Service use of rural and urban Medicaid beneficiaries suffering from depression: the role of supply

Depression in primary care: part 2-management

Depression is a common and heterogeneous condition with a chronic and recurrent natural course that is frequently seen in the primary care setting. Primary care providers play a central role in managing depression and concurrent physical comorbidities, and they face challenges in diagnosing and treating the condition. In this two part series, we review the evidence available to help to guide primary care providers and practices to recognize and manage depression. The first review outlined an approach to screening and diagnosing depression in primary care. This second review presents an evidence based approach to the treatment of depression in primary care, detailing the recommended lifestyle, drug, and psychological interventions at the individual level. It also highlights strategies that are being adopted at an organizational level to manage depression more effectively in primary care.

Health system constraints in integrating mental health services into primary healthcare in rural Uganda: perspectives of primary care providers

Background

The World Health Organization issued recommendations to guide the process of integrating mental health services into primary healthcare. However, there has been general as well as context specific shortcomings in the implementation of these recommendations. In Uganda, mental health services are intended to be decentralized and integrated into general healthcare, but, the services are still underutilized especially in rural areas.

Purpose

The purpose of this study was to explore the health systems constraints to the integration of mental health services into PHC in Uganda from the perspective of primary health care providers (PHCPs).

Methods

This was a cross sectional qualitative study guided by the Supporting the Use of Research Evidence (SURE) framework. We used a semi-structured interview guide to gain insight into the health systems constraints faced by PHCPs in integrating mental health services into PHC.

Results

Key health systems constraints to integrating mental health services into PHC identified included inadequate practical experience during training, patient flow processes, facilities, human resources, gender related factors and challenges with accessibility of care.

Conclusion

There is need to strengthen the training of healthcare providers as well as improving the health care system that supports health workers. This would include periodic mental healthcare in-service training for PHCPs; the provision of adequate processes for outreach, and receiving, referring and transferring patients with mental health problems; empowering PHCPs at all levels to manage and treat mental health problems and adequately provide the necessary medical supplies; and increase the distribution of health workers across the health facilities to address the issue of high workload and compromised quality of care provided.

Electronic supplementary material

The online version of this article (10.1186/s13033-019-0272-0) contains supplementary material, which is available to authorized users.

Individual and contextual-level factors associated with continuity of care for adults with schizophrenia

This retrospective cohort study examined rates of conformance to continuity of care treatment guidelines and factors associated with conformance for persons with schizophrenia. Subjects were 8,621 adult Ohio Medicaid recipients, aged 18-64, treated for schizophrenia in 2004. Information on individual-level (demographic and clinical characteristics) and contextual-level variables (county socio-demographic, economic, and health care resources) were abstracted from Medicaid claim files and the Area Resource File. Outcome measures captured four dimensions of continuity of care: (1) regularity of care; (2) transitions; (3) care coordination, and (4) treatment engagement. Multilevel modeling was used to assess the association between individual and contextual-level variables and the four continuity of care measures. The results indicated that conformance rates for continuity of care for adults with schizophrenia are below recommended guidelines and that variations in continuity of care are associated with both individual and contextual-level factors. Efforts to improve continuity of care should target high risk patient groups (racial/ethnic minorities, the dually diagnosed, and younger adults with early onset psychosis), as well as community-level risk factors (provider supply and geographic barriers of rural counties) that impede access to care.

Screening and Follow-Up Monitoring for Substance Use in Primary Care: An Exploration of Rural-Urban Variations

BACKGROUND

Rates of substance use in rural areas are close to those of urban areas. While recent efforts have emphasized integrated care as a promising model for addressing workforce shortages in providing behavioral health services to those living in medically underserved regions, little is known on how substance use problems are addressed in rural primary care settings.

OBJECTIVE

To examine rural-urban variations in screening and monitoring primary care- based patients for substance use problems in a state-wide mental health integration program.

DESIGN

This was an observational study using patient registry.

SUBJECTS

The study included adult enrollees (n = 15,843) with a mental disorder from 133 participating community health clinics.

MAIN OUTCOMES

We measured whether a standardized substance use instrument was used to screen patients at treatment entry and to monitor symptoms at follow-up visits.

KEY RESULTS

While on average 73.6 % of patients were screened for substance use, follow-up on substance use problems after initial screening was low (41.4 %); clinics in small/isolated rural settings appeared to be the lowest (13.6 %). Patients who were treated for a mental disorder or substance abuse in the past and who showed greater psychiatric complexities were more likely to receive a screening, whereas patients of small, isolated rural clinics and those traveling longer distances to the care facility were least likely to receive follow-up monitoring for their substance use problems.

CONCLUSIONS

Despite the prevalent substance misuse among patients with mental disorders, opportunities to screen this high-risk population for substance use and provide a timely follow-up for those identified as at risk remained overlooked in both rural and urban areas. Rural residents continue to bear a disproportionate burden of substance use problems, with rural-urban disparities found to be most salient in providing the continuum of services for patients with substance use problems in primary care.

The influence of patients' preference/attitude towards psychotherapy and antidepressant medication on the treatment of major depressive disorder

BACKGROUND AND OBJECTIVES

Preferences and attitudes patients hold towards treatment are important, as these can influence treatment outcome. In depression research, the influence of patients' preference/attitudes on outcome and dropout has mainly been studied for antidepressant medication, and less for psychological treatments. We investigated the effects of patients' preference and attitudes towards psychological treatment and antidepressant medication on treatment outcome and dropout, and tested specificity of effects.

METHODS

Data are based on a randomized trial testing the effectiveness of behavioural activation (BA) vs antidepressant medication (ADM) for major depression (MDD) in Iran. Patients with MDD (N = 100) were randomized to BA (N = 50) or ADM (N = 50). Patients' preference/attitudes towards psychotherapy and ADM were assessed at baseline and associated with dropout and treatment outcome using logistic regression and multilevel analysis.

RESULTS

High scores on psychotherapy preference/attitude and low scores on ADM preference/attitude predicted dropout from ADM, while no association between dropout and preference/attitude was found in BA. Psychotherapy preference/attitude moderated the differential effect of BA and ADM on one outcome measure, but the association disappeared after one year.

LIMITATIONS

Because in Iran most patients have only access to ADM, offering a psychological treatment for depression could attract especially those patients that prefer this newly available treatment.

CONCLUSIONS

Patients' preferences and attitudes towards depression treatments influence dropout from ADM, and moderate the short-term difference in effectiveness between BA and ADM. The fact that dropout from BA was not affected by preference/attitude speaks for its acceptability among patients.

The association between rural residence and the use, type, and quality of depression care

OBJECTIVE

To assess the association between rurality and depression care.

METHODS

Data were extracted for 10,319 individuals with self-reported depression in the Medical Expenditure Panel Survey. Pharmacotherapy was defined as an antidepressant prescription fill, and minimally adequate pharmacotherapy was defined as receipt of at least 4 antidepressant fills. Psychotherapy was defined as an outpatient counseling visit, and minimally adequate psychotherapy was defined as > or = 8 visits. Rurality was defined using Metropolitan Statistical Areas (MSAs) and Rural Urban Continuum Codes (RUCCs).

RESULTS

Over the year, 65.1% received depression treatment, including 58.8% with at least 1 antidepressant prescription fill and 24.5% with at least 1 psychotherapy visit. Among those in treatment, 56.2% had minimally adequate pharmacotherapy treatment and 36.3% had minimally adequate psychotherapy treatment. Overall, there were no significant rural-urban differences in receipt of any type of formal depression treatment. However, rural residence was associated with significantly higher odds of receiving pharmacotherapy (MSA: OR 1.16 [95% CI, 1.01-1.34; P= .04] and RUCC: OR 1.04 [95% CI, 1.00-1.08; P= .05]), and significantly lower odds of receiving psychotherapy (MSA: OR 0.62 [95% CI, 0.53-0.74; P < .01] and RUCC: OR 0.91 [95% CI, 0.88-0.94; P < .001]). Rural residence was not significantly associated with the adequacy of pharmacotherapy, but it was significantly associated with the adequacy of psychotherapy (MSA: OR 0.53 [95% CI, 0.41-0.69; P < .01] and RUCC: OR 0.92 [95% CI, 0.86-0.99; P= .02]). Psychiatrists per capita were a mediator in the psychotherapy analyses.

CONCLUSIONS

Rural individuals are more reliant on pharmacotherapy than psychotherapy. This may be a concern if individuals in rural areas turn to pharmacotherapy because psychotherapists are unavailable rather than because they have a preference for pharmacotherapy.

Depression and anxiety outcomes at a free clinic in a rural state

PURPOSE

To describe the diagnostic and treatment patterns for depression and anxiety in clients receiving care at a free clinic.

DATA SOURCES

Charts for 43 clients who received antidepressant or anxiolytic medications were randomly selected and reviewed.

CONCLUSIONS

Clients presented to the clinic symptomatic; almost two thirds had been treated elsewhere. Most clients received pharmacological treatment and referral for counseling. Forty-four percent of the clients were still being treated at their last visit, but 33% were no longer being seen, and it could not be determined if they were receiving care at another clinic.

IMPLICATIONS FOR PRACTICE

If sustained relationships with clients with depression and anxiety can be developed, appropriate care can be provided.

The relationship between school characteristics and the availability of mental health and related health services in middle and high schools in the United States

Problems related to mental illness are increasingly becoming the focal point of public concern over the safety and performance of schools, yet little is known about the availability and quality of school-based mental health services in the United States. In this article it is estimated that approximately 50% of US middle and high schools have any mental health counseling services available onsite and approximately 11% have mental health counseling, physical examinations, and substance abuse counseling available on-site. There are substantial differences in mental health counseling availability by region, urbanicity, and school size, with rural schools, schools in the Midwest and South regions, and small schools being least likely to offer mental health counseling. Multivariate estimates suggest that disparities between schools in the availability of mental health counseling and related health services may be partly explained by differences in access to Medicaid for financing of health services provided at school.

Diagnosed mental and physical health conditions in the United States nursing home population: differences between urban and rural facilities

CONTEXT

There has been limited examination of the differences in health characteristics of the rural long-term care population. Recognizing these differences will allow policymakers to improve access to long-term care services in rural communities.

PURPOSE

To determine whether differences in likelihood of diagnosis exist between urban and rural nursing home residents for 8 common medical conditions: 4 mental health conditions (depression, anxiety, Alzheimer's, and non-Alzheimer's dementia) and 4 physical health conditions (cancer, emphysema/chronic obstructive pulmonary disease, heart disease, and stroke/transient ischemic attack).

METHODS

We used multivariate logistic regression to examine data derived from the 1996 Nursing Home Component of the Medical Expenditure Panel Survey, a multistage stratified probability sample of 815 nursing homes and 5899 residents, representing 3.1 million individuals in the United States who spent 1 or more nights in nursing homes during 1996.

FINDINGS

Residents in rural homes were less likely to be diagnosed with depression compared to those in homes in large metropolitan areas, and residents in homes in small metropolitan areas were less likely to have cancer than those in large metropolitan areas. Diagnostic status between urban and rural residents was comparable for the other 6 conditions.

CONCLUSIONS

Further research is necessary to determine whether and why depression is inadequately diagnosed in rural nursing homes and to ascertain which types of cancer are responsible for the observed differential. Such research is particularly important for elderly nursing home residents who are more likely to suffer from chronic conditions that require significant medical supervision.

Use, quality, and outcomes of care for mental health: the rural perspective

This review synthesizes empirical research in rural mental health services to identify current research priorities to improve the mental health of rural Americans. Using a conceptual framework of the multiple determinants of use, quality, and outcomes, the authors address (1) how key constructs are operationalized, (2) their theoretical influence on the care process, (3) reported differences for nonmetropolitan and metropolitan individuals or within nonmetropolitan individuals, (4) salient issues rural advocates have raised, and (5) key research questions. While the authors recognize that rurality is a useful political umbrella to organize advocacy efforts, they propose that investigators no longer employ any of the multiple definitions of the term in the literature as even intrarural comparisons have not provided compelling evidence about the underlying causes of observed outcomes differences. Until these underlying causes have been identified, it is difficult to determine which components of the nonmetropolitan service system need to be improved.

Health risk factors among Iowa farmers

This study compares the prevalence of the health risk factors for chronic disease and injury among farmers with their prevalence among other workers, using data from the Iowa Behavioral Risk Factor Surveillance System. From January 1999 to December 1999, there were 3,620 adults who participated in the survey. This report focuses on the 2,140 subjects who reported they were working. We calculated the percentage with each health risk factor, the adjusted odds ratio (OR) and the associated 95% confidence interval (CI), comparing the prevalence of health risks among farmers and other workers. Most health conditions and risk factors were similar among farmers and other workers. However, we found that farmers had some protective behaviors. They had better oral health (OR = 0.34, 95% CI 0.20-0.57) and were less likely to smoke (OR = 0.14, 95% CI 0.06-0.29) than other workers. In contrast, we found that farmers reported some high-risk behaviors compared to other workers. They were less likely to have smoke detectors at home (OR = 0.39, 95% CI 0.18-0.82), or to have had stool blood screening for colorectal cancer (OR = 0.41, 95% CI 0.1 7-1.00). These results suggest areas for future research to define targeted preventive interventions in farm communities.

Effects of managed mental health care on service use in urban and rural Maine

This study takes advantage of a "natural experiment" resulting from the reassignment of all Maine state employees to a managed behavioral health plan in December 1992. By comparing mental health claims before and after that date, the effects of a behavioral health carve-out on mental health utilization by rural and urban beneficiaries were investigated. Following the implementation of the carve-out, the penetration rate, defined as the proportion of beneficiaries who sought help for an affective disorder, increased significantly in both rural and urban areas (P < 0.001). However, the rural penetration rate remained significantly lower than the urban rate (before implementation, 25.8 vs. 52.2 users per 1,000 enrollees, P < 0.001; after implementation, 57.8 vs. 85.8 users per 1,000 enrollees, P < 0.001). Similarly, rural utilization rates, defined as the average number of outpatient mental health visits per user, were significantly lower than urban rates both before and after implementation of the carve-out (before, 9.2 us. 12.9 visits per user, P < 0.001; after, 9.8 vs. 13.3 visits per user, P < 0.001). Before-after differences were not significant. In addition, the proportion of mental health care provided in the primary care setting increased after implementation of the carve-out (from 9.5 percent of all visits before to 12.6 percent of all visits after, P < 0.001). The increase in penetration rates can be attributed, in part, to a member education initiative undertaken during the transition from fee-for-service to managed care. This type of carve-out arrangement does not threaten to reduce access to mental health services, provided the managed behavioral health organization (MBHO) managing the carve-out is willing to accept primary care practitioners as part of its provider network.