Increases in morbid obesity in the USA: 2000-2005

BACKGROUND

It is well known that citizens of developed countries are more likely to be overweight than they were 20 years ago. The most serious health problems are not associated with overweight or moderate obesity, however, but with clinically severe or morbid obesity (e.g. more than 100 pounds (45kg) overweight). There is no reason to expect that morbid obesity trends parallel overweight or moderate obesity. If morbid obesity is a rare pathological condition that has biological causes, the more than 10-fold increase in bariatric surgery procedures over the past eight years in the USA could have even lowered the prevalence of morbid obesity-and may very well stem the problem in other countries.

OBJECTIVE

To estimate trends for extreme weight categories (BMI>40 and >50) for the period between 1986 and 2005 in the USA, and to investigate whether trends have changed since 2000.

METHODS

Data from The Behavioral Risk Factor Surveillance System (a random-digit telephone survey of the household population of the USA), for the period from 1986 to 2005, were analysed. The main outcome measure was body mass index (BMI), calculated from self-reported weight and height.

RESULTS

From 2000 to 2005, the prevalence of obesity (self-reported BMI over 30) increased by 24%. However, the prevalence of a (self-reported) BMI over 40 (about 100 pounds (45kg) overweight) increased by 50% and the prevalence of a BMI over 50 increased by 75%, two and three times faster, respectively. The heaviest BMI groups have been increasing at the fastest rates for 20 years.

CONCLUSIONS

The prevalence of clinically severe obesity is increasing at a much faster rate among adults in the USA than is the prevalence of moderate obesity. This is consistent with the public health idea that the population weight distribution is shifting, which disproportionately increases extreme weight categories. Because comorbidities and resulting service use are much higher among severely obese individuals, the widely published trends for overweight/obesity underestimate the consequences for population health. The aggressive and costly expansion of bariatric surgery in recent years has had no visible effect on containing morbid obesity rates in the USA.

Morbid obesity rates continue to rise rapidly in the United States

Clinically severe or morbid obesity (body mass index (BMI) >40 or 50 kg m(-2)) entails far more serious health consequences than moderate obesity for patients, and creates additional challenges for providers. The paper provides time trends for extreme weight categories (BMI >40 and >50 kg m(-2)) until 2010, using data from the Behavioral Risk Factor Surveillance System. Between 2000 and 2010, the prevalence of a BMI >40 kg m(-2) (type III obesity), calculated from self-reported height and weight, increased by 70%, whereas the prevalence of BMI >50 kg m(-2) increased even faster. Although the BMI rates at every point in time are higher among Hispanics and Blacks, there were no significant differences in trends between them and non-Hispanic Whites. The growth rate appears to have slowed down since 2005. Adjusting for self-report biases, we estimate that in 2010 15.5 million adult Americans or 6.6% of the population had an actual BMI >40 kg m(-2). The prevalence of clinically severe obesity continues to be increasing, although less rapidly in more recent years than prior to 2005.

A 100-kD HeLa cell octamer binding protein (OBP100) interacts differently with two separate octamer-related sequences within the SV40 enhancer

Numerous eukaryotic upstream promoter and enhancer regions contain a functional octamer sequence ATGCAAAT. We have examined the interactions between an octamer binding protein isolated from HeLa cells and the SV40 and immunoglobulin heavy-chain (IgH) gene enhancers. A partially purified octamer binding activity forms a single complex with the IgH enhancer octamer in a gel retardation assay, but two complexes with a SV40 enhancer fragment containing a single 72-bp element. By using point mutants and both dimethyl sulfate and diethyl pyrocarbonate modification interference assays, we show that the SV40 complexes result from binding of a factor to the octamer-related sequence ATGCAAAG (Octa1) and to an adjacent previously unidentified octamer-related sequence ATGCATCT (Octa2). The base-specific interactions with Octa1 and Octa2 differ; chemical modifications over a 10-bp sequence TATGCAAAGC affect Octa1 binding whereas Octa2 binding is affected by modifications spanning a 13-bp sequence ATGCATCTCAATT in which the octamer-like sequence is not centered. The octamer binding activity has been purified extensively by a DNA affinity precipitation procedure and SDS-polyacrylamide gel electrophoresis. The purified protein, OBP100, has an apparent molecular weight of 100 kD and binds both SV40 Octa1 and Octa2, as well as the IgH enhancer. The distinct interactions of OBP100 with the differently sized Octa1 and Octa2 binding sites suggest remarkably flexible sequence recognition between OBP100 and its binding sites.

Body mass index in elementary school children, metropolitan area food prices and food outlet density

OBJECTIVE

The aim of this study was to examine the association between food prices and food outlet density and changes in the body mass index (BMI) among elementary school children in the USA.

METHODS

The Early Childhood Longitudinal Study followed a nationally representative sample of kindergarten children over 4 years. We merged individual-level data to (a) metropolitan data on food prices and (b) per capita number of restaurants, grocery stores and convenience stores in the child's home and school zip code. The dependent variables were BMI changes over 1 and 3 years. We analysed mean changes with least-squares regression, and median changes and 85th percentile changes with quantile regression. We controlled for baseline BMI, age, real family income and sociodemographic characteristics.

RESULTS

Lower real prices for vegetables and fruits were found to predict a significantly lower gain in BMI between kindergarten and third grade; half of that effect was found between kindergarten and first grade. Lower meat prices had the opposite effect, although this effect was generally smaller in magnitude and was insignificant for BMI gain over 3 years. Differences across subgroups were not statistically significant due to smaller sample sizes in subgroup analyses, but the estimated effects were meaningfully larger for children in poverty, children already at risk for overweight or overweight in kindergarten, and Asian and Hispanic children. There were no significant effects for dairy or fast-food prices, nor for outlet density, once we had controlled for individual characteristics and random intercepts to adjust standard errors for the sampling design.

DISCUSSION

The geographic variation in fruit and vegetable prices is large enough to explain a meaningful amount of the differential gain in BMI among elementary school children across metropolitan areas. However, as consumption information was not available, we cannot confirm that this is the actual pathway. We found no effects of food outlet density at the neighbourhood level, possibly because availability is not an issue in metropolitan areas.

Childhood overweight and elementary school outcomes

OBJECTIVE

To examine the link between childhood overweight status and elementary school outcomes.

DESIGN

Prospective study design: multivariate regression models examining the association between changes in overweight status and school outcomes between kindergarten entry and end of third grade, after controlling for various child, family and school characteristics.

SUBJECTS

Nationally representative sample of US children who entered kindergarten in 1998, with longitudinal data on body mass index (BMI) and school outcomes at kindergarten entry and end of third grade.

MEASUREMENTS

Wide range of elementary school outcomes collected in each wave including academic achievement (math and reading standardized test scores); teacher reported internalizing and externalizing behavior problems (BP), social skills (self-control, interpersonal skills) and approaches to learning; school absences; and grade repetition. Measurements of height and weight in each wave were used to compute BMI and indicators of overweight status based on CDC growth charts. A rich set of control variables capturing child, family, and school characteristics.

RESULTS

Moving from not-overweight to overweight between kindergarten entry and end of third grade was significantly associated (P<0.05) with reductions in test scores, and teacher ratings of social-behavioral outcomes and approaches to learning among girls. However, this link was mostly absent among boys, with two exceptions - boys who became overweight had significantly fewer externalizing BPs (P<0.05), but more absences from school compared to boys who remained normal weight. Being always-overweight was associated with more internalizing BP among girls but fewer externalizing BPs among boys.

CONCLUSION

Change in overweight status during the first 4 years in school is a significant risk factor for adverse school outcomes among girls but not boys. Girls who become overweight during the early school years and those who start school being overweight and remain that way may need to be monitored carefully.

Three-month comparison of bimatoprost and latanoprost in patients with glaucoma and ocular hypertension

A multicenter, randomized, investigator-masked, parallel-group trial compared bimatoprost and latanoprost for efficacy and safety in patients with glaucoma or ocular hypertension. Patients received bimatoprost 0.03% (n = 119) or latanoprost 0.005% (n = 113) once daily in the evening for 3 months. Visits were at prestudy, baseline (day 0), week 1, and months 1, 2, and 3. Primary outcome measures were mean IOP and the percentage of patients achieving IOP of 17 mm Hg or lower at 8:00 AM. Secondary outcome measures were diurnal IOP measurements (8:00 AM, 12 noon, 4:00 PM, 8:00 PM) at month 3 and safety measures including adverse events. Mean IOP was lower with bimatoprost than with latanoprost at all time points during the 3-month follow-up, although the between-group difference was not always statistically significant. At month 3 at 12 noon, mean IOP was as much as 1.0 mm Hg lower with bimatoprost (P = .021). Target pressures of < or = 17 mm Hg were reached more often with bimatoprost than with latanoprost at 8:00 AM (53% vs 43%; P = .029). Over all diurnal measurements at month 3, low target pressures of < or = 13, < or = 14, and < or = 15 mm Hg were achieved significantly more often with bimatoprost (P < or = .006). Both drugs were safe and well tolerated. Conjunctival hyperemia was more common with bimatoprost, while headache was more frequent with latanoprost. Bimatoprost provided lower mean pressures than latanoprost at every time point throughout the study and was statistically superior in achieving low target pressures. More patients reached low target pressures with bimatoprost.

OBP100 binds remarkably degenerate octamer motifs through specific interactions with flanking sequences

We have used the 100-kD HeLa cell octamer-binding protein OBP100 as a model to study flexible DNA sequence recognition by promoter-binding proteins. OBP100 binds to the conserved octamer motif ATGCAAAT found in numerous promoters and additionally to two degenerate octamer motifs (sites I and II) within the SV40 enhancer region. We show here that OBP100 binds the herpes simplex virus immediate early promoter TAATGARAT (R = purine) motif itself, extending the flexibility of OBP100 sequence recognition to sequences that bear very little resemblance (four matches over a 14-bp region). Nevertheless, a progression of OBP100-binding sites can be established that links the sequences of these two apparently unrelated binding sites by incremental steps. Mutational and chemical modification interference analyses of a degenerate octamer binding site (SV40 site II) show that specific sequences, which are not normally conserved but flank the degenerate octamer motif, can compensate for the degeneracy in the octamer core sequence. Thus, different regions of the binding site sequence (core or flanking) can diverge separately but not independently of one another. These results suggest that flexible DNA sequence recognition arises because there are few obligatory contact sites for OBP100 binding, but, rather, specific binding reflects the sum of many independent interactions.

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.

National estimates of mental health utilization and expenditures for children in 1998

No recent national data on expenditures and utilization are available to provide a benchmark for reform of mental health systems for children and adolescents. The most recent estimates, from 1986, predate the dramatic growth of managed care. This study provides updated national estimates. Treatment expenditures are estimated to be $11.68 billion ($172 per child). Adolescents have the highest expenditures at $293 per child followed by $163 per child aged 6 to 11 and $35 per preschool-aged child. Outpatient services account for 57%, inpatient for 33%, and psychotropic medications for 9% of the total. Unlike earlier reports, outpatient care now accounts for the majority of expenditures. This finding replicates the differences between recent managed care data and earlier actuarial databases for privately insured adults and confirms the trend from inpatient toward outpatient care.

Suburban sprawl and physical and mental health

OBJECTIVE

To study the association between objective measures of suburban sprawl and chronic medical conditions and mental health disorders in the USA.

METHODS

Cross-sectional analysis of survey data merged with objective measures of suburban sprawl. Outcomes are self-reported medical conditions, mental health disorders and health-related quality of life.

RESULTS

Sprawl significantly predicts chronic medical conditions and health-related quality of life, but not mental health disorders. An increase in sprawl from one standard deviation less to one standard deviation more than average implies 96 more chronic medical problems per 1000 residents, which is approximately similar to an aging of the population of 4 years.

CONCLUSIONS

A robust association between sprawl and physical (but not mental) health suggests that suburban design may be an important new avenue for health promotion and disease prevention.

Costs and use of mental health services before and after managed care

This paper tracks access, utilization, and costs of mental health care for a private employer over nine years during which mental health benefits were carved out of the medical plan and managed care was introduced. Prior to the carve-out, mental health costs increased by around 30 percent annually; in the first year after the change, costs dropped by more than 40 percent; in the six follow-up years, costs continued to decline slowly. This cost reduction was not attributable to decreased initial access, as the number of persons using any mental health care increased following the change. Instead, the cost reduction was the result of (1) fewer outpatient sessions per user, (2) reduced probability of an inpatient admission, (3) reduced length-of-stay for an inpatient episode, and (4) substantially lower costs per unit of service.

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

OBJECTIVE

To compare change over time in symptoms of depression and limitations in role and physical functioning of patients receiving prepaid or fee-for-service care within and across clinician specialties.

METHOD

Observational study of change in outcomes over 2 years for 617 depressed patients of psychiatrists, psychologists, other therapists, and general medical clinicians in three urban sites in the United States.

RESULTS

Psychiatrists treated psychologically sicker patients than other clinicians in all payment types. Among psychiatrists' patients, those initially receiving prepaid care acquired new limitations in role/physical functioning over time, while those receiving fee-for-service care did not. This finding was most striking in independent practice associations but varied by site and organization. Patients of psychiatrists were more likely to use antidepressant medication than were patients of other clinicians, but among psychiatrists' patients, there was a sharp decline over time in the use of such medication in prepaid compared with fee-for-service care. Outcomes did not differ by payment type for depressed patients of other specialty groups, or overall.

CONCLUSION

Depressed patients of psychiatrists merit policy interest owing to their high levels of psychological sickness. For these patients, functioning outcomes were poorer in some prepaid organizations. The nonexperimental evidence favors (but cannot prove) an explanation based on care received, such as a reduction in medications, rather than on preexisting sickness differences.

Gonadotropin releasing hormone binding sites in human epithelial ovarian carcinomata

As a first step to investigate whether gonadotropin releasing hormone (GnRH) analogs might be able to modulate directly the proliferation of human epithelial ovarian carcinomata, we checked if binding sites for GnRH are present in these malignancies. Specific binding of [125I][D-Ala6-des Gly10]-GnRH-ethylamide (GnRH agonist = GnRH-A) could be demonstrated in plasma membranes from 32 out of 40 ovarian carcinomata tested. This binding was dependent on temperature, time and plasma membrane concentration. Mathematical analysis of the binding data showed that the interaction of GnRH-A with the binding sites was consistent with a single class of low affinity, high capacity binding sites (Ka = 1.42 +/- 0.14 X 10(5) M-1; range: 0.3-3.8 X 10(5) M-1; R = 209 +/- 69 X 10(-12) M/mg membrane protein; range 16-400 X 10(-12) M/mg MP; means +/- S.E., n = 32). Native GnRH and the GnRH antagonist [D-p-Glu1, D-Phe2, D-Trp3,6]-GnRH had Ka values comparable to those of the GnRH-A used. [125I]GnRH-A binding could not be displaced by oxytocin, thyrotropin releasing hormone and corticotropin releasing factor in concentrations up to 10(-4) M. Somatostatin cross-reacted with binding sites from some carcinomata, while it did not displace GnRH-A binding in membranes from others. Though the functional role of this specific binding site for GnRH in human epithelial ovarian carcinomata is still obscure, it might be part of an autocrine regulatory system and provide a possible point of attack for therapeutic approaches using GnRH analogs in this malignancy.

Is there a robust relationship between neighbourhood food environment and childhood obesity in the USA?

OBJECTIVES

To examine the robustness of the relationship between neighbourhood food environment and youth body mass index (BMI) percentile using alternative measures of food environment and model specifications.

STUDY DESIGN

Observational study using individual-level longitudinal survey data of children in fifth and eighth grades merged with food outlet data based on student residential census tracts.

METHODS

The relationship between food environment and BMI was examined with two individual outcomes (BMI percentile in eighth grade and change in BMI percentile from fifth to eighth grade) and three alternative measures of food environment (per-capita counts of a particular outlet type, food environment indices, and indicators for specific combinations of outlet types).

RESULTS

No consistent evidence was found across measures (counts of a particular type of food outlet per population, food environment indices, and indicators for the presence of specific combinations of types of food stores) and outcomes to support the hypothesis that improved access to large supermarkets results in lower youth BMI; or that greater exposure to fast food restaurants, convenience stores and small food stores increases BMI.

CONCLUSIONS

To the extent that there is an association between food environment and youth BMI, the existence of more types of food outlets in an area, including supermarkets, is associated with higher BMI.

Gonadotropin-releasing hormone antagonist protocol: a novel method of ovarian stimulation in poor responders

OBJECTIVE

To estimate the efficacy of gonadotropin-releasing hormone (GnRH) antagonist 'Cetrorelix' in poor responders comparing with the standard long protocol.

DESIGN

The study population consisted of 21 poor responders who underwent ICSI and treated with Cetrorelix according to the multiple-dose protocol and who were compared with 21 poor responders treated according to the long protocol and who also underwent ICSI. Patients in both groups were matched for chronological age, the number of follicles found by ultrasound at the retrieval day and cause of infertility. Fifteen patients of GnRH antagonist group were treated with the combination of GnRH antagonist with clomiphene citrate (CC) plus gonadotropins, while six patients were treated with the combination of GnRH antagonist plus gonadotropins, but without CC.

RESULTS

The use of GnRH antagonist in a multiple dose protocol gave a pregnancy rate of 14.28% which was in the range expected for patient with poor response, but with shorter treatment duration and with fewer ampoules of gonadotropins as compared with the use of a GnRH agonist protocol in a depot formulation. Within Cetrorelix group patients who received CC had a significant shorter duration of stimulation and needed fewer ampoules as compared with patients in the same group who did not receive CC.

CONCLUSIONS

A GnRH antagonist multiple dose protocol may be the protocol of choice for the treatment of poor responders. The use of GnRH antagonist Cetrorelix ended with significantly less ampoules of gonadotropins and a shorter duration of stimulation.

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.

Neuropsychological effects of chronic asymptomatic increased lead absorption. A controlled study

Twenty-seven asymptomatic children with confirmed chronic increased lead absorption were compared with 27 matched control children for evidence of neuropsychological impairment. Evaluation of each child included a complete history, physical examination, quantitative neurological tests, and comprehensive psychological tests. There was significantly increased incidence of hyperactive behavior in the subjects with increased lead levels, but there was no significant difference in any of the quantitative test results. Uncontrolled variables, especially lead absorption in infancy and adverse environmental pressures other than lead, still leave questions about the relationship between chronic lead exposure and behavior of intelligence.

Experience with the elective transfer of two embryos under the conditions of the german embryo protection law: results of a retrospective data analysis of 2573 transfer cycles

The German embryo protection law (Embryonenschutzgesetz, ESchG) does not allow embryo selection. Therefore, only as many oocytes at the pronuclear stage (PN), as are planned to be transferred, are allowed to be cultured. It is not known whether, under these conditions, it is possible to reduce the number of embryos for transfer without a corresponding reduction of the overall pregnancy rate (PR). We retrospectively analysed 2573 consecutive transfer cycles following either in-vitro fertilization (IVF) or IVF/intracytoplasmic sperm injection. Out of these cycles, 234, 329 and 792 were performed with one, two, and three embryos respectively, because only that number was available (non-elective transfer). Another 123 and 1095 transfer cycles were performed with two and three embryos, respectively, which were selected from a higher number of PN oocytes (elective transfer). The clinical ongoing PR were 3.9, 9.1 and 17.7% respectively for the groups with non-elective transfer of 1, 2 and 3 embryos, and 22.0 and 22.5% for the groups with elective transfers with two and three embryos, respectively. There was no statistically significant difference in PR between the two elective embryo transfer groups up to the age of 40 years. The multiple pregnancy rate was reduced by 7.9%. The reduction of the number of embryos transferred from three to two can be performed even under the conditions of the ESchG without an effect on the overall PR.

Comparison of cryopreservation of supernumerary pronuclear human oocytes obtained after intracytoplasmic sperm injection (ICSI) and after conventional in-vitro fertilization

A comparison was made of pronuclear stage human oocytes obtained either after classical in-vitro fertilization (IVF) or after intracytoplasmic sperm injection (ICSI). After ICSI or IVF, three fertilized oocytes from each patient were kept in culture for a further 24 h before embryo transfer. The surplus oocytes were cryopreserved using the 'open freezing system' and 1,2-propanediol and sucrose as cryoprotectants. A cohort of 817 and 1626 oocytes in pronuclear stage were frozen after IVF and ICSI respectively. Of these, 333 and 744 zygotes have been thawed, of which 78 and 76.5% were morphologically intact zygotes after IVF and ICSI respectively. From the 204 (ICSI) and 89 (IVF) zygote transfers performed, 34 (17%) and 18 (20%) pregnancies were established. Both groups showed a similar abortion rate of approximately 20%. It is concluded that pronuclear stage oocytes resulting from ICSI can be successfully frozen/thawed and the survival and pregnancy rates achieved are comparable to those for zygotes obtained after IVF.

Implementing publicly funded risk contracts with community mental health organizations

The study analyzed the experience of the Los Angeles County Department of Mental Health with implementation of new contractual arrangements for services for patients with severe mental illness. The arrangements shifted the financial risk for treatment to community organizations and paid a fixed annual rate per enrolled patient without further adjustment for severity of illness. Patients were assigned to the program based on high prior treatment costs. The new contractual approach enhanced programs' flexibility and accountability and increased their emphasis on principles of psychosocial rehabilitation. Challenges in implementation included disenrollment of the majority of assigned patients by the community organizations at risk for high treatment costs. Prior treatment costs for continuing cases, while high, were lower than those for disenrolled cases. Existing information systems provided limited clinical and cost data, making it difficult to monitor providers' performance. Risk contracting required substantial clinical, fiscal, and management changes at community organizations and the mental health authority. The analysis suggests that mental health authorities that are planning to institute risk contracts need to balance fiscal incentives with performance guarantees and to pay particular attention to information systems requirements and to the severity of patients' illness. Although risk contracts present challenges, they can lead to improvements in service delivery that persist beyond the implementation phase.

Tracking changes in behavioral health services: how have carve-outs changed care?

This special issue of the Journal of Behavioral Health Services & Research on mental health carve-outs brings together some of the latest research on recent policy and market changes affecting behavioral health services. This introductory article provides background information about carve-outs and the managed behavioral health care industry. This article also reviews prior research in the mental health carve-out field.

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.