National prevalence of receipt of antidepressant prescriptions by persons without a psychiatric diagnosis

OBJECTIVE

The study addressed recent concerns regarding increasing prescription of antidepressant drugs to patients with no recorded psychiatric diagnosis.

METHODS

Records from ten large integrated health systems in the Mental Health Research Network were used to examine diagnoses received by 1,011,946 health plan members who filled at least one antidepressant prescription in 2010.

RESULTS

Among individuals filling antidepressant prescriptions, psychiatric diagnoses recorded during the year were depressive disorders (48%), anxiety disorders (27%), bipolar disorders (3%), and attention deficit disorders (3%). The proportion of those filling prescriptions who had no psychiatric diagnosis was 39%, which fell to 27% after the analysis excluded prescriptions for antidepressants often prescribed for nonpsychiatric indications (tricyclic antidepressants, trazodone, and bupropion).

CONCLUSIONS

Prescription of antidepressants to patients without an appropriate diagnosis appears to be less common than previously reported.

Comparative performance of Patient Health Questionnaire-9 and Edinburgh Postnatal Depression Scale for screening antepartum depression

OBJECTIVE

We sought to evaluate the psychometric properties of two widely used screening scales: the Patient Health Questionnaire (PHQ-9) and Edinburgh Postnatal Depression Scale (EPDS) among pregnant Peruvian women.

METHODS

This cross-sectional study included 1517 women receiving prenatal care from February 2012 to March 2013. A structured interview was used to collect data using PHQ-9 and EPDS. We examined reliability, construct and concurrent validity between two scales using internal consistency indices, factor structures, correlations, and Cohen׳s kappa.

RESULTS

Both scales had good internal consistency (Cronbach׳s alpha>0.8). Correlation between PHQ-9 and EPDS scores was fair (rho=0.52). Based on exploratory factor analysis (EFA), both scales yielded a two-factor structure. EFA including all items from PHQ-9 and EPDS yielded four factors, namely, "somatization", "depression and suicidal ideation", "anxiety and depression", and "anhedonia". The agreement between the two scales was generally fair at different cutoff scores with the highest Cohen׳s kappa being 0.46.

CONCLUSIONS

Both the PHQ-9 and EPDS are reliable and valid scales for antepartum depression assessment. The PHQ-9 captures somatic symptoms, while EPDS detects depressive symptoms comorbid with anxiety during early pregnancy. Our findings suggest simultaneous administration of both scales may improve identification of antepartum depressive disorders in clinical settings.

Health care contacts in the year before suicide death

BACKGROUND

Suicide prevention is a public health priority, but no data on the health care individuals receive prior to death are available from large representative United States population samples.

OBJECTIVE

To investigate variation in the types and timing of health services received in the year prior to suicide, and determine whether a mental health condition was diagnosed.

DESIGN

Longitudinal study from 2000 to 2010 within eight Mental Health Research Network health care systems serving eight states.

PARTICIPANTS

In all, 5,894 individuals who died by suicide, and were health plan members in the year before death.

MAIN MEASURES

Health system contacts in the year before death. Medical record, insurance claim, and mortality records were linked via the Virtual Data Warehouse, a federated data system at each site.

KEY RESULTS

Nearly all individuals received health care in the year prior to death (83 %), but half did not have a mental health diagnosis. Only 24 % had a mental health diagnosis in the 4-week period prior to death. Medical specialty and primary care visits without a mental health diagnosis were the most common visit types. The individuals more likely to make a visit in the year prior to death (p < 0.05) tended to be women, individuals of older age (65+ years), those where the neighborhood income was over $40,000 and 25 % were college graduates, and those who died by non-violent means.

CONCLUSIONS

This study indicates that opportunities for suicide prevention exist in primary care and medical settings, where most individuals receive services prior to death. Efforts may target improved identification of mental illness and suicidal ideation, as a large proportion may remain undiagnosed at death.

Designing messaging to engage patients in an online suicide prevention intervention: survey results from patients with current suicidal ideation

Background

Computerized, Internet-delivered interventions can be efficacious; however, uptake and maintaining sustained client engagement are still big challenges. We see the development of effective engagement strategies as the next frontier in online health interventions, an area where much creative research has begun. We also argue that for engagement strategies to accomplish their purpose with novel targeted populations, they need to be tailored to such populations (ie, content is designed with the target population in mind). User-centered design frameworks provide a theoretical foundation for increasing user engagement and uptake by including users in development. However, deciding how to implement this approach to enage users in mental health intervention development is challenging.

Objective

The aim of this study was to get user input and feedback on acceptability of messaging content intended to engage suicidal individuals.

Methods

In March 2013, clinic intake staff distributed flyers announcing the study, “Your Feedback Counts” to potential participants (individuals waiting to be seen for a mental health appointment) together with the Patient Health Questionnaire. The flyer explained that a score of two or three (“more than half the days” or “nearly every day” respectively) on the suicide ideation question made them eligible to provide feedback on components of a suicide prevention intervention under development. The patient could access an anonymous online survey by following a link. After providing consent online, participants completed the anonymous survey.

Results

Thirty-four individuals provided data on past demographic information. Participants reported that they would be most drawn to an intervention where they knew that they were cared about, that was personalized, that others like them had found it helpful, and that included examples with real people. Participants preferred email invitations with subject lines expressing concern and availability of extra resources. Participants also provided feedback about a media prototype including a brand design and advertisement video for introducing the intervention.

Conclusions

This paper provides one model (including development of an engagement survey, audience for an engagement survey, methods for presenting results of an engagement survey) for including target users in the development of uptake strategies for online mental health interventions.

Does response on the PHQ-9 Depression Questionnaire predict subsequent suicide attempt or suicide death?

OBJECTIVE As use of standard depression questionnaires in clinical practice increases, clinicians will frequently encounter patients reporting thoughts of death or suicide. This study examined whether responses to the Patient Health Questionnaire for depression (PHQ-9) predict subsequent suicide attempt or suicide death. METHODS Electronic records from a large integrated health system were used to link PHQ-9 responses from outpatient visits to subsequent suicide attempts and suicide deaths. A total of 84,418 outpatients age ≥13 completed 207,265 questionnaires between 2007 and 2011. Electronic medical records, insurance claims, and death certificate data documented 709 subsequent suicide attempts and 46 suicide deaths in this sample. RESULTS Cumulative risk of suicide attempt over one year increased from .4% among outpatients reporting thoughts of death or self-harm "not at all" to 4% among those reporting thoughts of death or self-harm "nearly every day." After adjustment for age, sex, treatment history, and overall depression severity, responses to item 9 of the PHQ-9 remained a strong predictor of suicide attempt. Cumulative risk of suicide death over one year increased from .03% among those reporting thoughts of death or self-harm ideation "not at all" to .3% among those reporting such thoughts "nearly every day." Response to item 9 remained a moderate predictor of subsequent suicide death after the same factor adjustments. CONCLUSIONS Response to item 9 of the PHQ-9 for depression identified outpatients at increased risk of suicide attempt or death. This excess risk emerged over several days and continued to grow for several months, indicating that suicidal ideation was an enduring vulnerability rather than a short-term crisis.

Use of antipsychotic medications in pediatric populations: what do the data say?

Recent reports of antipsychotic medication use in pediatric populations describe large increases in rates of use. Much interest in the increasing use has focused on potentially inappropriate prescribing for non-Food and Drug Administration-approved uses and use amongst youth with no mental health diagnosis. Different studies of antipsychotic use have used different time periods, geographic and insurance populations of youth, and aggregations of diagnoses. We review recent estimates of use and comment on the similarities and dissimilarities in rates of use. We also report new data obtained on 11 health maintenance organizations that are members of the Mental Health Research Network in order to update and extend the knowledge base on use by diagnostic indication. Results indicate that most use in pediatric populations is for disruptive behaviors and not psychotic disorders. Differences in estimates are likely a function of differences in methodology; however, there is remarkable consistency in estimates of use by diagnosis.

Electronic health records based phenotyping in next-generation clinical trials: a perspective from the NIH Health Care Systems Collaboratory

Widespread sharing of data from electronic health records and patient-reported outcomes can strengthen the national capacity for conducting cost-effective clinical trials and allow research to be embedded within routine care delivery. While pragmatic clinical trials (PCTs) have been performed for decades, they now can draw on rich sources of clinical and operational data that are continuously fed back to inform research and practice. The Health Care Systems Collaboratory program, initiated by the NIH Common Fund in 2012, engages healthcare systems as partners in discussing and promoting activities, tools, and strategies for supporting active participation in PCTs. The NIH Collaboratory consists of seven demonstration projects, and seven problem-specific working group 'Cores', aimed at leveraging the data captured in heterogeneous 'real-world' environments for research, thereby improving the efficiency, relevance, and generalizability of trials. Here, we introduce the Collaboratory, focusing on its Phenotype, Data Standards, and Data Quality Core, and present early observations from researchers implementing PCTs within large healthcare systems. We also identify gaps in knowledge and present an informatics research agenda that includes identifying methods for the definition and appropriate application of phenotypes in diverse healthcare settings, and methods for validating both the definition and execution of electronic health records based phenotypes.

Is treatment adherence consistent across time, across different treatments and across diagnoses?

OBJECTIVE

The objective was to examine consistency of adherence across depression treatments and consistency of adherence between depression treatments and treatments for chronic medical illness.

METHODS

For 25,456 health plan members beginning psychotherapy for depression between 2003 and 2008, health plan records were used to examine adherence to all episodes of psychotherapy, antidepressant medication, antihypertensive medication and lipid-lowering medication.

RESULTS

Within treatments, adherence to psychotherapy in one episode predicted approximately 20% greater likelihood of subsequent psychotherapy adherence [odds ratio (OR)=2.20, 95% confidence interval (CI) 1.83-2.64]. Similarly, adherence to antidepressant medication in one episode predicted approximately 20% greater likelihood of subsequent antidepressant adherence (OR=1.99, 95% CI 1.74-2.28). Across treatments, adherence to antidepressant medication predicted approximately 10% greater likelihood of concurrent or subsequent adherence to psychotherapy (OR=1.52, 95% CI 1.42-1.63), a 4% greater likelihood of adherence to antihypertensive medication (OR=1.24, 95% CI 1.14-1.37) and a 3% greater likelihood of adherence to lipid-lowering medication (OR=1.16, 95% CI 1.03-1.32). Adherence to psychotherapy predicted a 2% greater likelihood of concurrent or subsequent adherence to antihypertensive medication (OR=1.11, 95% CI 1.04-1.19) and was not a significant predictor of adherence to lipid-lowering medication (OR=0.99, 95% CI 0.90-1.18).

CONCLUSIONS

Adherence is moderately consistent across episodes of depression treatment. Depression treatment adherence is a statistically significant, but relatively weak, predictor of adherence to antihypertensive or lipid-lowering medication.

Response to past depression treatments is not accurately recalled: comparison of structured recall and patient health questionnaire scores in medical records

OBJECTIVE

Assessing response to prior depression treatments is common in research and clinical practice, but few data are available regarding accuracy of patient recall. Data from a population-based survey were linked to electronic medical records to examine agreement between patients' recalled treatment response and depression severity scores in the medical records.

METHOD

Electronic medical records from a large health system identified 1,878 adult patients with 2 or more episodes of clinician-diagnosed major depressive disorder or dysthymia between January 2005 and December 2009 (diagnoses had been recorded using ICD-9 codes). These potential participants were mailed an invitation letter, and, of these, 578 completed an online or mailed survey including structured recall of response to each prior depression treatment, rating both global improvement during treatment and improvement specifically attributed to treatment. For 269 of the survey participants, at least 1 treatment episode could be unambiguously linked to both pretreatment and posttreatment Patient Health Questionnaire (PHQ-9) depression scores in the electronic medical records. Analyses examined the agreement between patients' recall of treatment response and response according to PHQ-9 scores from the medical records.

RESULTS

Agreement between recall and the medical records was poor for both overall improvement following treatment (κ = 0.10; 95% CI, 0.00-0.19) and improvement attributed to treatment (κ = 0.12; 95% CI, 0.00-0.25). Agreement remained poor when the sample was limited to medication treatment episodes, episodes lasting 3 months or more, or episodes for which the participant was "very sure" of his or her ability to recall. Agreement reached a fair level only for episodes in the 6 months prior to the survey, for both overall improvement (κ = 0.23; 95% CI, 0.08-0.39) and improvement attributed to treatment (κ = 0.36; 95% CI, 0.12-0.59).

CONCLUSIONS

Patients' recall of response to past depression treatments agrees poorly with data from medical records. Interview assessment of prior treatment response may not be a useful tool for research or clinical practice.

Early dropout from psychotherapy for depression with group- and network-model therapists

Administrative data were used to examine early dropout among 16,451 health plan members calling to request psychotherapy for depression. Compared to members referred to group-model therapists, those referred to network-model therapists were more likely to drop out before the initial visit (OR 2.33, 95% CI 2.17-2.50) but less likely to drop out after the first visit (OR 0.45, 95% CI 0.43-0.48). These differences were unaffected by adjustment for neighborhood income and educational attainment, antidepressant use, or generosity of insurance coverage. Efforts to increase the effectiveness of psychotherapy may required different strategies in group- and network-model practice.

A web-delivered care management and patient self-management program for recurrent depression: a randomized trial

OBJECTIVE This study assessed the impact of an Internet-delivered care management and patient self-management program, eCare for Moods, on patients treated for recurrent or chronic depression. METHODS Patients with recurrent or chronic depression were randomly assigned to eCare (N=51) or usual specialty mental health care (N=52). The 12-month eCare program integrates with ongoing depression care, links to patients' electronic medical records, and provides clinicians with panel management and decision support. Participants were interviewed at baseline and six, 12, 18, and 24 months after enrollment. Telephone interviewers blind to treatment used a timeline follow-back method to estimate depression severity on a 6-point scale for each of the 105 study weeks (including the baseline). Differences between groups in weekly severity over two years were examined by generalized estimating equations. RESULTS Participants in eCare experienced more reduction in depressive symptoms (estimate=-.74 on the 6-point scale over two years; 95% confidence interval [CI]=-1.38 to -.09, p=.025) and were less often depressed (-.24 over two years; CI=-.46 to -.03, p=.026). At 24 months, 43% of eCare and 30% of usual-care participants were depression free; the number needed to treat to attain one additional depression-free participant was 8. eCare participants had other favorable outcomes: improved general mental health (p=.002), greater satisfaction with specialty care (p=.003) and with learning new coping skills (p&lt;.001), and more confidence in managing depression (p=.006). CONCLUSIONS Internet-delivered care management can help improve outcomes of patients treated for recurrent or chronic depression.

Assessing the accuracy of profiling methods for identifying top providers: performance of mental health care providers

Provider profiling as a means to describe and compare the performance of health care professionals has gained momentum in the past decade. As a key component of pay-for-performance programs profiling has been increasingly used to identify top-performing providers. However, rigorous examination of the performance of statistical methods for profiling when used to classify top-performing providers is lacking. The objective of this study was to compare the classification accuracy of three methods for identifying providers exceeding performance thresholds and to analyze data on satisfaction with mental health care providers at Group Health Cooperative using these methods. Questionnaire data on patient satisfaction with mental health care providers at Group Health Cooperative was collected between April 2008 and January 2010. Simulated data were used to compare the classification accuracy of alternative statistical methods. We evaluated sensitivity, specificity, and root mean squared error of alternative statistical methods using simulated data. For Group Health providers, we compared agreement of alternative approaches to classification. We found that when between-provider variability in performance was low, all three methods exhibited poor classification accuracy. When used to evaluate mental health care provider performance, we found substantial uncertainty in the estimates and poor agreement across methods. Based on these findings, we recommend providing uncertainty estimates for provider rankings and caution against the use of any classification method when between-provider variability is low.

Is dropout after a first psychotherapy visit always a bad outcome?

OBJECTIVE

The authors compared outcomes reported by patients who did or did not return for treatment after an initial psychotherapy visit.

METHODS

Members of a group health plan were surveyed about initial psychotherapy visits occurring between March and September 2010. The survey assessed satisfaction with care and therapeutic alliance during the visit and later clinical improvement.

RESULTS

Of the 2,666 members who returned surveys, 906 (34%) did not return for a second visit within 45 days. The distribution of satisfaction, therapeutic alliance, and self-rated improvement scores between patients who did and did not return differed significantly (p<.001). Patients who did not return were more likely to report the most favorable and the least favorable outcomes.

CONCLUSIONS

Failure to return after an initial psychotherapy visit can represent successful and satisfying treatment. Systematic outreach and outcome assessment are necessary to identify the patients who drop out of therapy after unsuccessful and unsatisfying treatment.

Impact of deductibles on initiation and continuation of psychotherapy for treatment of depression

OBJECTIVE

To estimate the impact of deductibles on the initiation and continuation of psychotherapy for depression.

DATA SOURCES/STUDY SETTING

Data from health care encounters and claims from Group Health Cooperative, a large integrated health care system in Washington State, was merged with information from a centralized behavioral health triage call center to conduct study analyses.

STUDY DESIGN

A retrospective observational design using a hierarchical logistic regression model was used to estimate initiation and continuation probabilities for use of psychotherapy, adjusting for key sociodemographic/economic factors and prior use of behavioral health services relevant to individual decisions to seek mental health care.

DATA COLLECTION/EXTRACTION METHODS

Analyses were based on merged datasets on patient enrollment, insurance benefits, use of mental health and general medical services and information collected by a triage specialist at a centralized behavioral health call center.

PRINCIPAL FINDINGS

Among individuals with unmet deductibles between $100 and $500, we found a statistically significant lower likelihood of making an initial visit, but there was no statistically significant effect on making an initial or subsequent visit among individuals that had met their deductible.

CONCLUSIONS

Unmet deductibles appear to influence the likelihood of initiating psychotherapy for treating depression.

Randomized trial of depression follow-up care by online messaging

BACKGROUND

Quality of antidepressant treatment remains disturbingly poor. Rates of medication adherence and follow-up contact are especially low in primary care, where most depression treatment begins. Telephone care management programs can address these gaps, but reliance on live contact makes such programs less available, less timely, and more expensive.

OBJECTIVE

Evaluate the feasibility, acceptability, and effectiveness of a depression care management program delivered by online messaging through an electronic medical record.

DESIGN

Randomized controlled trial comparing usual primary care treatment to primary care supported by online care management

SETTING

Nine primary care clinics of an integrated health system in Washington state

PARTICIPANTS

Two hundred and eight patients starting antidepressant treatment for depression.

INTERVENTION

Three online care management contacts with a trained psychiatric nurse. Each contact included a structured assessment (severity of depression, medication adherence, side effects), algorithm-based feedback to the patient and treating physician, and as-needed facilitation of follow-up care. All communication occurred through secure, asynchronous messages within an electronic medical record.

MAIN MEASURES

An online survey approximately five months after randomization assessed the primary outcome (depression severity according to the Symptom Checklist scale) and satisfaction with care, a secondary outcome. Additional secondary outcomes (antidepressant adherence and use of health services) were assessed using computerized medical records.

KEY RESULTS

Patients offered the program had higher rates of antidepressant adherence (81% continued treatment more than 3 months vs. 61%, p = 0.001), lower Symptom Checklist depression scores after 5 months (0.95 vs. 1.17, p = 0.043), and greater satisfaction with depression treatment (53% "very satisfied" vs. 33%, p = 0.004).

LIMITATIONS

The trial was conducted in one integrated health care system with a single care management nurse. Results apply only to patients using online messaging.

CONCLUSIONS

Our findings suggest that organized follow-up care for depression can be delivered effectively and efficiently through online messaging.

An online recovery plan program: can peer coaching increase participation?

OBJECTIVE

A pilot study evaluated whether the addition of online coaching from a peer specialist increased participation in an online program featuring educational and interactive modules to promote self-management of bipolar disorder.

METHODS

A total of 118 participants with bipolar disorder recruited from online and in-person support groups and clinical settings were enrolled in MyRecoveryPlan. Half the group was randomly assigned to receive online coaching support from a certified peer specialist.

RESULTS

Participants offered online peer coaching were more likely to return to the program after registration (71% versus 44%, p=.005) and to continue using the program after three weeks (38% versus 9%, p<.001). This pattern was consistent for all program elements.

CONCLUSIONS

The addition of online coaching from a peer specialist significantly increased engagement and retention in the program, but further research is needed to evaluate the program's effects on clinical and recovery outcomes.

An online recovery plan program: can peer coaching increase participation?

OBJECTIVE

A pilot study evaluated whether the addition of online coaching from a peer specialist increased participation in an online program featuring educational and interactive modules to promote self-management of bipolar disorder.

METHODS

A total of 118 participants with bipolar disorder recruited from online and in-person support groups and clinical settings were enrolled in MyRecoveryPlan. Half the group was randomly assigned to receive online coaching support from a certified peer specialist.

RESULTS

Participants offered online peer coaching were more likely to return to the program after registration (71% versus 44%, p=.005) and to continue using the program after three weeks (38% versus 9%, p<.001). This pattern was consistent for all program elements.

CONCLUSIONS

The addition of online coaching from a peer specialist significantly increased engagement and retention in the program, but further research is needed to evaluate the program's effects on clinical and recovery outcomes.

A randomized controlled trial of behavioral weight loss treatment versus combined weight loss/depression treatment among women with comorbid obesity and depression

BACKGROUND

Obesity is associated with clinical depression among women. However, depressed women are often excluded from weight loss trials.

PURPOSE

This study examined treatment outcomes among women with comorbid obesity and depression.

METHODS

Two hundred three (203) women were randomized to behavioral weight loss (n = 102) or behavioral weight loss combined with cognitive-behavioral depression management (n = 101).

RESULTS

Average participant age was 52 years; mean baseline body mass index was 39 kg/m(2). Mean Patient Health Questionnaire and Hopkins Symptom Checklist (SCL-20) scores indicated moderate to severe baseline depression. Weight loss and SCL-20 changes did not differ between groups at 6 or 12 months in intent-to-treat analyses (p = 0.26 and 0.55 for weight, p = 0.70 and 0.25 for depressive symptoms).

CONCLUSIONS

Depressed obese women lost weight and demonstrated improved mood in both treatment programs. Future weight loss trials are encouraged to enroll depressed women.