Patterns of health care costs associated with depression and substance abuse in a national sample

Excess healthcare costs of psychological distress in young women: Evidence from linked national Medicare claims data

The prevalence of mental health disorders in young adults is increasing, yet there is limited empirical evidence on its economic consequences. We contribute to the literature by estimating the healthcare costs of psychological distress using panel data of young women (aged 18-23 years with a 5-year follow-up) from the Australian Longitudinal Study on Women's Health and linked administrative data from Medicare Australia. Our empirical strategy is based on the classical two-part model of healthcare costs with individual specific fixed-effects. We complement our analysis with a test for selection on unobservables to address potential concerns of endogeneity. We find that young women with psychological distress have 15% higher annual healthcare costs (excluding hospital costs) than women with no psychological distress. A large proportion of these costs is driven by the use of antidepressants and the services of psychiatrists and psychologists. We further find that women with psychological distress have higher out-of-pocket costs on these mental health related services compared to non-mental health specific services. Additionally, we show that the effect of psychological distress on healthcare costs is highest during the first 6 months of onset, which gradually decreases afterwards. The findings justify the importance of policy initiatives towards early prevention and treatment of psychological distress, especially among young women.

Predicting dropout from psychological treatment using different machine learning algorithms, resampling methods, and sample sizes

OBJECTIVE

The occurrence of dropout from psychological interventions is associated with poor treatment outcome and high health, societal and economic costs. Recently, machine learning (ML) algorithms have been tested in psychotherapy outcome research. Dropout predictions are usually limited by imbalanced datasets and the size of the sample. This paper aims to improve dropout prediction by comparing ML algorithms, sample sizes and resampling methods.

METHOD

Twenty ML algorithms were examined in twelve subsamples (drawn from a sample of N = 49,602) using four resampling methods in comparison to the absence of resampling and to each other. Prediction accuracy was evaluated in an independent holdout dataset using the F₁-Measure.

RESULTS

Resampling methods improved the performance of ML algorithms and down-sampling can be recommended, as it was the fastest method and as accurate as the other methods. For the highest mean F₁-Score of .51 a minimum sample size of N = 300 was necessary. No specific algorithm or algorithm group can be recommended.

CONCLUSION

Resampling methods could improve the accuracy of predicting dropout in psychological interventions. Down-sampling is recommended as it is the least computationally taxing method. The training sample should contain at least 300 cases.

Chronic disease and medical spending of Chinese elderly in rural region

OBJECTIVE

To determine whether or not chronic disease positively impacts medical costs among the rural elderly in China and to calculate medical expenditure induced by chronic disease between different groups of the rural elderly, as well as provide insight into the factors that affect medical losses induced by chronic disease among different household registration groups and different New Rural Pension Scheme statuses.

DESIGN

To estimate the share of medical expenses induced by chronic disease, this article uses a two-part model and a four-part model to analyze the causal effect of chronic disease on medical services and then uses a counter-factual method to estimate the share of medical expenses.

SETTING

The rapid development of China has changed nearly every aspect of life for the rural elderly. Many are concerned about the increasing prevalence of physical health issues, particularly chronic diseases, among the rural elderly. Nevertheless, there are no articles using nationally representative panel datasets that report differences in the cost of chronic disease between sub-populations.

PARTICIPANTS

The panel dataset used for this study comes from the China Family Panel Studies (CFPS) data. In this study, we use the CFPS data for the years 2012, 2014 and 2016 to create a panel dataset that includes 2730 rural elderly for 3 years.

INTERVENTIONS

This article reports the representative estimate of medical expenditures attributable to chronic disease among rural elderly in China. On this basis, we estimate per capita medical spending among rural elderly under the condition of logarithmic normal distribution of different parameters between urban and rural or between groups that participate in the New Rural Pension Program and groups that do not.

MAIN OUTCOME MEASURES

This study indicates that physical health status has a significant impact on both the probability of undergoing medical care and the size of medical expenditures among the rural elderly, and the influence was significant for all patients, including outpatients and inpatients.

RESULTS

Chronic illness has significant effects on individual medical expenses, and they aggregately contribute to 63.96% of total personal expected medical expenditure. Specifically, the medical spending caused by chronic disease was part of a non-uniform distribution, with the rural, male, older, married and higher educated groups spending more money on medical costs induced by chronic disease.

CONCLUSIONS

Examining trends in the prevalence of chronic diseases and evaluating medical spending on chronic diseases can prevent and control potential medical costs among rural elderly, especially for vulnerable groups, which helps to predict future health-care needs.

Local Health Department Activities to Reduce Emergency Department Visits for Substance Use Disorders

The Affordable Care Act (ACA) provides financial incentives to prevent substance use disorders (SUDs). Local health departments (LHDs) can receive funds to establish care teams that partner with primary care providers and health systems. This study estimates the potential effect of LHDs on emergency visits for SUDs, using linked data sets from the Healthcare Cost and Utilization Project Emergency Department (ED) sample for the State of Maryland-2012, the National Association of County and City Health Officials Profiles Survey 2013, and Area Health Resource File 2013 to estimate potential effect of LHDs' provision of SUD preventive care and SUD-related policy implementation. Local health department involvement in SUD-related policy during the past 2 years and provision of preventive care for behavioral health in the past year significantly reduced the probability of having a SUD-related ED visit by 11% and 6%, respectively, after controlling for individual characteristics (odds ratio [OR] = 0.89, p < .001; OR = 0.93, p < .001). After adjusting for the individual and contextual factors, LHD involvement in policy was still associated with 14% reduction in SUD-related ED visits (OR = 0.86, p < .001). Results offer insights on the extent to which the LHD activities can possibly affect SUD-related ED visits and provide a foundation for future work to identify effective LHD interventions.

Depressive costs: medical expenditures on depression and depressive symptoms among rural elderly in China

OBJECTIVES

To provide an evaluation of medical expenditures induced by depression and depressive symptoms among rural elderly in China.

STUDY DESIGN

The panel dataset used for this study is taken from the China Family Panel Studies (CFPS) data for the years 2012 and 2016. We examined the case of rural elderly who were 60 years old or older at the time of the 2012 survey and 64 years old or older at the time of the 2016 survey and then created a panel dataset that includes 2938 rural elderly for both years to estimate the influence of depressive symptoms/depression on medical cost.

METHODS

Both two part model and four part model were used to estimate the influence of depressive symptoms and depression on medical expenditure. Then a counter-factual method was used to calculate the cost of depressive symptoms and depression among rural elderly in China.

RESULTS

Mental health status has significant effects on individual medical expenses, and they aggregately contribute to 47.26% of total personal expected medical expenditures. Specifically, the rural group, the female group, the widowed group, and the poorly educated group have higher medical expenditures because of depressive status than the other groups.

CONCLUSIONS

Mental health status significantly increased both the chance of undergoing medical care and the degree of medical expenditure among rural elderly in China. This situation is more serious in some vulnerable groups. Therefore, the Chinese government needs to reform its mental health of rural elderly and insurance institutions to eliminate the policy-caused barriers to mental health resources, especially for vulnerable groups.

Factors Related to Change in Depression among North Korean Refugee Youths in South Korea

This study investigated change in depression and revealed factors related to change using one-year follow-up data. A sample of 108 North Korean Refugee Youths (NKRYs) aged 13 to 26 years (66 females) was recruited from two alternative schools for NKRYs in South Korea. Based on the Center for Epidemiologic Studies Depression Scale cut-off score of 16, respondents were grouped based on change in depression score after one year as stable low, alleviated, deteriorated, or prolonged. Multinomial logistic regression assessed the influence of baseline psychological scores (resilience, emotional regulation strategy, and self-esteem), and reported social support (psychological/practical) on the odds of group classification. With the stable low group as the reference category, those with alleviated depression at Time 2 had significantly higher odds of expressive suppression and tended to have lower self-esteem at Time 1. The deteriorated depression group was more likely than the stable low group to have lower resilience and cognitive appraisal scores. Those with prolonged high depression were more likely than the stable low group to have lower resilience, less practical social support, and lower self-esteem. Psychological interventions, particularly those focused on increasing self-esteem and resilience, could be helpful for NKRYs with potential risk of depression. In addition, practical support should be provided on an as-needed basis to prevent chronic depression among NKRYs.

Comparative Effectiveness of Coalitions Versus Technical Assistance for Depression Quality Improvement in Persons with Multiple Chronic Conditions

Significance

Prior research suggests that Community Engagement and Planning (CEP) for coalition support compared with Resources for Services (RS) for program technical assistance to implement depression quality improvement programs improves 6- and 12-month client mental-health related quality of life (MHRQL); however, effects for clients with multiple chronic medical conditions (MCC) are unknown.

Objective

To explore effectiveness of CEP vs RS in MCC and non-MCC subgroups.

Design

Secondary analyses of a cluster-randomized trial.

Setting

93 health care and community-based programs in two neighborhoods.

Participants

Of 4,440 clients screened, 1,322 depressed (Patient Health Questionnaire, PHQ8) provided contact information, 1,246 enrolled and 1,018 (548 with ≥3 MCC) completed baseline, 6- or 12-month surveys.

Intervention

CEP or RS for implementing depression quality improvement programs.

Outcomes and Analyses

Primary: depression (PHQ9 <10), poor MHRQL (Short Form Health Survey, SF-12<40); Secondary: mental wellness, good physical health, behavioral health hospitalization, chronic homelessness risk, work/workloss days, services use at 6 and 12 months. End-point regressions were used to estimate intervention effects on outcomes for subgroups with ≥3 MCC, non-MCC, and intervention-by-MCC interactions (exploratory).

Results

Among MCC clients at 6 months, CEP vs RS lowered likelihoods of depression and poor MHRQL; increased likelihood of mental wellness; reduced work-loss days among employed and likelihoods of ≥4 behavioral-health hospitalization nights and chronic homelessness risk, while increasing faith-based and park community center depression services; and at 12 months, likelihood of good physical health and park community center depression services use (each P<.05). There were no significant interactions or primary outcome effects for non-MCC.

Conclusions

CEP was more effective than RS in improving 6-month primary outcomes among depressed MCC clients, without significant interactions.

Health-economic outcomes in hospital patients with medical-psychiatric comorbidity: A systematic review and meta-analysis

BACKGROUND

Hospital inpatients often experience medical and psychiatric problems simultaneously. Although this implies a certain relationship between healthcare utilization and costs, this relationship has never been systematically reviewed.

OBJECTIVE

The objective is to examine the extent to which medical-psychiatric comorbidities relate to health-economic outcomes in general and in different subgroups. If the relationship is significant, this would give additional reasons to facilitate the search for targeted and effective treatments for this complex population.

METHOD

A systematic review in Embase, Medline, Psycinfo, Cochrane, Web of Science and Google Scholar was performed up to August 2016 and included cross-references from included studies. Only peer-reviewed empirical studies examining the impact of inpatient medical-psychiatric comorbidities on three health-economic outcomes (length of stay (LOS), medical costs and rehospitalizations) were included. Study design was not an exclusion criterion, there were no restrictions on publication dates and patients included had to be over 18 years. The examined populations consisted of inpatients with medical-psychiatric comorbidities and controls. The controls were inpatients without a comorbid medical or psychiatric disorder. Non-English studies were excluded.

RESULTS

From electronic literature databases, 3165 extracted articles were scrutinized on the basis of title and abstract. This resulted in a full-text review of 86 articles: 52 unique studies were included. The review showed that the presence of medical-psychiatric comorbidity was related to increased LOS, higher medical costs and more rehospitalizations. The meta-analysis revealed that patients with comorbid depression had an increased mean LOS of 4.38 days compared to patients without comorbidity (95% CI: 3.07 to 5.68, I2 = 31%).

CONCLUSIONS

Medical-psychiatric comorbidity is related to increased LOS, medical costs and rehospitalization; this is also shown for specific subgroups. This study had some limitations; namely, that the studies were very heterogenetic and, in some cases, of poor quality in terms of risk of bias. Nevertheless, the findings remain valid and justify the search for targeted and effective interventions for this complex population.

Depression hurts, depression costs: The medical spending attributable to depression and depressive symptoms in China

Due to its fast economic growth and lifestyle changes, China is experiencing a rapid epidemiological transition from communicable to noncommunicable diseases (NCDs). Mental disorder such as depression is an important yet often neglected NCD and is becoming a growing cause of disability, suicides, and disease burden. This paper provides the first nationally representative estimate of the medical cost attributable to depression and depressive symptoms among the adult population in China. On the basis of the 2012 China Family Panel Studies survey, our results indicate that these mental health conditions have significant impacts on the individual medical expenditure, and they jointly contribute to 14.7% of total personal expected medical spending in China, with depression and depressive symptoms accounting for 6.9% and 7.8%, respectively. Given that patients with mental illness face multiple psychological and institutional barriers in seeking appropriate treatment, the high depression-induced medical costs may be primarily driven by the cost-shifting effect from mental health care to general health care, as mental disorders often coexist with other NCDs such as diabetes and hypertension. As an implication, our study calls for an urgent reform of China's mental health and insurance systems to remove the policy-induced obstacles for the access to mental health care resources.

Comparative Effectiveness of Coalitions Versus Technical Assistance for Depression Quality Improvement in Persons with Multiple Chronic Conditions

SIGNIFICANCE

Prior research suggests that Community Engagement and Planning (CEP) for coalition support compared with Resources for Services (RS) for program technical assistance to implement depression quality improvement programs improves 6- and 12-month client mental-health related quality of life (MHRQL); however, effects for clients with multiple chronic medical conditions (MCC) are unknown.

OBJECTIVE

To explore effectiveness of CEP vs RS in MCC and non-MCC subgroups.

DESIGN

Secondary analyses of a cluster-randomized trial.

SETTING

93 health care and community-based programs in two neighborhoods.

PARTICIPANTS

Of 4,440 clients screened, 1,322 depressed (Patient Health Questionnaire, PHQ8) provided contact information, 1,246 enrolled and 1,018 (548 with ≥3 MCC) completed baseline, 6- or 12-month surveys.

INTERVENTION

CEP or RS for implementing depression quality improvement programs.

OUTCOMES AND ANALYSES

Primary: depression (PHQ9 <10), poor MHRQL (Short Form Health Survey, SF-12<40); Secondary: mental wellness, good physical health, behavioral health hospitalization, chronic homelessness risk, work/workloss days, services use at 6 and 12 months. End-point regressions were used to estimate intervention effects on outcomes for subgroups with ≥3 MCC, non-MCC, and intervention-by-MCC interactions (exploratory).

RESULTS

Among MCC clients at 6 months, CEP vs RS lowered likelihoods of depression and poor MHRQL; increased likelihood of mental wellness; reduced work-loss days among employed and likelihoods of ≥4 behavioral-health hospitalization nights and chronic homelessness risk, while increasing faith-based and park community center depression services; and at 12 months, likelihood of good physical health and park community center depression services use (each P<.05). There were no significant interactions or primary outcome effects for non-MCC.

CONCLUSIONS

CEP was more effective than RS in improving 6-month primary outcomes among depressed MCC clients, without significant interactions.

Evaluation of an integrated group cognitive-behavioral treatment for comorbid mood, anxiety, and substance use disorders: A pilot study

This paper presents the development and preliminary evaluation of an integrated group cognitive-behavioral treatment (CBT) for comorbid mood, anxiety, and substance use disorders. The 12-session, manualized treatment was developed collaboratively by a mental health program in a teaching hospital and a community-based addictions service and administered in both settings. Results from an uncontrolled effectiveness trial of 29 treatment completers suggest that integrated group CBT may reduce stress and alcohol use symptoms and improve substance refusal self-efficacy. Changes in symptoms of anxiety, depression, and drug use were not significant, although the effect size for anxiety reduction was in the medium range. Nonetheless, the clinical significance of treatment effects on mood, anxiety, and substance use symptoms was modest. Changes in coping skills and quality of life were not significant, although medium-to-large effects were observed for changes in several coping skills. Participants reported being highly satisfied with treatment, found the treatment strategies to be useful, and noted an improvement in their functioning, particularly socially. Methodological and sample size limitations warrant more rigorous follow-up investigations of this treatment. Results are considered in the context of the current literature on integrated psychological treatments for these common comorbidities.

Therapist Effects on and Predictors of Non-Consensual Dropout in Psychotherapy

BACKGROUND

Whereas therapist effects on outcome have been a research topic for several years, the influence of therapists on premature treatment termination (dropout) has hardly been investigated. Since dropout is common during psychological treatment, and its occurrence has important implications for both the individual patient and the healthcare system, it is important to identify the factors associated with it.

METHOD

Participants included 707 patients in outpatient psychotherapy treated by 66 therapists. Multilevel logistic regression models for dichotomous data were used to estimate the impact of therapists on patient dropout. Additionally, sociodemographic variables, symptoms, personality style and treatment expectations were investigated as potential predictors.

RESULTS

It was found that 5.7% of variance in dropout could be attributed to therapists. The therapist's effect remained significant after controlling for patient's initial impairment. Furthermore, initial impairment was a predictor of premature termination. Other significant predictors of dropout on a patient level were male sex, lower education status, more histrionic and less compulsive personality style and negative treatment expectations.

CONCLUSIONS

The findings indicate that differences between therapists influence the likelihood of dropout in outpatient psychotherapy. Further research should focus on variables, which have the potential to explain these inter-individual differences between therapists (e.g., therapist's experience or self-efficacy). Copyright © 2016 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGES

There are substantial differences between therapists concerning their average dropout rates. At the patient level, higher initial impairment, male sex, lower education, less compulsive personality style, more histrionic personality style and low treatment expectations seem to be risk factors of non-consensual treatment termination. Psychometric feedback during the course of treatment should be used to identify patients who are at risk for dropout.

Accuracy of reported service use in a cohort of people who are chronically homeless and seriously mentally ill

BACKGROUND

Self-reported service use is an integral feature of interventional research with people who are homeless and mentally ill. The objective of this study was to investigate the accuracy of self-reported involvement with major categories of publicly funded services (health, justice, social welfare) within this sub-population.

METHODS

Measures were administered pre-randomization in two randomized controlled trials, using timeline follow back with calendar aids for Health, Social, and Justice Service Use, compared to linked administrative data. Variables examined were: psychiatric admissions (both extended stays of more than 6 months and two or more stays within 5 years); emergency department visits, general hospitalization and jail in the past 6 months; and income assistance in the past 1 month. Participants (n = 433) met criteria for homelessness and a least one mental illness.

RESULTS

Prevalence adjusted and bias adjusted kappa (PABAK) values ranged between moderate and almost perfect for extended psychiatric hospital separations (PABAK: 0.77; 95 % confidence interval (CI) = 0.71, 0.83), multiple psychiatric hospitalizations (PABAK = 0.50, 95 % CI = 0.41, 0.59), emergency department visits (PABAK: 0.77; 95 % CI = 0.71, 0.83), jail (PABAK: 0.74; 95 % CI = 0.68, 0.81), and income assistance (PABAK: 0.82; 95 % CI = 0.76, 0.87). Significant differences in under versus over reporting were also found.

CONCLUSIONS

People who are homeless and mentally ill reliably reported their overall use of health, justice, and income assistance services. Evidence of under-reporting and over-reporting of certain variables has implications for specific research questions. ISRCTN registry: 57595077 (Vancouver at Home Study: Housing First plus Assertive Community Treatment versus congregate housing plus supports versus treatment as usual); and 66721740 (Vancouver at Home study: Housing First plus Intensive Case management versus treatment as usual).

The Association Between Self-Rated Mental Health Status and Total Health Care Expenditure: A Cross-Sectional Analysis of a Nationally Representative Sample

Both clinical diagnoses and self-rated measures of mental illness are associated with a variety of outcomes, including physical well-being, health utilization, and expenditure. However, much of current literature primarily utilizes clinically diagnosed data.This cross-sectional study explores the impact of mental illness and health care expenditure using 2 self-rated measures: self-rated measured of perceived mental health status (SRMH) and Kessler Screening Scale for Psychological Distress (K6).Data from the 2011 Medical Expenditure Panel Survey Household Component, a nationally representative sample of noninstitutionalized individuals (n = 18,295), were analyzed using bivariate χ tests and a 2-part model (logistics regression and generalized linear model regression for the first and second stages, respectively).Although predictive of any health expenditure, SRMH alone was not highly predictive of the dollar value of that health expenditure conditional on any spending. By comparison, the K6 measure was significantly and positively associated with the probability of any health expenditure as well as the dollar value of that spending. Taken together, both the K6 and SRMH measures suggest a positive relationship between poor mental health and the probability of any health expenditure and total expenditure conditional on any spending, even when adjusting for other confounding factors such as race/ethnicity, sex, age, educational attainment, insurance status, and some regional characteristics.Our results suggest that psychological distress and SRMH may represent potential pathways linking poor mental health to increased health care expenditure. Further research exploring the nuances of these relationships may aid researchers, practitioners, and policy makers in addressing issues of inflated health care expenditure in populations at risk for poor mental health.

The Relationship Between Posttraumatic Stress Symptoms and Physical Health in a Survey of U.S. Veterans of the Iraq and Afghanistan Era

BACKGROUND

Although a large body of literature has linked posttraumatic stress disorder (PTSD) with poor physical health among older veterans, less is known regarding the association between PTSD and health among relatively younger cohorts of veterans.

OBJECTIVE

The current study examined the association between PTSD and self-reported health among a sample of veterans who served in the recent conflicts in Iraq and Afghanistan.

METHOD

Veterans (N = 1030) who served in the wars in Iraq and Afghanistan completed measures of PTSD symptom severity and self-rated health between September 2009 and February 2010. Analyses examined the association between PTSD symptoms and health outcomes.

RESULTS

In analyses adjusted for age, sex, race, and combat exposure, PTSD symptom severity was positively related to the number of health conditions and health symptoms reported (ps<0.001). Additionally, in analyses adjusted for age, sex, race, combat exposure, number of health conditions, and number of health symptoms, PTSD symptom severity was associated with an increased likelihood of rating one's health as poor or fair and an increased likelihood of reporting that one's physical health limits participation in activities (ps<0.001).

CONCLUSION

These findings suggest that, consistent with previous research, PTSD symptom severity has a broad negative effect on physical health among veterans of the Iraq and Afghanistan era. Health promotion among veterans with PTSD may help attenuate risk of physical health consequences.

Prevalence of comorbid depression and obesity in general practice: a cross-sectional survey

Background

General practice is a common setting for the provision of weight-management advice, as well as the treatment of depression. While there is some evidence of a reciprocal relationship between obesity and depression, there are limited data about the rates of depression among general practice patients who are underweight, normal weight, overweight, and obese.

Aim

To explore the prevalence of depression among underweight, normal weight, overweight, and obese general practice patients.

Design and setting

A cross-sectional survey was conducted in 12 Australian general practices.

Method

Patients aged ≥18 years and older who were presenting for general practice care were eligible to participate. Consenting patients completed a touchscreen computer survey assessing self-reported weight and height. Depression was assessed by the Patient Health Questionnaire-9 (PHQ-9), with a score of ≥10 used to indicate possible depression.

Results

Data were obtained from 3361 participants. The prevalence of depression was 24% (95% confidence interval [CI] = 11.86 to 39.28) among underweight participants, 11% (95% CI = 8.5 to 14.0) among normal weight participants, 12% (95% CI = 0.9 to 15.2) among overweight participants, and 23% (95% CI = 17.8 to 29.0) among obese participants. The prevalence of depression was higher for women than for men across all weight categories except underweight.

Conclusion

Weight and depression demonstrated a U-shaped relationship, with higher prevalence of depression observed among underweight and obese general practice patients. These conditions may act as red flags for opportunistic screening of depression in the general practice setting.

Self-efficacy and social networks after treatment for alcohol or drug dependence and major depression: disentangling person and time-level effects

Proximal personal and environmental factors typically predict outcomes of treatment for alcohol or drug dependence (AODD), but longitudinal treatment studies have rarely examined these factors in adults with co-occurring psychiatric disorders. In adults with AODD and major depression, the aims of this study were to: (a) disaggregate person-and time-level components of network substance use and self-efficacy, (b) examine their prospective effects on posttreatment alcohol/drug use, and (c) examine whether residential environment moderated relations between these proximal factors and substance use outcomes. Veterans (N = 201) enrolled in a trial of group psychotherapy for AODD and independent MDD completed assessments every 3 months during 1 year of posttreatment follow-up. Outcome variables were percent days drinking (PDD) and using drugs (PDDRG). Proximal variables included abstinence self-efficacy and social network drinking and drug use. Self-efficacy and network substance use at the person-level prospectively predicted PDD (ps < .05) and PDDRG (ps < .05). Within-person, time-level effects of social networks predicted future PDD (ps < .05) but not PDDRG. Controlled environments moderated person-level social network effects (ps < .05), such that greater time in controlled settings attenuated the association between a heavier drinking/using network and posttreatment drinking and drug use. Both individual differences and time-specific fluctuations in proximal targets of psychosocial interventions are related to posttreatment substance use in adults with co-occurring AODD and MDD. More structured environmental settings appear to alleviate risk associated with social network substance use, and may be especially advised for those who have greater difficulty altering social networks during outpatient treatment.

The continuing care model of substance use treatment: what works, and when is "enough," "enough?"

There is little disagreement in the substance use treatment literature regarding the conceptualization of substance dependence as a cyclic, chronic condition consisting of alternating episodes of treatment and subsequent relapse. Likewise, substance use treatment efforts are increasingly being contextualized within a similar disease management framework, much like that of other chronic medical conditions (diabetes, hypertension, etc.). As such, substance use treatment has generally been viewed as a process comprised of two phases. Theoretically, the incorporation of some form of lower intensity continuing care services delivered in the context of outpatient treatment after the primary treatment phase (e.g., residential) appears to be a likely requisite if all stakeholders aspire to successful long-term clinical outcomes. Thus, the overarching objective of any continuing care model should be to sustain treatment gains attained in the primary phase in an effort to ultimately prevent relapse. Given the extant treatment literature clearly supports the contention that treatment is superior to no treatment, and longer lengths of stay is associated with a variety of positive outcomes, the more prudent question appears to be not whether treatment works, but rather what are the specific programmatic elements (e.g., duration, intensity) that comprise an adequate continuing care model. Generally speaking, it appears that the duration of continuing care should extend for a minimum of 3 to 6 months. However, continuing care over a protracted period of up to 12 months appears to be essential if a reasonable expectation of robust recovery is desired. Limitations of prior work and implications for routine clinical practice are also discussed.

The economic, public health, and caregiver burden of late-life depression

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.

Elevated specific peripheral cytokines found in major depressive disorder patients with childhood trauma exposure: a cytokine antibody array analysis

Taking into consideration the previous evidence of revealing the relationship of early life adversity, major depressive disorder (MDD), and stress-linked immunological changes, we recruited 22 MDD patients with childhood trauma exposures (CTE), 21 MDD patients without CTE, and 22 healthy controls without CTE, and then utilized a novel cytokine antibody array methodology to detect potential biomarkers underlying MDD in 120 peripheral cytokines and to evaluate the effect of CTE on cytokine changes in MDD patients. Although 13 cytokines were identified with highly significant differences in expressions between MDD patients and normal controls, this relationship was significantly attenuated and no longer significant after consideration of the effect of CTE in MDD patients. Depressed individuals with CTE (TD patients) were more likely to have higher peripheral levels of those cytokines. Severity of depression was associated with plasma levels of certain increased cytokines; meanwhile, the increased cytokines led to a proper separation of TD patients from normal controls during clustering analyses. Our research outcomes add great strength to the relationship between depression and cytokine changes and suggest that childhood trauma may play a vital role in the co-appearance of cytokine changes and depression.

Differences in neurobiological pathways of four "clinical content" subtypes of depression

Although often considered as a mental disorder, depression is best described as a behavioral-neurobiological phenomenon. In addition, although usually reported as a unitary diagnosis, major depressive episode is composed of a range of different symptoms that can occur in nearly 1500 possible combinations to fulfill the required diagnostic criterion. To investigate and describe the underlying behavioral and neurobiological substrates of these symptoms, they were clustered into "clinical content" subtypes of depression according to their predominant common behavioral characteristics. These subtypes were then found to possess different neurobiological pathways that argue for different treatment approaches.

12-step affiliation and attendance following treatment for comorbid substance dependence and depression: a latent growth curve mediation model

Among substance-dependent individuals, comorbid major depressive disorder (MDD) is associated with greater severity and poorer treatment outcomes, but little research has examined mediators of posttreatment substance use outcomes within this population. Using latent growth curve models, the authors tested relationships between individual rates of change in 12-step involvement and substance use, utilizing posttreatment follow-up data from a trial of group Twelve-Step Facilitation (TSF) and integrated cognitive-behavioral therapy (ICBT) for veterans with substance dependence and MDD. Although TSF patients were higher on 12-step affiliation and meeting attendance at end-of-treatment as compared with ICBT, they also experienced significantly greater reductions in these variables during the year following treatment, ending at similar levels as ICBT. Veterans in TSF also had significantly greater increases in drinking frequency during follow-up, and this group difference was mediated by their greater reductions in 12-step affiliation and meeting attendance. Patients with comorbid depression appear to have difficulty sustaining high levels of 12-step involvement after the conclusion of formal 12-step interventions, which predicts poorer drinking outcomes over time. Modifications to TSF and other formal 12-step protocols or continued therapeutic contact may be necessary to sustain 12-step involvement and reduced drinking for patients with substance dependence and MDD.

Reducing costs of acute care for ambulatory care-sensitive medical conditions: the central roles of comorbid mental illness

BACKGROUND

New patient-centered models of ambulatory care aim to substitute better primary care for preventable acute care within existing primary care practices. This study aims to identify whether mental illness and other characteristics of primary care patients are related to risk for an acute event for an ambulatory care-sensitive condition (ACSC).

METHODS

We conducted a 2-year, longitudinal analysis comparing ambulatory care-sensitive admissions and emergency department (ED) visits for a cohort of 18,526 primary care patients followed in 5 veterans affairs (VA) primary care sites. We compared rates, risks, and costs of ACSC-related acute events during a follow-up year for patients with and without mental illness seen during the previous year in primary care.

RESULTS

The 12-month rate of ACSC admissions was 31.7 admissions per 1000 patients with mental health diagnoses compared with 21.0 admissions per 1000 patients without (P=0.0009). The ACSC-associated ED visit rate was also significantly higher (P<0.0001). In adjusted analyses controlling for demographics, chronic disease, illness severity, and prior ambulatory care, those with depression or drug use disorders had higher odds of receiving ACSC-related acute care (odds ratio=1.10, 95% confidence interval: 1.03, 1.17 for depression; odds ratio=1.48, 95% confidence interval: 1.05, 1.99 for drug use disorders). Costs per admission and ED visit were similar across patient groups. Higher medication use and lower medication regimen complexity were significantly associated with decreased risk for ACSC events.

CONCLUSIONS

Prior mental health diagnoses and medication use were independent risk factors for ACSC-related acute care. These risk factors require focused attention if the full benefits of new primary care models are to be achieved.

Characterizing the psychological distress response before and after a cancer diagnosis

Psychological distress among cancer survivors is common. It is unknown if symptoms predate diagnosis or differ from patients without cancer because studies are limited to patient follow-up. Linked cohort (Wisconsin Longitudinal Study) and tumor registry records were used to assess the psychological distress response pre- to post-cancer diagnosis. Adjusted predicted probabilities of being in one of five categories of change for three psychological distress measures (depression, anxiety, well-being) were compared for participants diagnosed with cancer between 1993-1994 and 2004-2005 and participants without cancer (N = 5,162). Cancer survivors were more likely to experience clinically significant increases (≥0.8 standard deviation) in depression (15, 95 % CI = 12-18 %) and anxiety (19 %, CI = 16-22 %) compared to their no-cancer counterparts (10 %, CI = 10-11 %; 11 %, CI = 11-12 %). Cancer survivors <5 years from diagnosis were more likely to experience worsening depression. Survivors ≥5 years were more likely to experience worsening anxiety. No significant results were found for well-being. Characterizing the psychological distress response is a prerequisite for identifying at-risk patients and communicating expected symptoms, allowing for proactive resource provision.

Training addiction counselors to implement CBT for depression

Many clients in publicly funded substance abuse treatment programs suffer from depression yet lack access to effective mental health treatment. This study sought to examine whether addiction counselors could be effectively trained to deliver group CBT for depression and to ascertain client perceptions of the treatment. Five counselors were trained in the therapy and treated 113 clients with depression symptoms. Counselors demonstrated high fidelity to the therapy and client perceptions of the therapy were positive. Our results suggest that training addiction counselors to deliver group CBT for depression is a promising integrated treatment approach for co-occurring depression and substance disorders.

Excess health care service utilization and costs associated with underrecognition of psychiatric comorbidity in a medical/surgical inpatient setting

Psychiatric comorbidity is common among chronically medically ill populations and the presence of psychiatric conditions tends to be associated with increased costs and excess utilization of general medical services. The purpose of this pilot investigation was to determine whether differences in nonpsychiatric inpatient hospitalization frequency, duration, and costs existed between patients receiving outpatient psychiatric treatment and patients without identified psychiatric problems. Length of stay and cost information for patients that had at least 1 inpatient medical/surgical hospitalization during a 6-month period was extracted from the hospital's inpatient billing database (n = 10,865). The medical record numbers of these patients were then cross-referenced against the outpatient psychiatry-billing database for the same 6-month period, thereby identifying all patients that had both a nonpsychiatric inpatient hospitalization and an outpatient psychiatry visit (n = 149). Patients identified as having outpatient psychiatry involvement had significantly more nonpsychiatric hospitalizations on average (mean = 1.60) than nonpsychiatric patients (mean = 1.34) during the study period (t4381 = 2.94, P = .003). There was no difference in the total costs associated with these hospitalizations between the 2 groups. Those that had a psychiatry consult during the nonpsychiatric hospitalization had a significantly higher length of stay and costs than those without. Thus, the criteria used to determine whether or not a psychiatry consultation is triggered, and the timing of the consultation request need further study.

Four potential criteria for deciding when to use antidepressants or psychotherapy for unipolar depression: a literature review

OBJECTIVE

To evaluate the literature supporting four potential criteria for deciding whether to use psychotherapy or pharmacology when treating depression.

METHOD

Literature review of the evidence from the last 10 years on presenting patient's demographics, aetiology, comorbidity, and genetic factors, as predictors of treatment outcome efficacy.

RESULTS

Demographic information has little support as a potential criteria for decision-making; aetiology (melancholic vs. non-melancholic) has significant support; presence of personality disorder comorbidity is unproven as a criterion but may have some value; genetic predisposition has the strongest evidence supporting it as a criteria for treatment decision-making.

CONCLUSION

Although some presenting cases will be easier to classify than others, there are substantial data supporting the screening of patients according to three of these criteria.

Joining the dots: neurobiological links in a functional analysis of depression

Depression is one of the major contributors to the Total Disease Burden and afflicts about one-sixth of Western populations. One of the most effective treatments for depression focuses upon analysis of causal chains in overt behaviour, but does not include brain-related phenomena as steps along these causal pathways. Recent research findings regarding the neurobiological concomitants of depressive behaviour suggest a sequence of structural and functional alterations to the brain which may also produce a beneficial outcome for the depressed individual--that of adaptive withdrawal from uncontrollable aversive stressors. Linking these brain-based explanations to models of observable contingencies for depressive behaviour can provide a comprehensive explanation of how depressive behaviour occurs and why it persists in many patients.

Service utilization during and after outpatient treatment for comorbid substance use disorder and depression

Patients with comorbid substance use disorder (SUD) and depression incur greater treatment costs than those with either disorder alone. Integrated treatment targeting both issues concurrently has been shown to reduce substance use and depression in this population, but little is known about the effects of such treatment on the utilization of costly health services. This study compared 18-month patterns of service utilization for 236 veterans with comorbid SUD depression randomly assigned to 6 months of either Integrated Cognitive Behavioral Therapy (ICBT) or Twelve-Step Facilitation Therapy. Treatment group differences were found for the utilization of psychotropic medication services and inpatient hospitalization. Higher rates of therapy attendance, lower baseline depression, and receiving ICBT all predicted shorter admissions for those hospitalized during treatment. Ethnicity and gender predicted medication service use both during and following treatment. The findings provide evidence supporting the long-term cost-effectiveness of integrated treatment for this high-risk population.

Beyond symptomatic improvement:assessing real-world outcomes in patients with major depressive disorder

OBJECTIVE

To quantify the negative impact that major depressive disorder (MDD) has on quality of life, disability, and work, family, and overall psychosocial functioning. Available scales that assess these areas of impairment as they relate to patients with MDD are described.

DATA SOURCES

PUBMED SEARCHES WERE CONDUCTED USING THE FOLLOWING TERMS: (MDD OR major depressive disorder) AND (absenteeism OR absente*); AND (quality of life OR QOL); AND (psychosocial function*); AND (presente* OR presenteeism); AND (health care cost* OR [health care] cost*); AND (health outcome*); AND (functional outcome*); AND (family life); AND (disabil* OR disability); AND (work function*); AND (unemployment OR unemploy*). The literature search was conducted in July 2008 and was restricted to English language articles. There were no limits set on the dates of the search.

STUDY SELECTION

Two hundred twenty potential articles were identified. Among these studies, 48 presented primary data directly demonstrating the effect of MDD on quality of life, disability, and work, family, and overall psychosocial functioning.

DATA EXTRACTION

Primary data were compiled from these studies and are summarily described. Available scales that assess quality of life, disability, and work, family, and overall psychosocial functioning are also described.

DATA SYNTHESIS

MDD was found to be associated with significant disability and declines in functioning and quality of life. The Sheehan Disability Scale, the 36-item Short-Form Health Survey, and the Work Limitations Questionnaire were the most commonly used scales according to this review of the literature, but the majority of studies used direct and indirect disability measures, such as health care and other disability-related costs.

CONCLUSIONS

In addition to assessing symptomatic outcomes, physicians should routinely assess their depressed patients on "real-world" outcomes. The development of a concise functional outcome measure specific to MDD is necessary for busy clinical practices.

Is depression "evolutionary" or just "adaptive"? A comment

Some recent explanations of depression have suggested that it may be "evolutionary" in that there are advantages to the depressed individual which arise from some aspects of depressive symptomatology. While the depressive behaviour of withdrawal from the adverse environment may provide some immediate benefits to the depressed individual, thus making it potentially "adaptive" in the short-term, this does not fit the biological definition of "evolutionary". In fact, depression does not meet two of the three required criteria from natural selection in order to be evolutionary. Therefore, while some depressive behaviour may be advantageous for the depressed individual, and is therefore "adaptive" in an immediate sense, it cannot be accurately described as "evolutionary". Implications for research and clinical practice are discussed.

Malfunction in GABA and Glutamate as Pathways to Depression: A Review of the Evidence

With nearly one fifth of the population experiencing depression sometime during their lives, plus the recent finding that depression rivals smoking in its association with mortality, the search for effective pharmacological treatments for depression remains urgent. However, despite this heavy disease burden upon society, the various waves of antidepressants developed in the last 40 years have shown significant side effects and little specific efficacy over placebo. One potential treatment may be via re-establishment of glutamate and GABA neurotransmitter systems that have been shown to malfunction in depressed patients. The literature describing possible causal links between GABA and/or glutamate malfunction and depression is reviewed, plus those studies which provide experimental data to confirm this hypothesis. While there is plausible support for the links between malfunction of these neurotransmitters and depression, few data exist yet regarding development of effective antidepressant medications based upon these findings.

Helping nursing homes "at risk" for quality problems: a statewide evaluation

The Quality Improvement Program for Missouri (QIPMO), a state school of nursing project to improve quality of care and resident outcomes in nursing homes, has a special focus to help nursing homes identified as "at risk" for quality concerns. In fiscal year 2006, 92 of 492 Medicaid-certified facilities were identified as "at risk" using quality indicators (QIs) derived from Minimum Data Set (MDS) data. Sixty of the 92 facilities accepted offered on-site clinical consultations by gerontological expert nurses with graduate nursing education. Content of consultations include quality improvement, MDS, care planning, evidence-based practice, and effective teamwork. The 60 "at-risk" facilities improved scores 4%-41% for 5 QIs: pressure ulcers (overall and high risk), weight loss, bedfast residents, and falls; other facilities in the state did not. Estimated cost savings (based on prior cost research) for 444 residents who avoided developing these clinical problems in participating "at-risk" facilities was more than $1.5 million for fiscal year 2006. These are similar to estimated savings of $1.6 million for fiscal year 2005 when 439 residents in "at-risk" facilities avoided clinical problems. Estimated savings exceed the total program cost by more than $1 million annually. QI improvements demonstrate the clinical effectiveness of on-site clinical consultation by gerontological expert nurses with graduate nursing education.

Subtypes of depression in a nationally representative sample

BACKGROUND

Continued research efforts aim to elucidate the heterogeneity in depression. The identification of meaningful and valid subtypes has implications for research and clinical practice. Based on patterns of depressive symptomatology, this study identified a typology of depressive syndromes using data from a large, nationally representative survey.

METHODS

Analyses were based on a subsample of 12,180 respondents from the 2001-2002 Wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Latent class analysis was applied to the DSM-IV 'A' criteria for major depression to identify homogenous subtypes or classes of depressive syndromes. Associations between the emergent latent classes and demographic and clinical characteristics were assessed.

RESULTS

Three clinically relevant subtypes were identified, in addition to a class who reported few depressive symptoms: severely depressed (40.9%), psychosomatic (30.6%), cognitive-emotional (10.2%) and non-depressed (18.3%). The odds of experiencing negative life events, psychiatric disorders, and having a family background of major depression were significantly higher for the severely depressed, psychosomatic and cognitive-emotional classes, compared to the non-depressed class. Several unique differences between the latent classes also emerged.

LIMITATIONS

Methodological shortcomings included: reliance on lay interviewer-administered structured interviews to determine diagnoses; basing sample selection on the endorsement of screener items; and, using measures of 'any anxiety disorder', 'any mood disorder', and 'any personality disorder' to determine psychiatric disorder prevalence rates.

CONCLUSIONS

Significant heterogeneity in depressive symptomatology exists in this U.S. sample. Profiling symptom patterns is potentially useful as a first step in developing tailored intervention and treatment programmes.

The Charlson comorbidity index is adapted to predict costs of chronic disease in primary care patients

OBJECTIVE

(1) To determine chronic illness costs for large cohort of primary care patients, (2) to develop prospective model predicting total costs over one year, using demographic and clinical information including widely used comorbidity index.

STUDY DESIGN AND SETTING

Data including diagnostic, medication, and resource utilization were obtained for 5,861 patients from practice-based computer system over a 1-year period beginning December 1, 1993, for retrospective analysis. Hospital cost data were obtained from hospital cost accounting system.

RESULTS

Average annual per patient cost was $2,655. Older patients and those with Medicare or Medicaid had higher costs. Hospital costs were $1,558, accounting for 58.7% of total costs. In the predictive model, individuals with higher comorbidity incurred exponentially higher annual costs, from $4,317 with comorbidity score of two, to $5,986 with score of three, to $13,326 with scores greater than seven. To use an adapted comorbidity index to predict total yearly costs, four conditions should be added to the index: hypertension, depression, and use of warfarin with a weight of one, skin ulcers/cellulitis, a weight of two.

CONCLUSION

The adapted comorbidity index can be used to predict resource utilization. Predictive models may help to identify targets for reducing high costs, by prospectively identifying those at high risk.

Chronic physical conditions and use of health services among persons with mental disorders: results from the Israel National Health Survey

OBJECTIVE

This study aimed to determine the association between common mental disorders and common chronic physical conditions and the contribution of mental disorders to the likelihood of being a higher user of health services.

METHOD

A representative sample extracted from the National Population Register of noninstitutionalized residents of Israel aged 21 or older were interviewed at their homes between May 2003 and April 2004. Mental disorders were assessed using a revised version of the World Mental Health Composite International Diagnostic Interview. Chronic physical conditions were measured via a checklist of chronic physical disorders.

RESULTS

Current mood or anxiety disorders were found to be associated with higher likelihood of chronic pain, cardiovascular conditions, diabetes and respiratory conditions beyond the sociodemographic characteristics and the risk factors (BMI or smoking). Current mood or anxiety disorders increased the likelihood of being a higher user of primary care beyond the effects of gender, population group, self-evaluation of general health, chronic pain or chronic conditions.

CONCLUSION

The results regarding the prevalence of mental-physical comorbidity emphasize the need for integration in the physical and mental care of people with mental disorders.

Depression case finding in primary care: a method for the mandates

The current mandates for depression screening in primary care create a dilemma for clinicians. How should screening be implemented in the face of limited evidence for sustainable strategies for effective depression monitoring and management in primary care. In this article we review the issues surrounding primary care depression screening, and develop the argument for a case-finding strategy that includes careful choice of a single instrument, focused identification of high-risk patients, and systematic monitoring of outcomes. We believe this is a sustainable method that primary care clinicians can implement to address the spirit of current depression screening mandates.

Insomnia symptoms and their correlates among the elderly in geriatric homes in Alexandria, Egypt

The prevalence of sleep complaints increases steadily with age. Studies investigating insomnia among elderly people living in geriatric homes, especially among Egyptians, are scarce. This study aimed to determine the prevalence of insomnia symptoms among the elderly living in geriatric homes in Alexandria and their correlates. A cross-sectional survey of a representative sample of elderly population of geriatric homes in Alexandria was implemented. A total of 177 persons aged 60 years or older participated. Difficulty initiating sleep was reported by 65% of the participants. Approximately half of them had difficulty maintaining their sleep (50.8%) or had non-restful sleep (51.4%). Short sleep was reported by 43.5% of the participants, while early morning awakening was reported by 28.2%. Advanced age (> or = 75 years) was significantly associated with increased risk for early morning awakening, non-restful sleep and short sleep. Women had approximately a fourfold risk of non-restful sleep as opposed to men. Short stay in geriatric homes (<1 year) was associated with 2.5-fold increased risk of non-restful sleep. Unmarried status was strongly and positively related to difficulty to maintain sleep and non-restful sleep. Depressive status was significantly associated with an increased risk of difficulty to maintain sleep and decreased risk of early morning awakening. Conclusively, the present study showed that insomnia symptoms are highly prevalent among the elderly living in geriatric homes. It also revealed that although age, gender, and other socio-demographic factors are correlated with insomnia symptoms, other factors are highly important. Health care providers should take these factors in consideration when dealing with elderly patients who complain of insomnia.

Hospitalization risks in the treatment of schizophrenia: comparison of antipsychotic medications

This study used administrative claims data to compare the relative risks for hospitalization among commercially insured patients with schizophrenia receiving atypical and typical antipsychotic drugs. Cox proportional hazard regression estimates, adjusted for differences in patient characteristics, suggested that among patients treated with the 4 atypical antipsychotic drugs, only olanzapine had a significantly higher risk for hospitalization than the typical antipsychotic drugs (hazard ratio [HR], 1.81; 95% confidence interval [CI], 1.20-2.75). In addition, risk for hospitalization with olanzapine was significantly higher than that for risperidone (HR, 1.34; 95% CI, 1.03-1.74) and numerically higher than that for quetiapine (HR, 1.40; 95% CI, 0.94-2.07). Overall, olanzapine was associated with a higher risk for hospitalization than the typical antipsychotic drugs and among the atypical antipsychotic drugs, risperidone and, potentially, quetiapine.

How Much Does Quality Mental Health Care Profit Employers?

OBJECTIVE

Employers provide most American mental health benefits and are increasingly cost conscious. However, commonplace anxiety and depressive disorders have enormous economic and workplace performance costs.

METHODS

We performed multiple literature searches on several areas of pertinent research (and on key articles) covering the past 5 years.

RESULTS

Substantial research exists about anxiety and depression costs, such as performance and productivity, absenteeism, presenteeism, disability, physical disability exacerbation, mental health treatment, increased medical care costs, exacerbating of physical illness, and studies of mental health care limitations and cost-offset. Research addressing the potential value of higher quality mental health care is limited.

CONCLUSIONS

Commonplace anxiety and depressive disorders are costly in the workplace. Employers and researchers remain largely unaware of the value of quality care and psychiatric skills. Effective solutions involve the increased use of psychiatric skills and appropriate treatment.

Mental Health Status and Use of General Medical Services for Persons With Human Immunodeficiency Virus

BACKGROUND

Serious medical illness often is accompanied by psychological distress. Individuals experiencing mental disorders or symptoms have higher rates of morbidity and mortality, worse social functioning, and use of general medical services.

OBJECTIVES

We sought to examine the association between mental health and use of general medical services for persons in care for HIV.

DESIGN AND PARTICIPANTS

We used longitudinal data from the HIV Cost and Services Utilization Study (HCSUS), a nationally representative sample of 2267 HIV+ adults receiving care and who completed all 3 interviews during an 18-month period.

MAIN OUTCOME MEASURES

Probability of use and general medical expenditures, by type of service.

RESULTS

HIV+ individuals who screened positive for depression or had 5 or more mental health symptoms at baseline spent 20% to 25% more for general medical services in the following 12 months than HIV+ adults without mental health symptoms, after adjusting for disease severity and patient characteristics. Higher spending was largely the result of greater use of inpatient and emergency services.

CONCLUSIONS

Psychological distress remains an independent predictor of general medical service use, although the magnitude of effect diminishes with better controls for physical well-being and previous service use. Identifying HIV patients with symptoms of affective or anxiety disorders may reduce overall treatment costs modestly.