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Petersen T, Papakostas GI, Mahal Y, Guyker WM, Beaumont EC, Alpert JE, Fava M, Nierenberg AA. Psychosocial functioning in patients with treatment resistant depression. Eur Psychiatry 2020; 19:196-201. [PMID: 15196600 DOI: 10.1016/j.eurpsy.2003.11.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2003] [Revised: 10/24/2003] [Accepted: 11/20/2003] [Indexed: 11/28/2022] Open
Abstract
AbstractBackgroundDepression is a disorder that causes disability, with a profound adverse impact on all areas of psychosocial functioning. This is particularly true for those with treatment resistant depression (TRD). However, to date, no systematic assessments of psychosocial functioning for patients with TRD have been conducted.MethodsIn the present study, we used the Longitudinal Interval Follow-up Evaluation (LIFE) scale to measure psychosocial functioning in 92 patients with TRD. These patients met formal criteria for TRD and were part of a clinical trial examining the efficacy of lithium augmentation of nortriptyline.ResultsClinicians rated this sample of patients as experiencing mild to moderate impairment in work-related activities, good to fair interpersonal relations, poor level of involvement in recreational activities, and mild impairment of ability to enjoy sexual activity. Patients and clinicians rated global social adjustment as poor.ConclusionsPatients with formally defined TRD experience significant impairment in psychosocial functioning. In this sample a tendency existed for both clinicians and patients to assign more severely impaired global ratings when compared with ratings for specific functional areas.
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Affiliation(s)
- Timothy Petersen
- Department of Psychiatry, Depression Clinical and Research Program, Massachusetts General Hospital, 15 Parkman Street, WAC 812 Boston, MA 02114, USA.
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Tunnard C, Rane LJ, Wooderson SC, Markopoulou K, Poon L, Fekadu A, Juruena M, Cleare AJ. The impact of childhood adversity on suicidality and clinical course in treatment-resistant depression. J Affect Disord 2014; 152-154:122-30. [PMID: 23880448 DOI: 10.1016/j.jad.2013.06.037] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 05/07/2013] [Accepted: 06/17/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Childhood adversity is a risk factor for the development of depression and can also affect clinical course. We investigated this specifically in treatment-resistant depression (TRD). METHODS One hundred and thirty-seven patients with TRD previously admitted to an inpatient affective disorders unit were included. Clinical, demographic and childhood adversity (physical, sexual, emotional abuse; bullying victimization, traumatic events) data were obtained during admission. Associations between childhood adversity, depressive symptoms and clinical course were investigated. RESULTS Most patients had experienced childhood adversity (62%), with traumatic events (35%) and bullying victimization (29%) most commonly reported. Childhood adversity was associated with poorer clinical course, including earlier age of onset, episode persistence and recurrence. Logistic regression analyses revealed childhood adversity predicted lifetime suicide attempts (OR 2.79; 95% CI 1.14, 6.84) and childhood physical abuse predicted lifetime psychosis (OR 3.42; 95% CI 1.00, 11.70). LIMITATIONS The cross-sectional design and retrospective measurement of childhood adversity are limitations of the study. CONCLUSIONS Childhood adversity was common amongst these TRD patients and was associated with poor clinical course, psychosis and suicide attempts. Routine assessment of early adversity may help identify at risk individuals and inform clinical intervention.
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Affiliation(s)
- Catherine Tunnard
- Division of Psychological Medicine and Psychiatry, Section of Neurobiology of Mood Disorders, Institute of Psychiatry, King's College London, 103 Denmark Hill, London SE5 8AZ, UK; The National Affective Disorder Unit, South London and Maudsley NHS Foundation Trust, UK
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Zivin K, Wharton T, Rostant O. The economic, public health, and caregiver burden of late-life depression. Psychiatr Clin North Am 2013; 36:631-49. [PMID: 24229661 PMCID: PMC4024243 DOI: 10.1016/j.psc.2013.08.008] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This article reviews the burden of late-life depression (LLD) from several perspectives, including costs of depression treatment and treatment of other comorbid psychiatric and medical conditions; the impact of LLD on job functioning, disability, and retirement; and how LLD influences others, such as family members and caregivers.
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Affiliation(s)
- Kara Zivin
- Serious Mental Illness Treatment Resource and Evaluation Center, Center for Clinical Management Research, Department of Veterans Affairs, Plymouth Road, Ann Arbor, MI 48109, USA; Department of Psychiatry, University of Michigan Medical School, Plymouth Road, Ann Arbor, MI 48109, USA; Institute for Social Research, University of Michigan Medical School, Thompson Street, Ann Arbor, MI 48104, USA.
| | - Tracy Wharton
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI
| | - Ola Rostant
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI
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Dismuke CE, Egede LE. Association of serious psychological distress with health services expenditures and utilization in a national sample of US adults. Gen Hosp Psychiatry 2011; 33:311-7. [PMID: 21762826 DOI: 10.1016/j.genhosppsych.2011.03.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Revised: 03/28/2011] [Accepted: 03/29/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The Kessler six-item scale has been shown to be a valid and reliable measure of serious psychological distress (SPD) in community samples. We examined the effect of SPD on health service expenditures and utilization for seven categories in a national probability sample of community dwelling adults in the United States. METHODS We used the two-step sample selection model to examine the association between SPD and total, office-based, outpatient, emergency department (ED), inpatient, dental, home health and prescription expenditures and utilization in 18,330 US adults who participated in the 2007 Medical Expenditure Panel Survey (MEPS). RESULTS SPD was significantly associated with $1735 ( 95% CI: $702-2769) higher total expenditures, $285 higher office expenditures ( 95% CI: $30-539), $183 higher ED expenditures (95% CI: $64-303), $282 (95% CI: $62-503) higher home health expenditures, $614 (95% CI: $403-825) higher prescription expenditures and $41 (95% CI: -$103 to $22) lower dental expenditures. SPD was associated with 3.09 (95% CI: 2.09-4.08) more office visits, 0.27 (95% CI: 0.17-0.36) more ED visits, 0.84 (95% CI: 0.36-1.32) more inpatient visits, 2.93 (95% CI: 0.13-5.70) more home health visits, 8.13 (95% CI: 6.08-10.18) more prescriptions and 0.18 (95% CI: -0.30 to -0.07) less dental visits. CONCLUSIONS Among US adults, SPD is associated with significant increases in total expenditures and most other categories of expenditure and utilization. Targeted interventions to mitigate the adverse effects of SPD are needed.
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Affiliation(s)
- Clara E Dismuke
- Center for Disease Prevention and Health Interventions for Diverse Populations, Ralph H. Johnson VA Medical Center, Charleston, SC 29401, USA
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Rost K, Hsieh YP, Xu S, Harman J. Gender differences in hospitalization after emergency room visits for depressive symptoms. J Womens Health (Larchmt) 2011; 20:719-24. [PMID: 21417934 DOI: 10.1089/jwh.2010.2396] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Depressed women have greater than three times the odds of hospitalization as clinically comparable men. The objective of this study is to understand if these gender differences emerge in admissions decisions after depressed individuals' arrival at the emergency room (ER). METHODS We used multivariate logistic regression to examine gender differences in hospitalization after 6266 ER visits for depressive symptoms in the nationally representative 1998-2007 National Hospital Ambulatory Care Medical Survey. RESULTS ER visits by depressed women have only 0.82 the odds of hospitalization (95% confidence interval [CI] 0.70-0.96, p=0.02) in models adjusted for sociodemographic, clinical, and system covariates. Sensitivity analyses demonstrate gender differences in visits by patients with no injury but not in visits by patients with self-inflicted injury. CONCLUSIONS These findings suggest that admission decisions after ER visits are not responsible for the increased risk of hospitalization previously reported in depressed women, as ER visits by women with depressive symptoms actually have lower odds of hospitalization than visits by men. We encourage further research to explore the causes and consequences of this practice pattern to move toward rational delivery systems committed to providing comparable treatment to clinically comparable individuals regardless of gender.
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Affiliation(s)
- Kathryn Rost
- Department of Medical Humanities and Social Sciences, Florida State University College of Medicine, Tallahassee, FL 32306-4300, USA.
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Stakeholder Benefit from Depression Disease Management: Differences by Rurality? J Behav Health Serv Res 2010; 38:114-21. [DOI: 10.1007/s11414-009-9204-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Accepted: 12/01/2009] [Indexed: 12/01/2022]
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Fortney J, Rushton G, Wood S, Zhang L, Xu S, Dong F, Rost K. Community-level risk factors for depression hospitalizations. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2007; 34:343-52. [PMID: 17294123 DOI: 10.1007/s10488-007-0117-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2006] [Accepted: 01/12/2007] [Indexed: 11/27/2022]
Abstract
This study measured geographic variation in depression hospitalizations and identified community-level risk factors. Depression hospitalizations were identified from the Statewide Inpatient Database. The dependent variable was specified as the indirectly standardized hospitalization rate. County-level data for 14 states were collected from federal agencies. The Bayesian spatial regression model included socio-demographic, economic, and health system characteristics as independent variables. There were 8.5 depression hospitalizations per 1,000 residents. 8.8% of counties had hospitalization rates 33% greater than the standardized rate. Significant risk factors included unemployment, poverty, physician supply, and hospital bed supply. Significant protective factors included rurality, economic dependence, and housing stress.
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Affiliation(s)
- John Fortney
- Health Services Research and Development, Center for Mental Health and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA.
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Malhi GS, Parker GB, Crawford J, Wilhelm K, Mitchell PB. Treatment-resistant depression: resistant to definition? Acta Psychiatr Scand 2005; 112:302-9. [PMID: 16156838 DOI: 10.1111/j.1600-0447.2005.00602.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To better define treatment-resistant depression (TRD) so as to assist clinical management and refine treatment guidelines. METHOD In this study, we examine a broad range of clinical variables in depressed patients (n=196) referred to a tertiary referral Mood Disorders Unit (MDU). Information was collected from patients, referrers and assessors over a period of 32 months and included evaluations of treatments, treatment resistance and related variables. Data were analysed across trichotomized 'high', 'low' and 'no' treatment resistance groupings of patients. RESULTS A significantly greater proportion of patients with melancholia were amongst the high TRD group, and this was consistent across different strategies for evaluating melancholia. CONCLUSION Melancholia perhaps provides a prototypic TRD subset that perhaps reflects some innate aspects of melancholic depression or factors such as the impact of ageing. Research into TRD is needed to both replicate this finding and perhaps explicate it further.
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Affiliation(s)
- G S Malhi
- Black Dog Institute, Prince of Wales Medical Research Institute, Sydney, NSW, Australia.
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Kathol RG, McAlpine D, Kishi Y, Spies R, Meller W, Bernhardt T, Eisenberg S, Folkert K, Gold W. General medical and pharmacy claims expenditures in users of behavioral health services. J Gen Intern Med 2005; 20:160-7. [PMID: 15836550 PMCID: PMC1490055 DOI: 10.1111/j.1525-1497.2005.40099.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To quantify the magnitude of general medical and/or pharmacy claims expenditures for individuals who use behavioral health services and to assess future claims when behavioral service use persists. DESIGN Retrospective cost trends and 24-month cohort analyses. SETTING A Midwest health plan. PARTICIPANTS Over 250,000 health plan enrollees during 2000 and 2001. MEASUREMENTS Claims expenditures for behavioral health services, general medical services, and prescription medications. MAIN RESULTS Just over one tenth of enrollees (10.7%) in 2001 had at least 1 behavioral health claim and accounted for 21.4% of total general medical, behavioral health, and pharmacy claims expenditures. Costs for enrollees who used behavioral health services were double that for enrollees who did not use such services. Almost 80% of health care costs were for general medical services and medications, two thirds of which were not psychotropics. Total claims expenditures in enrollees with claims for both substance use and mental disorders in 2000 were 4 times that of those with general medical and/or pharmacy claims only. These expenditures returned to within 15% of nonbehavioral health service user levels in 2001 when clinical need for behavioral health services was no longer required but increased by another 37% between 2000 and 2001 when both chemical dependence and mental health service needs persisted. CONCLUSIONS The majority of total claims expenditures in patients who utilize behavioral health services are for medical, not behavioral, health benefits. Continued service use is associated with persistently elevated total general medical and pharmacy care costs. These findings call for studies that better delineate: 1) the interaction of general medical, pharmacy, and behavioral health service use and 2) clinical and/or administrative approaches that reverse the high use of general medical resources in behavioral health patients.
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Affiliation(s)
- Roger G Kathol
- Department of Internal Medicine, University of Minnesota, Minneapolis, MN, USA.
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Rozario PA, Morrow-Howell N, Proctor E. Comparing the Congruency of Self-Report and Provider Records of Depressed Elders??? Service Use by Provider Type. Med Care 2004; 42:952-9. [PMID: 15377927 DOI: 10.1097/00005650-200410000-00003] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND An accurate accounting of service use is necessary to understand use patterns and outcomes. Yet such an accounting remains challenging, in part because of the reliability and validity of the collection method and sources. OBJECTIVES This study describes 2 methods of data collection: self-report and the retrieval of provider records. We report on the effort, yield, and challenges of retrieving records. Then, we compare the congruency and completeness of 2 methods: self-report and provider records. Finally, we examine the impact of various patients' characteristics on congruency rates. METHOD Our sample of depressed older participants was recruited from an inpatient geropsychiatry unit before they were discharged into the community. We interviewed participants at 3 points during a 6-month period. Provider records were obtained across provider type, based on self-report and snowballing technique. We calculated congruency rates and examined completeness of either data source on 91 participants with completed provider records. Using logistic regression, we examined the differences in congruency by provider type as well as factors related to the congruency. RESULTS The record retrieval process is labor-intensive and challenging. We found that congruency rates were statistically higher for pharmacy and hospital providers and lower for physicians. We also found higher counts of service use, higher depression levels, and being married were significantly related with lower congruency between self-report of service use and provider records. DISCUSSION Although we found relatively high congruency rates between self-report and service records, the choice of methods depends on the purpose of the research and breadth of provider types.
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Affiliation(s)
- Philip A Rozario
- Adelphi University School of Social Work, Garden City, New York, USA.
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Rost K, Fortney J, Fischer E, Smith J. Use, quality, and outcomes of care for mental health: the rural perspective. Med Care Res Rev 2002; 59:231-65; discussion 266-71. [PMID: 12205828 DOI: 10.1177/1077558702059003001] [Citation(s) in RCA: 108] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Eagles JM, Howie FL, Cameron IM, Wileman SM, Andrew JE, Robertson C, Naji SA. Use of health care services in seasonal affective disorder. Br J Psychiatry 2002; 180:449-54. [PMID: 11983643 DOI: 10.1192/bjp.180.5.449] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Little is known about the presentation and management of seasonal affective disorder (SAD) in primary care. AIMS To determine the use of health care services by people suffering from SAD. METHOD Following a screening of patients consulting in primary care, 123 were identified as suffering from SAD. Each was age- and gender-matched with two primary care consulters with minimal seasonal morbidity, yielding 246 non-seasonal controls. From primary care records, health care usage over a 5-year period was established. RESULTS Patients with SAD consulted in primary care significantly more often than controls and presented with a wider variety of symptoms. They received more prescriptions, underwent more investigations and had more referrals to secondary care. CONCLUSIONS Patients with SAD are heavy users of health care services. This may reflect the condition itself, its comorbidity or factors related to the personality or help-seeking behaviour of sufferers.
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Affiliation(s)
- John M Eagles
- Royal Cornhill Hospital, Cornhill Road, Aberdeen AB25 2ZH, Scotland, UK.
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Rost K, Fortney J, Zhang M, Smith J, Smith GR. Treatment of depression in rural Arkansas: policy implications for improving care. J Rural Health 2002; 15:308-15. [PMID: 11942563 DOI: 10.1111/j.1748-0361.1999.tb00752.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Policy-makers have long suspected that greater barriers to care result in depressed rural residents being less likely to receive high-quality treatment. This study recruited 470 depressed community residents in a 1992 telephone survey, followed 95 percent of them through one year, and abstracted additional data on their health care utilization from insurance claims, medical and pharmacy records. Bivariate and multivariate models demonstrated that during the year following the baseline, there were no significant rural-urban differences in the rate (probability of any outpatient depression treatment), type (probability of receiving general medical depression care only), or quality (completion of guideline-concordant acute-stage care) of outpatient depression treatment. Annual expenditures for outpatient depression treatment were lower for rural subjects compared with their urban counterparts. Rural subjects had 3.05 times the odds of being admitted to a hospital for physical problems and 3.06 times the odds of being admitted to a hospital for mental health problems during the year following baseline compared with urban subjects. Cost-offset analyses demonstrate that every dollar invested in depression treatment was associated with a $2.61 decrease in the cost of treating physical problems in depressed rural residents. Limited insurance coverage and limited availability of services were the most significant barriers to specialty and general medical outpatient treatment for depression in both rural and urban residents. More than 80 percent of depressed residents in both rural and urban areas visited a primary care provider during the year following baseline. The potential cost offset of depression treatment in rural populations plus the improvement in productivity observed in both rural and urban populations indicate that it may be economically possible to improve quality of care for depression without bankrupting an already strained health care budget.
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Affiliation(s)
- K Rost
- University of Arkansas for Medical Sciences, Center for Rural Mental Healthcare Research, Little Rock 72204, USA
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Tuunainen A, Langer RD, Klauber MR, Kripke DF. Short version of the CES-D (Burnam screen) for depression in reference to the structured psychiatric interview. Psychiatry Res 2001; 103:261-70. [PMID: 11549413 DOI: 10.1016/s0165-1781(01)00278-5] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A new screen for depression was compared with clinician diagnoses based on the Structured Clinical Interview for DSM-IV (SCID) as the standard. Post-menopausal women (n=436) completed the Burnam screen, a short version of the Center for Epidemiologic Studies Depression Scale (CES-D). The Burnam screen had a sensitivity of 74% and a specificity of 87% for current major depression and dysthymia, but the positive predictive value was low (20%) and the overall error rate was 14%. For lifetime mood disorders, sensitivity was very low for detecting affected subjects, even though specificity and positive predictive value were higher than for current conditions. Substituting a more sensitive cutpoint slightly improved the screen's ability to detect subjects with lifetime mood disorders. Even algorithms that used coefficients optimized for these data gave little improvement in the psychometric properties of the Burnam screen. These results re-emphasize the difficulty of using a one-stage screen to detect accurately a depressive diagnosis.
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Affiliation(s)
- A Tuunainen
- Department of Psychiatry, University of California, San Diego, CA, USA.
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Abstract
Primary care physicians have an important historical role in the delivery of mental health care despite the evolution of psychiatry as a specialty. Collaboration between primary care physicians and psychiatrists has been limited by problems of access to psychiatric care or consultation. Although managed care, in some forms, has been successful in addressing this issue, it has largely served as a new barrier to effective collaboration and to meeting the mental health care needs of patients.
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Affiliation(s)
- G N McNeil
- Department of Psychiatry, University of Vermont School of Medicine, Burlington, USA
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Cuffel BJ, Goldman W, Schlesinger H. Does managing behavioral health care services increase the cost of providing medical care? J Behav Health Serv Res 1999; 26:372-80. [PMID: 10565098 DOI: 10.1007/bf02287298] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This study examined the possibility that managing behavioral health care services achieves savings by cost shifting--by denying care or impeding access to care--and in that way encouraging patients to seek needed behavioral health care in the medical care system. In 1993, a large industrial company carved out employee behavioral health care from its unmanaged, indemnity medical care benefits and offered employees an enhanced benefit package through a managed behavioral health care company. This study compared the use and cost of behavioral health care and medical care services for two years before the carve-out and for three years afterward. The rate of behavioral health care usage remained the same or increased after the carve-out, while the cost of providing the care decreased. Controlling for trends that began before the inception of managed behavioral health, medical care costs decreased for those using behavioral health care services. No evidence supporting cost shifting was found.
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