=2195). The Short Form Health Survey (SF-36) assessed health-related quality of life. Patient self-report determined ethnicity.

RESULTS

Before adjusting for demographic factors, African-Americans and Hispanics had highest rates of depressive symptoms. Asian-Americans had the lowest. After adjusting for demographics (particularly gender and income), we found few statistically significant differences in prevalence or severity of depression. However, among the depressed, Whites were the most, and African-Americans the least likely to report suicidal ideation (p<0. 01), and Hispanics and Whites were more likely to have melancholia (p<0.01). African-Americans reported the poorest quality of life.

LIMITATIONS

DSM III criteria (though few changes in DSM IV), and relatively small sample size of Asian-Americans compared to other groups.

CONCLUSIONS

Gender and socioeconomic status are more significant factors than ethnicity in determining risk for depressive disorder. However, ethnic differences in symptom presentation, and health-related quality of life could have clinical and social consequences, and merit further study.

Community effects on access to behavioral health care

OBJECTIVE

To explore the effects of community-level factors on access to any behavioral health care and specialty behavioral health care.

DATA

Healthcare for Communities household survey data, merged to supplemental data from the 1990 Census Area Resource File, 1995 U.S. Census Bureau Small Area Estimates, and 1994 HMO enrollment data.

STUDY DESIGN

We use a random intercept model to estimate the influences of community-level factors on access to any outpatient care, any behavioral health care conditional on having received outpatient care, and any specialty behavioral health care conditional on having received behavioral health care.

DATA COLLECTION

HCC data were collected in 1997 from about 10,000 households nationwide but clustered in 60 sites.

PRINCIPAL FINDINGS

Individuals in areas with greater HMO presence have better overall access to care, which in turn affects access to behavioral health care; individuals in poorer communities have less access to specialty care compared to individuals in wealthier communities.

CONCLUSIONS

Our findings of lower access to specialty care among those in poor communities raises concerns about the appropriateness and quality of the behavioral health care they are receiving. More generally, the findings suggest the importance of considering the current status and expected evolution of HMO penetration and the income level in a community when devising health care policy.

Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial

CONTEXT

Care of patients with depression in managed primary care settings often fails to meet guideline standards, but the long-term impact of quality improvement (QI) programs for depression care in such settings is unknown.

OBJECTIVE

To determine if QI programs in managed care practices for depressed primary care patients improve quality of care, health outcomes, and employment.

DESIGN

Randomized controlled trial initiated from June 1996 to March 1997.

SETTING

Forty-six primary care clinics in 6 US managed care organizations.

PARTICIPANTS

Of 27332 consecutively screened patients, 1356 with current depressive symptoms and either 12-month, lifetime, or no depressive disorder were enrolled.

INTERVENTIONS

Matched clinics were randomized to usual care (mailing of practice guidelines) or to 1 of 2 QI programs that involved institutional commitment to QI, training local experts and nurse specialists to provide clinician and patient education, identification of a pool of potentially depressed patients, and either nurses for medication follow-up or access to trained psychotherapists.

MAIN OUTCOME MEASURES

Process of care (use of antidepressant medication, mental health specialty counseling visits, medical visits for mental health problems, any medical visits), health outcomes (probable depression and health-related quality of life [HRQOL]), and employment at baseline and at 6- and 12-month follow-up.

RESULTS

Patients in QI (n = 913) and control (n = 443) clinics did not differ significantly at baseline in service use, HRQOL, or employment after nonresponse weighting. At 6 months, 50.9% of QI patients and 39.7% of controls had counseling or used antidepressant medication at an appropriate dosage (P<.001), with a similar pattern at 12 months (59.2% vs 50.1%; P = .006). There were no differences in probability of having any medical visit at any point (each P > or = .21). At 6 months, 47.5% of QI patients and 36.6% of controls had a medical visit for mental health problems (P = .001), and QI patients were more likely to see a mental health specialist at 6 months (39.8% vs 27.2%; P<.001) and at 12 months (29.1% vs 22.7%; P = .03). At 6 months, 39.9% of QI patients and 49.9% of controls still met criteria for probable depressive disorder (P = .001), with a similar pattern at 12 months (41.6% vs 51.2%; P = .005). Initially employed QI patients were more likely to be working at 12 months relative to controls (P = .05).

CONCLUSIONS

When these managed primary care practices implemented QI programs that improve opportunities for depression treatment without mandating it, quality of care, mental health outcomes, and retention of employment of depressed patients improved over a year, while medical visits did not increase overall.

Quality of care for primary care patients with depression in managed care

OBJECTIVE

To evaluate the process and quality of care for primary care patients with depression under managed care organizations.

METHOD

Surveys of 1204 outpatients with depression at the time of and after a visit to 1 of 181 primary care clinicians from 46 primary care clinics in 7 managed care organizations. Patients had depressive symptoms in the previous 30 days, with or without a 12-month depressive disorder by diagnostic interview. Process indicators were depression counseling, mental health referral, or psychotropic medication management at index visit and the use of appropriate antidepressant medication during the last 6 months.

RESULTS

Of patients with depressive disorder and recent symptoms, 29% to 43% reported a depression-specific process of care in the index visit, and 35% to 42% used antidepressant medication in appropriate dosages in the prior 6 months. Patients with depressive disorders rather than symptoms only and those with comorbid anxiety had higher rates of depression-specific processes and quality of care (P < .005). Recurrent depression, suicidal ideation, and alcohol abuse were not uniquely associated with such rates. Patients visiting for old problems or checkups received more depression-specific care than those with new problems or unscheduled visits. The 7 managed care organizations varied by a factor of 2-fold in rates of depression counseling and appropriate anti-depressant use.

CONCLUSIONS

Rates of process and quality of care for depression as reported by patients are moderate to low in managed primary care practices. Such rates are higher for patients with more severe forms of depression or with comorbid anxiety, but not for those with severe but "silent" symptoms like suicide ideation. Visit context factors, such as whether the visit is scheduled, affect rates of depression-specific care. Rates of care for depression are highly variable among managed care organizations, emphasizing the need for process monitoring and quality improvement for depression at the organizational level.

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

BACKGROUND

Health utility is the recommended outcome metric for medical cost-effectiveness studies. We compared health utility and quality of life for primary care patients with depression or chronic medical conditions.

METHODS

Respondents were outpatients (N = 17 558) of primary care clinicians (N = 181) in 7 managed care organizations. Utility was assessed by time tradeoff, or the years of life that patients would exchange for perfect health, and standard gamble, or the required chance of success to accept a treatment that can cause immediate death or survival in perfect health. Probable 12-month depressive disorder and affective syndromes were assessed through self-report items from a diagnostic interview. Medical conditions were assessed with self-report. Quality of life was assessed by the 12-Item Short-Form Health Survey. Regression models were used to compare quality of life and utility for patients with depression vs chronic medical conditions.

RESULTS

Patients with probable 12-month depressive disorder had worse mental health and role-emotional and social functioning and lower utility for their current health than patients with each chronic medical condition (for most comparisons, P<.001). Depressed patients had worse physical functioning than patients with 4 common chronic conditions but better physical functioning than patients with 4 other conditions (each P<.001). Patients with lifetime bipolar illness and 12-month double depression had the poorest quality of life and lowest utility.

CONCLUSIONS

Primary care patients with depressive conditions have poorer mental, role-emotional, and social functioning than patients with common chronic medical conditions, and physical functioning in the midrange. The low utility of depressed patients relative to patients with chronic medical conditions suggests that recovery from depression should be a high practice priority.

Evidence-based care for depression in managed primary care practices

This paper evaluates whether externally designed, evidence-based interventions for improving care for depression can be locally implemented in managed care organizations. The interventions were carried out as part of a randomized trial involving forty-six practices within six diverse, nonacademic managed care plans. Based on evaluation of adherence to the intervention protocol, we determined that local practice leaders are able to implement predesigned interventions for improving depression care. Adherence rates for most key intervention activities were above 70 percent, and many were near 100 percent. Three intervention activities fell short of the goal of 70 percent implementation and should be targets for future improvement.

The design of Healthcare for Communities: a study of health care delivery for alcohol, drug abuse, and mental health conditions

There is a shortage of data to inform policy debates about the quickly changing health care system. This paper describes Healthcare for Communities (HCC), a component of the Robert Wood Johnson Foundation's Health Tracking Initiative that was designed to fill this gap for alcohol, drug abuse, and mental health care. HCC bridges clinical perspectives and economic/policy research approaches, links data at market, service delivery, and individual levels, and features a household survey of nearly 9,600 individuals with an employer follow-back survey. Public use files will be available in late 1999.

Termination of social security benefits among Los Angeles recipients disabled by substance abuse

OBJECTIVES

Although a 1996 federal law terminated Social Security disability benefits to individuals disabled primarily by drug addiction and alcoholism, many were expected to successfully appeal for recertification based on mental illness. This study examined appeal and recertification in Los Angeles County.

METHODS

Data for 2,001 persons receiving Social Security disability benefits in 1996 because of substance abuse disability were obtained from the referral and monitoring agency, where each person had completed the Addiction Severity Index (ASI) during an initial visit in the past two years. Administrative data were obtained from the Social Security Administration. Severity of psychiatric symptoms--low, medium, or high--was based on the composite score on the ASI psychiatric subscale. Logistic regression analyses examined the relationship between severity and appeal and recertification status.

RESULTS

Fifty-one percent of the subjects scored in the medium- or high-severity range. Appeals were made by 80 percent of the 506 recipients with high scores, 72 percent of the 510 recipients with medium scores, and 74 percent of the 985 recipients with low scores. Recertification rates were 60 percent, 45 percent, and 47 percent, respectively. Compared with recipients who had low scores, those with high scores were more likely to appeal and to be recertified. However, benefits were terminated for 51 percent of recipients with high scores, including all those who did not appeal.

CONCLUSIONS

Many recipients of Social Security disability benefits with comorbid psychiatric problems lost benefits either because they did not appeal or because their appeal was denied.

Relationship between age and patients' current health state preferences

This article explores age differences in preferences for current health states, which is one way to measure trade-offs between "quantity of life" and the "quality" of those health states. Data are from 17,707 adult outpatients visiting 46 primary care, managed care practices. Patient preferences (utility) for their current health were assessed by standard gamble and time trade-off methods. Although older primary care patients' utility measurements for their current health were lower than other patient groups, most of the difference in value measurements was attributable to differences in health. Health providers should take care to assess individual preferences from all patients regardless of age.

What outcomes matter to patients?

OBJECTIVE

This study estimates the relative value to patients of physical, mental, and social health when making treatment decisions. Despite recommendations to use patient preferences to guide treatment decisions, little is known about how patients value different dimensions of their health status.

DESIGN

Cross-sectional data from quasi-experimental, prospective study.

SETTING

Forty-six primary care clinics in managed care organizations in California, Texas, Minnesota, Maryland, and Colorado.

PATIENTS

Consecutive adult outpatients (n = 16,689) visiting primary care providers.

MEASUREMENTS AND MAIN RESULTS

Medical Outcomes Study 12-Item Short Form (SF-12) health-related quality of life and patient preferences for their current health status, as assessed by standard gamble and time trade-off utility methods, were measured. Only 5% of the variance in standard gamble and time trade-off was explained by the SF-12. Within the SF-12, physical health contributes substantially to patient preferences (35%-55% of the relative variance explained); however, patients also place a high value on their mental health (29%-42%) and on social health (16%-23%). The contribution of mental health to preferences is stronger in patients with chronic conditions.

CONCLUSIONS

Patient preferences, which should be driving treatment decisions, are related to mental and social health nearly as much as they are to physical health. Thus, medical practice should strive to balance concerns for all three health domains in making treatment decisions, and health care resources should target medical treatments that improve mental and social health outcomes.

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

OBJECTIVE

Policy and clinical management decisions depend on data on the health and cost impacts of psychiatric treatments under usual care, i.e., effectiveness. Clinical trials, however, provide information on treatment efficacy under best-practice conditions. An understanding of the design, analysis, and conventions of both efficacy and effectiveness studies can lead to research that better informs clinical and societal questions.

METHOD

This paper contrasts the strengths and limitations of clinical trials and effectiveness studies for addressing policy and clinical decisions. These research approaches are assessed in terms of outcomes, treatments, service delivery context, implementation conventions, and validity.

RESULTS

Clinical trials and effectiveness research share problems of internal and external validity despite more attention to internal validity in clinical trials (e.g., randomization, blinding, standardized protocols) and to external validity in effectiveness studies (e.g., community-based treatments, representative samples).

CONCLUSIONS

To develop research at the interface of clinical trials and effectiveness studies, research goals must be redefined, and methods, such as cost-utility and econometric analyses, must be shared and developed. Development of hybrid designs that combine features of efficacy and effectiveness research will require separation of conventions such as frequency of follow-up, intensity of measurement, and sample size from the central scientific issues of aims and validity.

Treating depression in staff-model versus network-model managed care organizations

OBJECTIVE

To compare primary care providers' depression-related knowledge, attitudes, and practices and to understand how these reports vary for providers in staff or group-model managed care organizations (MCOs) compared with network-model MCOs including independent practice associations and preferred provider organizations.

DESIGN

Survey of primary care providers' depression-related practices in 1996.

SETTING AND PARTICIPANTS

We surveyed 410 providers, from 80 outpatient clinics, in 11 MCOs participating in four studies designed to improve the quality of depression care in primary care.

MEASUREMENTS AND MAIN RESULTS

We measured knowledge based on depression guidelines, attitudes (beliefs about burden, skill, and barriers) related to depression, and reported behavior. Providers in both types of MCO are equally knowledgeable about treating depression (better knowledge of pharmacologic than psychotherapeutic treatments) and perceive equivalent skills in treating depression. However, compared with network-model providers, staff/group-model providers have stronger beliefs that treating depression is burdensome to their practice. While more staff/group-model providers reported time limitations as a barrier to optimal depression treatment, more network-model providers reported limited access to mental health specialty referral as a barrier. Accordingly, these staff/group-model providers are more likely to treat patients with major depression through referral (51% vs 38%) or to assess but not treat (17% vs 7%), and network-model providers are more likely to prescribe antidepressants (57% vs 6%) as first-line treatment.

CONCLUSIONS

Whereas the providers from staff/group-model MCOs had greater access to and relied more on referral, the providers from network-model organizations were more likely to treat depression themselves. Given varying attitudes and behaviors, improving primary care for the treatment of depression will require unique strategies beyond enhancing technical knowledge for the two types of MCOs.

The design of Partners in Care: evaluating the cost-effectiveness of improving care for depression in primary care

This paper describes a study design that blends health services and clinical research approaches to examine the cost-effectiveness of treatments and of quality improvement for depression in primary care, managed care practices. Six managed care organizations in Los Angeles (Calif.), San Antonio (Tex.), San Luis Valley (Colo.), Twin Cities (Minn.), and Columbia (Md.) participated. Primary care clinics were randomized to one of two quality improvement interventions or care as usual. Interventions included patient and provider education, nurse-assisted patient assessment, and resources to support appropriate medication management or access to cognitive behavioral therapy. Practices implemented the interventions with study support. Providers and patients selected treatment. Patients with depressive symptoms regardless of comorbidities were eligible. Over 27,000 primary care patients visiting the practices of 181 primary care clinicians were screened for depression, 14% were potentially eligible, and 1356 enrolled into the 2-year longitudinal study. Enrollees were similar to eligibles, but usual care clinic patients tended to be less severely depressed than intervention clinic patients, partly due to clinic staff enthusiasm. The result of the study showed that studying treatment effects and quality improvement in nonacademic settings is feasible, but requires relaxation of design features of experiments that protect internal validity. The trade-off between certainty of causal inference and generalizability to usual care conditions is discussed. The strengths and limitations of this study design are compared to those of clinical trials and recent clinical effectiveness studies.

Empirically defined health states for depression from the SF-12

OBJECTIVE

To define objectively and describe a set of clinically relevant health states that encompass the typical effects of depression on quality of life in an actual patient population. Our model was designed to facilitate the elicitation of patients' and the public's values (utilities) for outcomes of depression.

DATA SOURCES

From the depression panel of the Medical Outcomes Study. Data include scores on the 12-Item Short Form Health Survey (SF-12) as well as independently obtained diagnoses of depression for 716 patients. Follow-up information, one year after baseline, was available for 166 of these patients.

METHODOLOGY

We use k-means cluster analysis to group the patients according to appropriate dimensions of health derived from the SF-12 scores. Chi-squared and exact permutation tests are used to validate the health states thus obtained, by checking for baseline and longitudinal correlation of cluster membership and clinical diagnosis.

PRINCIPAL FINDINGS

We find, on the basis of a combination of statistical and clinical criteria, that six states are optimal for summarizing the range of health experienced by depressed patients. Each state is described in terms of a subject who is typical in a sense that is articulated with our cluster-analytic approach. In all of our models, the relationship between health state membership and clinical diagnosis is highly statistically significant. The models are also sensitive to changes in patients' clinical status over time.

CONCLUSIONS

Cluster analysis is demonstrably a powerful methodology for forming clinically valid health states from health status data. The states produced are suitable for the experimental elicitation of preference and analyses of costs and utilities.

Physician knowledge, financial incentives and treatment decisions for depression

BACKGROUND: Two important policy levers to affect health care delivery are financing and informational interventions. Unfortunately, these two approaches have not been considered simultaneously and little is known about how their effects compare. AIMS OF THE STUDY: This paper estimates the relative role of financial incentives (prepaid versus fee for service) and provider information (perceived knowledge of antidepressant medications and skill in counseling for depression) on quality of care for less and more severely depressed patients and their health and cost outcomes. METHODS: We develop a theoretical model of provider behavior and estimate a reduced form using a multinomial probit model with heteroskedastic covariances. The likely effects of changing provider knowledge about depression treatment in primary care are then simulated and contrasted with the effects of a shift toward prepaid managed care as opposed to fee-for-service care. The empirical model is estimated using data from the Medical Outcomes Study. RESULTS: We conclude that financing and information have different effects and that their combination can achieve the conflicting goals of improved health outcomes and reduced direct treatment goals. Moreover, including family income as one important dimension of social cost suggests that the combination of informational interventions and a shift to prepaid care may dominate either one intervention in isolation from a social cost perspective. Specifically regarding information, we found that increasing provider knowledge could have the highly desirable effect of greater targeting of treatments to sicker patients while not raising overall treatment rates much - a treatment pattern that many hoped managed care could achieve, but for which there has been little evidence. CONCLUSIONS: Our analysis illustrates the value of considering these widely different policy goals simultaneously. We learned that variation in physician knowledge generally had stronger associations with clinically relevant practice patterns for depression than did a complete change in financing strategy. The moderate change in perceived knowledge we simulated (not near the extremes of observed values of perceived knowledge) was associated with enough improvement in appropriateness of care to more than offset the reduction in appropriateness with a complete shift from fee-for-service to prepaid managed care. IMPLICATIONS FOR HEALTH POLICY: The paper demonstrates the importance of considering different interventions simultaneously. Combining informational and financial interventions simultaneously can achieve better quality of care and reduce health care costs, something neither intervention can in isolation.

Medication management of depression in the United States and Ontario

OBJECTIVE

To compare rates of contact for mental problems and receipt of appropriate antidepressant medication management for persons in the general population with major depression in the United States and Ontario, Canada.

DESIGN

Survey using the U.S. National Comorbidity Survey and the Mental Health Supplement of the Ontario Health Survey.

PARTICIPANTS

All persons with major depression as described in DSM-III-R in the previous 12 months, from a multistage random sample of persons aged 21 to 54 years living in households in the United States (n = 574) and Ontario (n = 250) in 1990.

MEASUREMENTS AND MAIN RESULTS

Self-reported contact with general medical or mental health specialty providers for mental problems and appropriate medication management, defined as a combination of antidepressant medication use and four or more visits to any provider within the previous 12 months, were the main outcome measures. The proportion of depressed persons receiving appropriate management was lower in the United States than in Ontario (7.3% vs 14.9% in Ontario, adjusted odds ratio [AOR] 95% CI 0.4; 95% confidence interval [CI] 0.2, 0.8). This difference was largely the result of fewer Americans than Canadians having any mental health care from general medical physicians (9.6% in the United States vs 25.8% in Ontario; AOR 0.3; 95% CI 0.1, 0.5) rather than from specialty providers (20.8% in the United States vs 28.9% in Ontario; AOR 0.7; 95% CI 0.4, 1.1). These between-country differences were much greater for the poor than for those with higher incomes. The Ontario-United States AOR of making contact with either type of clinical provider was 7.5 (95% CI 2.7, 20.7) for lowest-income persons but 2.1 (95% CI 0.3, 5.6) for highest-income persons. The proportions of depressed recipients of any mental health care who received appropriate management were similar between countries (23.9% in the United States vs 27.7% in Ontario; AOR 0.8; 95% CI 0.3, 1.7).

CONCLUSIONS

Most persons with depression in the United States and Ontario do not receive appropriate medication management. The rate of appropriate medication management in the United States relative to Ontario is lower largely because there is less contact with general medical physicians for mental problems, especially for the poor. Economic barriers, rather than knowledge and attitudinal factors, appear to explain this difference.

Posttraumatic stress disorder and functioning and quality of life outcomes in a nationally representative sample of male Vietnam veterans

OBJECTIVE

Although posttraumatic stress disorder (PTSD) is a highly prevalent and often chronic condition, the relationship between PTSD and functioning and quality of life remains incompletely understood.

METHOD

The authors undertook an archival analysis of data from the National Vietnam Veterans Readjustment Study. The study subjects consisted of the nationally representative sample of male Vietnam veterans who participated in the National Vietnam Veterans Readjustment Study. The authors estimated PTSD at the time of the interview with the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder. They examined the following outcomes: diminished well-being, physical limitations, bed day in the past 2 weeks, compromised physical health status, currently not working, and perpetration of violence. Logistic models were used to determine the association between PTSD and outcome; adjustment was made for demographic characteristics and comorbid psychiatric and other medical conditions.

RESULTS

The risks of poorer outcome were significantly higher in subjects with PTSD than in subjects without PTSD in five of the six domains. For the outcome domains of physical limitations, not working, compromised physical health, and diminished well-being, these significantly higher risks persisted even in the most conservative logistic models that removed the shared effects of comorbid psychiatric and other medical disorders.

CONCLUSIONS

The suffering associated with combat related-PTSD extends beyond the signs and symptoms of the disorder to broader areas of functional and social morbidity. The significantly higher risk of impaired functioning and diminished quality of life uniquely attributable to PTSD suggests that PTSD may well be the core problem in this group of difficult to treat and multiply afflicted patients.

Treatment typically provided for comorbid anxiety disorders

OBJECTIVE

To study whether the extent and type of treatment for comorbid anxiety disorders varies for patients with depression, hypertension, diabetes, and heart disease treated by general medical clinicians.

METHODS

Data are from 2189 general medical patients with and without comorbid anxiety disorders in the Medical Outcomes Study. Treatment data were based on clinician reports of counseling provided during a visit and patient reports of recent medication use.

RESULTS

Patients with comorbid anxiety disorders were more likely to receive treatments for anxiety disorders than those without anxiety disorders. Among those with anxiety disorders, the use of psychosocial counseling and psychotropic medication was greater for patients with depression than for patients without depression who had chronic medical conditions. Minor tranquilizers were used more commonly than antidepressants, regardless of the type of comorbid condition. Among patients with anxiety disorders, those visiting medical subspecialists were more likely to use minor tranquilizers than those visiting family practitioners or internists. Patients of family physicians with chronic medical conditions (but not with depression) were less likely than similar patients of internists to use minor tranquilizers whether or not anxiety disorders were present.

CONCLUSIONS

Anxiety disorders co-occurring with another disease (medical illness or depression) increases the likelihood of counseling and the use of psychotropic medication in the general medical sector. Patients with a chronic medical illness with or without comorbid anxiety disorders visiting family physicians are less likely to use minor tranquilizers than those visiting subspecialists or internists.

Course of depression in patients with comorbid anxiety disorders

This study examined the extent to which the presence of comorbid anxiety disorder affected the course of depression. 650 depressed outpatients visiting general medical clinicians and mental health specialists were followed for 1 or 2 years. All types of anxiety increased the probability of a new depressive episode among patients with subthreshold depression. Co-occurring panic and phobia decreased the likelihood of remission. The initial number of depressive symptoms was greatest among depressed patients with comorbid anxiety and this relatively higher level persisted over two years. The findings emphasize the poor clinical prognosis associated with comorbid anxiety disorder.

Measuring health outcomes for depression

In this article, we describe the clinical and health-related quality of life outcome measures for depressed patients in the Medical Outcomes Study, a 4-year longitudinal study that started in 1986. We prioritize the measures in terms of importance, consider how they can be improved in future studies, and discuss how they should be used in more applied evaluations, such as studies by managed care companies and group practices. We emphasize the importance of identifying appropriate evaluation questions and selecting study designs and patient populations that permit meaningful answers about evaluating outcomes of care for depression. Although the outcome measures described here may be a useful starting point, they will need to be combined with carefully constructed measures of process of care as well, so that links between the two can be maximized.

Caring for depression in primary care: defining and illustrating the policy context

Depression is a socially important condition that is often undertreated. This article reviews data from the Medical Outcomes Study illustrating the policy importance of depression, highlighting style of treatment under prepaid managed or fee-for-service care and strategies to improve the cost-effectiveness and efficiency of care.

Socioeconomic burden of subsyndromal depressive symptoms and major depression in a sample of the general population

OBJECTIVE

The authors' goal was to evaluate the association between impairment in daily function and subsyndromal depressive symptoms as well as major depression to determine the economic and societal significance of these conditions.

METHOD

Using 12-month prevalence data gathered by the National Institute of Mental Health (NIMH) Epidemiologic Catchment Area Program (ECA), based on responses to the NIMH Diagnostic Interview Schedule, the authors divided the 2,393 subjects from the Los Angeles ECA site into three groups: subjects with subsyndromal depressive symptoms (N = 270), major depression (N = 102), and no depressive disorder or symptoms (N = 2,021). The groups were compared on 10 domains of functional outcome and well-being.

RESULTS

Significantly more subjects with depressive symptoms than subjects who had no disorder reported high levels of household strain, social irritability, and financial strain as well as limitations in physical or job functioning, restricted activity days, bed days, and poor health status. Significantly more subjects with major depression than subjects with no disorder reported major financial losses, bed days, high levels of financial strain, limitations in physical or job functioning, and poor health status. Except for lower self-ratings of health status, no significant differences were found between subjects with subsyndromal symptoms and those with major depression.

CONCLUSIONS

Significantly more people with subsyndromal depressive symptoms or major depression reported impairment in eight of 10 functional domains than did subjects with no disorder. The high 1-year prevalence of subsyndromal depressive symptoms, combined with the associated functional impairment, emphasizes the clinical and public health importance and need for additional investigations into these symptoms.

Informing the policy process: from efficacy to effectiveness data on pharmacotherapy

Health care delivery is rapidly changing, but are the right data available to inform the policy process? This article illustrates the use of observational data on quality and effectiveness of treatment for anticipating the consequences of alternative forms of health care delivery, with psychotropic medications used as the example. The data are from the Medical Outcomes Study. Patients in each specialty sector (general medical provider, psychiatrist, psychologist or master's-level therapist) have unique profiles of use of appropriate psychotropics, and there is less appropriate and less efficient medication management in prepaid than fee-for-service care, especially within psychiatry. Overall, effective psychotropic medications are underused, reducing the cost-effectiveness of care. Improving the quality of psychotropic medication management would improve patient functioning outcomes and cost effectiveness of care, but in the absence of compensating strategies, it would also raise treatment costs.

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

BACKGROUND

The comorbidity of psychiatric disorders with chronic health conditions has emerged as a topic of considerable clinical and policy interest, in part owing to the evidence that anxiety disorders themselves are associated with morbidity. However, the implications for health-related quality of life that result from anxiety disorders, which are comorbid to chronic medical or psychiatric illness, are not well understood, especially in primary care samples.

METHODS

A 2-year observational study of 875 adult patients with hypertension, diabetes, heart disease, and current depressive disorder or subthreshold depression receiving care from general medical providers was conducted. The unique effect of any comorbid anxiety disorder on functioning and well-being (determined with the use of the 36-Item Short-Form Health Survey [SF-36]) was estimated, as well as the differential impact at baseline, 2-year follow-up, and change over time, of any comorbid anxiety disorder for patients with chronic medical conditions or depression.

RESULTS

Patients with comorbid anxiety who received general medical care had lower levels of functioning and well-being than those without comorbid anxiety. These differences were most pronounced in mental health-related quality-of-life measures and when anxiety was comorbid with chronic medical conditions rather than with depression. Hypertensive and diabetic patients with comorbid anxiety were as debilitated as patients with depression or heart disease, and this low health-related quality of life persisted over time. Comorbid anxiety had less of an effect on patients with heart disease who already had a low health-related quality of life.

CONCLUSION

The finding of substantial differences in the quality of life between hypertensive and diabetic patients with and without comorbid anxiety disorder highlights the clinical and societal importance of identifying comorbid anxiety in these patients.

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

BACKGROUND

To assess how current policy trends may affect the use of counseling for depression, we examined the variation in the use of counseling and usual clinician counseling style for depression across specialty sectors (psychiatry, psychology, and general medicine) and reimbursement type (fee-for-service or prepaid).

METHODS

Three types of observational data from the RAND Medical Outcomes Study: (1) patient-reported demographics, depressive symptoms, clinical status, and perceptions about participation style; (2) clinician reports of counseling during specific patient encounters; and (3) clinician reports of the usual counseling and interpersonal style across patients who were seen in a practice.

RESULTS

While almost all depressed patients who were being treated by mental health specialists received brief counseling for at least 3 minutes, less than half of the depressed patients in the general medical sector received such counseling--even for those patients with a current depressive disorder. Counseling rates were lower under prepaid than fee-for-service care in general medical practices. Psychiatrists relied more on psychodynamic approaches, and psychologists relied more on behavioral therapies relative to each other, but both specialty groups provided longer sessions and used more formal psychotherapeutic techniques (e.g., interpretation) than did general medical clinicians. Clinicians who were treating more patients who had prepaid plans reported a lower proclivity for face-to-face counseling, and they spent less time when they were counseling patients compared with clinician who were treating more patients who had fee-for-service plans; however, these differences were not large.

CONCLUSION

The use of counseling in the usual care for depression varied by both specialty and payment system, while the usual clinician counseling style differed markedly by specialty, but only slightly by payment system.

Informing the policy process: from efficacy to effectiveness data on pharmacotherapy

Health care delivery is rapidly changing, but are the right data available to inform the policy process? This article illustrates the use of observational data on quality and effectiveness of treatment for anticipating the consequences of alternative forms of health care delivery, with psychotropic medications used as the example. The data are from the Medical Outcomes Study. Patients in each specialty sector (general medical provider, psychiatrist, psychologist or master's-level therapist) have unique profiles of use of appropriate psychotropics, and there is less appropriate and less efficient medication management in prepaid than fee-for-service care, especially within psychiatry. Overall, effective psychotropic medications are underused, reducing the cost-effectiveness of care. Improving the quality of psychotropic medication management would improve patient functioning outcomes and cost effectiveness of care, but in the absence of compensating strategies, it would also raise treatment costs.

Provider choice and continuity for the treatment of depression

The role of specialist versus generalist providers regularly surfaces in health-care reform debates about costs and quality of care. By changing incentives to seek and deliver care, different payments systems can affect both the probability of initial specialty care and the duration of this patient-provider relationship. The authors compare provider selection (psychiatrist, nonphysician mental-health specialist, general medical provider) and duration of this relationship among depressed patients in prepaid and fee-for-service plans. Regarding initial care, depressed patients in prepaid plans are significantly less likely to see a psychiatrist and more likely to see a nonphysician mental-health specialist than patients in fee-for-service plans. Although the mix of providers differs, patient demographic and clinical characteristics have similar effects on specialty in both payment systems, ie, there are no differences in who gets specialty care by type of payment, but in how many get specialty care. The average duration of a patient-provider relationship is significantly shorter in prepaid plans. Durations are significantly shorter for patients of both psychiatrists and general medical providers in prepaid plans, but do not differ by payments type for nonphysician therapists. In both payments systems, patients of nonphysician providers end the relationship sooner than patients of psychiatrists or general medical providers. Although the authors find provider switching to be associated significantly with discontinuing antidepressant medication, there is no significant direct effect on patient health outcomes.

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

BACKGROUND

The purpose of this study was to describe the prevalence of psychological distress and probable lifetime mental disorders among homeless mothers, their use of services, and the relationship between maternal and child mental health problems.

METHOD

The study involved a cross-sectional assessment of 110 mothers and 157 children living in homeless shelters in Los Angeles County.

RESULTS

The majority (72%) of sheltered homeless mothers reported high current psychological distress or symptoms of a probable lifetime major mental illness or substance abuse. However, few mothers (15%) in need of services received mental health care, and the main point of contact for those with a mental health problem was the general medical sector. Mothers with a probable mental disorder were also significantly more likely to have children with either depression or behavior problems.

CONCLUSIONS

Homeless mothers have a high level of unmet need for mental health services. The relationship between maternal and child problems underscores the need for homeless family interventions that promote access to psychiatric care for both generations.

Functioning and well-being of patients with panic disorder

OBJECTIVE

The authors compared the health-related quality of life of patients with panic disorder to that of patients with other major chronic medical and psychiatric conditions.

METHOD

The physical and mental health of a group of 433 patients with current panic disorder and 9,839 outpatients with psychiatric or medical disorders were assessed with the 20- and 36-item short-form surveys of the Medical Outcomes Study. After controlling for other disease conditions, demographics, and study site, the authors used multiple regression methods to estimate health-related quality of life levels for panic disorder patients and patients with hypertension, diabetes, heart disease, arthritis, chronic lung problems, and major depression.

RESULTS

Patients with panic disorder had levels of mental health and role functioning that were substantially lower than those of patients with other major chronic medical illnesses but were higher than or comparable to those of patients with depression. However, their physical functioning levels and perceptions of current health were more like those of patients with hypertension and were similar to general population norms.

CONCLUSIONS

Panic disorder is a serious societal health problem with large consequences, and it affects primarily psychological and role domains.

Prevalence of comorbid anxiety disorders in primary care outpatients

OBJECTIVE

To estimate the extent to which anxiety disorders (eg, panic disorder, phobia, and generalized anxiety disorder [GAD]) co-occur in patients with major medical and psychiatric conditions.

DESIGN

Observational study.

SETTING

Offices of primary care providers in three US cities, with mental health specialty providers included for comparative purposes.

PATIENTS

Adult patients (N = 2494) with hypertension, diabetes, heart disease (congestive heart failure or myocardial infarction), current depressive disorder, or subthreshold depression.

MEASURES

Current (past 12 months) and lifetime panic disorder, phobia, GAD, perceived need for help for emotional or family problems, and unmet need (ie, failure to get help that was needed).

METHODS

Comparisons of the prevalence of anxiety comorbidity in medically ill nondepressed patients of primary care providers and in depressed patients of both primary care and mental health specialty providers.

RESULTS

Among primary care patients, those with chronic medical illnesses or subthreshold depression had low rates of lifetime (1.5% to 3.5%) and current (1.0% to 1.7%) panic disorder, but those with current depressive disorder had much higher rates (10.9% lifetime and 9.4% current panic disorder). Concurrent phobia and GAD were more common (10.4% to 12.4% current GAD), especially among depressed patients (25% to 54% current GAD). Depending on the type of medical illness or depression, 14% to 66% of primary care patients had at least one concurrent anxiety disorder. Patient-perceived unmet need for care for personal or emotional problems was high among all primary care patients (54.6% to 72.9%).

CONCLUSION

Primary care clinicians should be aware of the possible coexistence of anxiety disorders (especially GAD) among their patients with chronic medical conditions, but especially among those with current depressive disorder.

Impact of prior and current alcohol use on use of services by patients with depression and chronic medical illnesses

OBJECTIVE

Alcohol use often co-occurs with other major chronic conditions, but its effect on health care utilization in this context is not understood. This study examines the impact of alcohol consumption on health care use by patients with chronic medical conditions or depression, or both.

DATA SOURCES/STUDY SETTING

Data came from the Medical Outcomes Study, an observational study of patients from the offices of general medical providers and mental health specialists in three U.S. cities.

STUDY DESIGN

Longitudinal data spanning four years for outpatient general medical visits and outpatient mental health visits were analyzed using a two-part model to assess the impact of alcohol use disorder, problem drinking, and current and past alcohol consumption on health care use by patients, controlling for patient demographics and health status.

DATA COLLECTION/EXTRACTION METHODS

Data were collected from 2,546 adult patients with hypertension, diabetes, heart disease (congestive heart failure or myocardial infarction), and/or current major depression or subthreshold depression using periodic, self-report surveys detailing health care utilization and health status information.

PRINCIPAL FINDINGS

Current alcohol consumption increases outpatient doctor visits, and problems related to current drinking decrease outpatient mental health visits.

CONCLUSIONS

Patterns of alcohol consumption have an impact on both mental health and overall health care use by patients with chronic medical conditions or depression.

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

OBJECTIVE

The authors sought to identify risk factors for rehospitalization in a seriously mentally ill population, focusing on factors that have the potential to be modified through community-based interventions.

METHOD

A case-control design was used in which 101 "case" subjects (recently readmitted psychiatric patients) and a comparison group of 101 subjects living in the community who had been previously hospitalized at the same time as the case subjects, but who in contrast had not been readmitted, were matched on gender, ethnicity, and length of time at risk for rehospitalization. The setting was the Mississippi public mental health system during the first 3 months of 1988, including Mississippi State Hospital and the 10 community mental health regions in its catchment area. The subjects were between the ages of 18 and 55 years, had had at least one previous Mississippi State Hospital admission, and had a primary chart diagnosis of schizophrenia; 197 informants, mostly family members, were also included in the study. Data were collected from structured interviews of subjects and informants, direct observation ratings of subjects, Mississippi State Hospital administrative records, and community mental health center administrative records.

RESULTS

Medication noncompliance, comorbid alcohol abuse, and a high level of criticism of subjects by informants were associated with greater risk of rehospitalization, while types and extent of outpatient service use, access to care, quality of life, and demographic variables (other than ethnicity and gender) were not.

CONCLUSIONS

These findings imply that interventions aimed at improving medication compliance, reducing alcohol abuse, and helping families cope with their mentally ill relatives could reduce the risk of hospitalization in this population.

Effects of Medicare's prospective payment system on service use by depressed elderly inpatients

OBJECTIVE

To determine the effects of Medicare's prospective payment system (PPS) on hospital care, changes in length of stay and intensity of clinical services received by 2,746 depressed elderly patients in 297 acute care general medical hospitals were studied.

METHODS

A pre-post design was used, and differences in sickness at admission were controlled for. Data on length of stay and use of specific clinical services were obtained from the medical record using a medical record abstraction form. Care provided on units exempt from PPS was compared with care provided in nonexempt units.

RESULTS

After implementation of PPS, the average length of stay fell by up to three days within the different types of acute care settings studied, but this decline was partially offset by proportionately more admissions to psychiatric units, which had longer lengths of stay. Intensity of clinical services increased after PPS implementation, especially in nonexempt psychiatric units.

CONCLUSION

Despite financial incentives for hospitals to reduce clinical services under PPS, its implementation was not associated with a marked decline in length of stay, when averaged across all treatment settings, and was associated with an increase in the intensity of many clinical services used by depressed elderly patients in general hospitals.

Personal and psychosocial risk factors for physical and mental health outcomes and course of depression among depressed patients

This article focuses on personal and psychosocial factors to identify those that predict change in functioning and well-being and clinical course of depression in depressed outpatients over time. Data from 604 depressed patients in The Medical Outcomes Study showed improvements in measures of functioning and well-being associated with patients who were employed, drank less alcohol, and had active coping styles. Better clinical course of depression was associated with patients who had high levels of social support, who had more active and less avoidant coping styles, who were physically active, and who had fewer comorbid chronic conditions. Findings provide some guidance as to what can be done to improve depressed patients' levels of physical and mental health and affect the clinical course of depression.

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

BACKGROUND

Studies to assess quality of care have become increasingly important for research and policy purposes.

OBJECTIVE

To evaluate the difference in quality of care between elderly depressed patients hospitalized in specialty psychiatric units and those hospitalized in general medical wards.

METHODS

We reviewed retrospectively the medical charts of 2746 patients with depression hospitalized in 297 general medical hospitals in five different states. Quality of care was assessed by clinical review of explicit and implicit information contained in the medical records of patients in specialty psychiatric units (n = 1295) and general medical wards (n = 1451). We also used other secondary data sources to determine postdischarge outcomes.

RESULTS

We found that (1) a higher percentage of admissions on the psychiatric units were considered appropriate, (2) overall psychological assessment was better on the psychiatric unit, (3) patients were more likely to receive psychological services on the psychiatric wards but more likely to receive traditional general medical services on medical wards, (4) there were more inpatient general medical complications on the psychiatric wards, and (5) implicit measures of clinical status at discharge were better for those on the psychiatric unit.

CONCLUSIONS

Although limited by reliance on medical record abstraction and a retrospective study design, our data indicate that the quality of care for the psychological aspects of the treatment of depression may be better on psychiatric units, while the quality of general medical components of care may be better on general medical wards.