Alcohol Consumption in Response to the COVID-19 Pandemic in the United States

OBJECTIVES

Excessive alcohol use is a serious and growing public health problem. Alcoholic beverage sales in the United States increased greatly immediately after the stay-at-home orders and relaxing of alcohol restrictions associated with the COVID-19 pandemic. However, it is not known to what degree alcohol consumption changed. This study assesses differences in alcohol drinking patterns before and after the enactment of stay-at-home orders.

METHODS

In May 2020, a cross-sectional online survey of 993 individuals using a probability-based panel designed to be representative of the US population aged 21 and older was used to assess alcohol drinking patterns before (February, 2020) and after (April, 2020) the enactment of stay-at-home orders among those who consumed alcohol in February, 2020 (n = 555). Reported differences in alcohol consumption were computed, and associations between differences in consumption patterns and individual characteristics were examined.

RESULTS

Compared to February, respondents reported consuming more drinks per day in April (+29%, P < 0.001), and a greater proportion reported exceeding recommended drinking limits (+20%, P < 0.001) and binge drinking (+21%, P = 0.001) in April. These differences were found for all sociodemographic subgroups assessed. February to April differences in the proportion exceeding drinking limits were larger for women than men (P = 0.026) and for Black, non-Hispanic people than White, non-Hispanic people (P = 0.028).

CONCLUSIONS

There is an association among the COVID-19 pandemic, the public health response to it, changes in alcohol policy, and alcohol consumption. Public health monitoring of alcohol consumption during the pandemic is warranted.

Implementation science on the margins: How do we demonstrate the value of implementation strategies?

Implementation science (IS) has developed as a field to assess effective ways to implement and disseminate evidence-based practices. Although the size and rigor of the field has improved, the economic evaluation of implementation strategies has lagged behind other areas of IS (Roberts, Healey, & Sevdalis, 2019). Beyond demonstrating the effectiveness of implementation strategies, there needs to be evidence that investments in these strategies are efficient or financially sustainable. In this editorial, we lay out conceptual challenges in applying economic evaluation to IS and the implications for conducting economic analyses in integrated primary care research. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Behavioral Health Coverage In The Individual Market Increased After ACA Parity Requirements

As of January 1, 2014, the Affordable Care Act designated mental health and substance use services as an essential health benefit in Marketplace plans and extended parity protections to the individual and small-group markets. We analyzed documents for seventy-eight individual and small-group plans in 2014 (after parity provisions took effect) and sixty comparison plans in 2013 (the year before parity provisions took effect) to understand the degree to which coverage for mental health and substance use care improved relative to medical/surgical benefits. The results suggest that plan issuers did what the provisions required them to do. Although in 2013 a lower proportion of plans covered mental health or substance use care, compared to medical/surgical care, in 2014 the proportions were the same. If essential health benefit requirements were to be removed and mental health and substance use coverage becomes similar to that in 2013, as many as 20 percent of the plans in our sample would not cover these conditions. To determine whether increases in behavioral health coverage will result in improved access to behavioral health services requires complementary data on the size of provider networks and use of services.

Cost and cost-effectiveness of computerized vs. in-person motivational interventions in the criminal justice system

INTRODUCTION

Although substance use is common among probationers in the United States, treatment initiation remains an ongoing problem. Among the explanations for low treatment initiation are that probationers are insufficiently motivated to seek treatment, and that probation staff have insufficient training and resources to use evidence-based strategies such as motivational interviewing. A web-based intervention based on motivational enhancement principles may address some of the challenges of initiating treatment but has not been tested to date in probation settings. The current study evaluated the cost-effectiveness of a computerized intervention, Motivational Assessment Program to Initiate Treatment (MAPIT), relative to face-to-face Motivational Interviewing (MI) and supervision as usual (SAU), delivered at the outset of probation.

METHODS

The intervention took place in probation departments in two U.S. cities. The baseline sample comprised 316 participants (MAPIT = 104, MI = 103, and SAU = 109), 90% (n = 285) of whom completed the 6-month follow-up. Costs were estimated from study records and time logs kept by interventionists. The effectiveness outcome was self-reported initiation into any treatment (formal or informal) within 2 and 6 months of the baseline interview. The cost-effectiveness analysis involved assessing dominance and computing incremental cost-effectiveness ratios and cost-effectiveness acceptability curves. Implementation costs were used in the base case of the cost-effectiveness analysis, which excludes both a hypothetical license fee to recoup development costs and startup costs. An intent-to-treat approach was taken.

RESULTS

MAPIT cost $79.37 per participant, which was ~$55 lower than the MI cost of $134.27 per participant. Appointment reminders comprised a large proportion of the cost of the MAPIT and MI intervention arms. In the base case, relative to SAU, MAPIT cost $6.70 per percentage point increase in the probability of initiating treatment. If a decision-maker is willing to pay $15 or more to improve the probability of initiating treatment by 1%, estimates suggest she can be 70% confident that MAPIT is good value relative to SAU at the 2-month follow-up and 90% confident that MAPIT is good value at the 6-month follow-up.

CONCLUSIONS

Web-based MAPIT may be good value compared to in-person delivered alternatives. This conclusion is qualified because the results are not robust to narrowing the outcome to initiating formal treatment only. Further work should explore ways to improve access to efficacious treatment in probation settings.

A time and motion study of Screening, Brief Intervention, and Referral to Treatment implementation in health-care settings

AIMS

Screening and brief intervention for harmful substance use in medical settings is being promoted heavily in the United States. To justify service provision fiscally, the field needs accurate estimates of the number and type of staff required to provide services, and thus the time taken to perform activities used to deliver services. This study analyzed the time spent in activities for the component services of the substance misuse Screening, Brief Intervention and Referral to Treatment (SBIRT) program implemented in emergency departments, in-patient units and ambulatory clinics.

DESIGN

Observers timed activities according to 18 distinct codes among SBIRT practitioners.

SETTING

Twenty-six US sites within four grantees.

PARTICIPANTS

Five hundred and one practitioner-patient interactions; 63 SBIRT practitioners.

MEASUREMENTS

Timing of practitioner activities.

INTERVENTIONS

Delivery of component services of SBIRT.

FINDINGS

The mean (standard error) time to deliver services was 1:19 (0:06) for a pre-screen (n = 210), 4:28 (0:24) for a screen (n = 97) and 6:51 (0:38) for a brief intervention (n = 66). Estimates of service duration varied by setting. Overall, practitioners spent 40% of their time supporting SBIRT delivery to patients and 13% of their time delivering services.

CONCLUSIONS

In the United States, support activities (e.g. reviewing the patient's chart, locating the patient, writing case-notes) for substance abuse Screening, Brief Intervention and Referral to Treatment require more staff time than delivery of services. Support time for screens and brief interventions in the emergency department/trauma setting was high compared with the out-patient setting.

Sustaining SBIRT in the wild: simulating revenues and costs for Screening, Brief Intervention and Referral to Treatment programs

AIMS

To examine the conditions under which Screening, Brief Intervention and Referral to Treatment (SBIRT) programs can be sustained by health insurance payments.

DESIGN

A mathematical model was used to estimate the number of patients needed for revenues to exceed costs.

SETTING

Three medical settings in the United States were examined: in-patient, out-patient and emergency department. Components of SBIRT were delivered by combinations of health-care practitioners (generalists) and behavioral health specialists.

PARTICIPANTS

Practitioners in seven SBIRT programs who received grants from the US Substance Abuse and Mental Health Services Administration (SAMHSA).

MEASUREMENTS

Program costs and revenues were measured using data from grantees. Patient flows were measured from administrative data and adjusted with prevalence and screening estimates from the literature.

FINDINGS

SBIRT can be sustained through health insurance reimbursement in out-patient and emergency department settings in most staffing mixes. To sustain SBIRT in in-patient programs, a patient flow larger than the national average may be needed; if that flow is achieved, the range of screens required to maintain a surplus is narrow. Sensitivity analyses suggest that the results are very sensitive to changes in the proportion of insured patients.

CONCLUSIONS

Screening, Brief Intervention and Referral to Treatment programs in the United States can be sustained by health insurance payments under a variety of staffing models. Screening, Brief Intervention and Referral to Treatment programs can be sustained only in an in-patient setting with above-average patient flow (more than 2500 screens). Screening, Brief Intervention and Referral to Treatment programs in out-patient and emergency department settings can be sustained with below-average patient flows (fewer than 125 000 out-patient visits and fewer than 27 000 emergency department visits).

Behavioral Health Outcomes Among Adults: Associations With Individual and Community-Level Economic Conditions

OBJECTIVE

This study examined the relationship between state and local economic conditions and serious psychological distress, substance use disorders, and mental health service utilization among adults in the United States.

METHODS

Using data from 21,100 adults who responded to the 2008-2010 National Survey on Drug Use and Health, a nationally representative survey of the U.S. civilian noninstitutionalized population living in households, the study used multivariate methods to examine associations between selected macroeconomic conditions and behavioral health outcomes.

RESULTS

Living in states in the top three quartiles for serious mortgage delinquency rate and in counties in the top three quartiles for unemployment rate was associated with a lower likelihood of using mental health services among individuals experiencing serious psychological distress (adjusted relative risk [ARR]=.54, .52, and .73, and ARR=.58, .62, and .71, respectively, versus quartile 1). Individual-level characteristics were the primary predictors associated with higher odds of having substance use disorders or experiencing serious psychological distress, but macroeconomic variables were not statistically significant predictors of these outcomes.

CONCLUSIONS

Both individual-level socioeconomic characteristics and population-level macroeconomic conditions were associated with behavioral health outcomes. Prevalence of serious psychological distress and substance use disorders and use of mental health services varied by economic measure. The findings suggest that access to and availability of mental health services for individuals experiencing serious psychological distress may be more challenging for those who do not have health insurance or who reside in regions with higher rates of mortgage foreclosures or higher rates of unemployment.

Cost of Screening, Brief Intervention, and Referral to Treatment in Health Care Settings

AIMS

This study analyzed service unit and annual costs of substance abuse screening, brief intervention, and referral to treatment (SBIRT) programs implemented in emergency department (ED), inpatient, and outpatient medical settings in three U.S. states and one tribal organization.

METHODS

Unit costs and annual costs were estimated from the perspective of service providers. Data for unit costs came from 26 performance sites, and data for annual costs came from 10 programs. A bottom-up approach was used to derive unit costs and included labor, space, and materials used in each SBIRT activity. Activities included direct SBIRT services and activities that support direct service delivery. Labor time spent in each activity was collected by trained observers using a time-and-motion approach. A top-down approach used cost questionnaires completed by program administrators to calculate annual costs and included labor, space, contracted services, overhead, training, travel, equipment, and supplies and materials. Costs were estimated in 2012 U.S. dollars.

RESULTS

Average unit costs for prescreening, screening, brief intervention, brief treatment, and referral to treatment were $0.61, $6.59, $10.48, $22.63, and $12.06 in ED; $0.86, $6.33, $9.07, $27.61, and $8.03 in inpatient; and $0.84, $3.98, $7.81, $27.94, and $9.23 in outpatient settings, respectively; over half of the costs were attributable to support activities. Across all settings, the average cost to provide SBIRT per positive screen, for 1year, was about $400.

CONCLUSIONS

Support activities comprise a large proportion of costs. Health administrators can use the results to budget and compare how much sites are reimbursed for SBIRT to how much services actually cost.

National estimates of behavioral health conditions and their treatment among adults newly insured under the ACA

OBJECTIVE

Approximately 25 million individuals are projected to gain insurance as a result of the Affordable Care Act (ACA). This study estimated the prevalence of behavioral health conditions and their treatment among individuals likely to gain coverage.

METHODS

Pooled 2008-2011 National Survey on Drug Use and Health data for adults (ages 18-64) were used. Estimates were created for all adults, current Medicaid beneficiaries, and uninsured adults with incomes that might make them eligible for the Medicaid expansion or tax credits for use in the health insurance marketplace.

RESULTS

Individuals who may gain insurance under the ACA had lower rates of serious mental illnesses (5.4%, Medicaid expansion; 4.7%, marketplace) compared with current Medicaid beneficiaries (9.6%). They had higher rates of substance use disorders (13.6%, Medicaid expansion; 14.3%, marketplace) compared with Medicaid recipients (11.9%).

CONCLUSIONS

There is significant need for behavioral health treatment among individuals who may gain insurance under the ACA.

The cost of implementing a jail diversion program for people with mental illness in San Antonio, Texas

Jail diversion programs for people with mental illness are designed to redirect offenders with mental illness into community treatment. Although much has been published about program models and their successes, little detail is available to policy makers and community stakeholders on the resources required to start and implement a jail diversion program and which agencies bear how much of the burden. The current study used data on a model jail diversion program in San Antonio, Texas, to address this research gap. Data on staff costs, client contacts, planning, and implementation were collected for three types of diversion: pre-booking police, post-booking bond, and post-booking docket. An activity-based costing algorithm was developed to which parameter values were applied. The start-up cost for the program was $556,638.69. Pre-booking diversion cost $370 per person; 90% of costs were incurred by community mental health agencies for short-term monitoring and screening (>80% of activities). Post-booking bond and docket diversion cost $238 and $205 per person, respectively; the majority of costs were incurred by the courts for court decisions. Developing a multiple-intercept jail diversion program requires significant up-front investment. The share of costs varies greatly depending on the type of diversion.

A prospective study of the associations among housing status and costs of services in a homeless population

OBJECTIVE

The complex needs of homeless populations result in use of a wide range of services and high costs for housing programs and psychiatric and general medical care. Allocation of resources often is not congruent with assessed needs. A series of cost-congruence hypotheses was developed to test assumptions that needs are associated with resources provided for appropriate services in homeless populations.

METHODS

Individuals (N=255) who were homeless were followed for two years and were categorized by housing status over time (consistently housed, housed late, lost housing, or consistently homeless). Detailed information about the individuals was obtained at baseline, and follow-up data were collected one and two years later. Extensive data about the costs of services provided by type (medical, psychiatric, substance abuse, and homeless maintenance and amelioration) were derived from 23 agencies, and service use information was collected from the agencies and by self-report. Multiple regression models were used to test the hypotheses.

RESULTS

Medical, psychiatric, and homeless maintenance costs varied by housing status. Serious mental illness predicted costs for psychiatric services, as expected, but also costs for substance abuse services and acute behavioral health care and total costs. Alcohol use disorders predicted substance abuse service costs.

CONCLUSIONS

This study followed a homeless cohort prospectively and provided estimates of costs of service use derived from a large number of agencies. This research increases the understanding of patterns of service use in a homeless population and informs the provision of services appropriate to the complex needs of this difficult-to-serve population.

Program- and service-level costs of seven screening, brief intervention, and referral to treatment programs

This paper examines the costs of delivering screening, brief intervention, and referral to treatment (SBIRT) services within the first seven demonstration programs funded by the US Substance Abuse and Mental Health Services Administration. Service-level costs were estimated and compared across implementation model (contracted specialist, inhouse specialist, inhouse generalist) and service delivery setting (emergency department, hospital inpatient, outpatient). Program-level costs were estimated and compared across grantee recipient programs. Service-level data were collected through timed observations of SBIRT service delivery. Program-level data were collected during key informant interviews using structured cost interview guides. At the service level, support activities that occur before or after engaging the patient comprise a considerable portion of the cost of delivering SBIRT services, especially short duration services. At the program level, average costs decreased as more patients were screened. Comparing across program and service levels, the average annual operating costs calculated at the program level often exceeded the cost of actual service delivery. Provider time spent in support of service provision may comprise a large share of the costs in some cases because of potentially substantial fixed and quasifixed costs associated with program operation. The cost structure of screening, brief intervention, and referral to treatment is complex and discontinuous of patient flow, causing annual operating costs to exceed the costs of actual service provision for some settings and implementation models.

Deriving costs of service use among an urban homeless population

The purpose of this study was to describe a novel approach to calculating service use costs across multiple domains of service for homeless populations. A randomly-selected sample of homeless persons was interviewed in St. Louis, MO and followed for 2 years. Service- and cost-related data were collected from homeless individuals and from the agencies serving them. Detailed interviews of study participants and of agency personnel in specific domains of service (medical, psychiatric, substance abuse, homeless maintenance, and homeless amelioration services) were conducted using a standardized approach. Service utilization data were obtained from agency records. Standardized service-related costs were derived and aggregated across multiple domains from agency-reported data. Housing status was not found to be significantly associated with costs. Although labor intensive, this approach to cost estimation allows costs to be accurately compared across domains. These methods could potentially be applied to other populations.

The impact on taxpayer costs of a jail diversion program for people with serious mental illness

Mental illness is prevalent among those incarcerated. Jail diversion is one means by which people with mental illness are treated in the community - often with some criminal justice system oversight - instead of being incarcerated. Jail diversion may lead to immediate reductions in taxpayer costs because the person is no longer significantly engaged with the criminal justice system. It may also lead to longer term reductions in costs because effective treatment may ameliorate symptoms, reduce the number of future offenses, and thus subsequent arrests and incarceration. This study estimates the impact on taxpayer costs of a model jail diversion program for people with serious mental illness. Administrative data on criminal justice and treatment events were combined with primary and secondary data on the costs of each event. Propensity score methods and a quasi-experimental design were used to compare treatment and criminal justice costs for a group of people who were diverted to a group of people who were not diverted. Diversion was associated with approximately $2800 lower taxpayer costs per person 2 years after the point of diversion (p<.05). Reductions in criminal justice costs drove this result. Jail diversion for people with mental illness may thus be justified fiscally.

Cost-effectiveness analysis of motivational interviewing with feedback to reduce drinking among a sample of college students

OBJECTIVE

This study evaluated the costs and cost-effectiveness of combining motivational interviewing with feedback to address heavy drinking among university freshmen.

METHOD

Microcosting methods were used in a prospective cost and cost-effectiveness study of a randomized trial of assessment only (AO), motivational interviewing (MI), feedback only (FB), and motivational interviewing with feedback (MIFB) at a large public university in the southeastern United States. Students were recruited and screened into the study during freshman classes based on recent heavy drinking. A total of 727 students (60% female) were randomized, and 656 had sufficient data at 3-months' follow-up to be included in the cost-effectiveness analysis. Effectiveness outcomes were changes in average drinks per drinking occasion and number of heavy drinking occasions.

RESULTS

Mean intervention costs per student were $16.51 for MI, $17.33 for FB, and $36.03 for MIFB. Cost-effectiveness analysis showed two cost-effective interventions for both outcomes: AO ($0 per student) and MIFB ($36 per student).

CONCLUSIONS

This is the first prospective cost-effectiveness study to our knowledge to examine MI for heavy drinking among students in a university setting. Despite being the most expensive intervention, MIFB was the most effective intervention and may be a cost-effective intervention, depending on a university's willingness to pay for changes in the considered outcomes.

Benefits and costs of substance abuse treatment programs for state prison inmates: results from a lifetime simulation model

Reflecting drug use patterns and criminal justice policies throughout the 1990s and 2000s, prisons hold a disproportionate number of society's drug abusers. Approximately 50% of state prisoners meet the criteria for a diagnosis of drug abuse or dependence, but only 10% receive medically based drug treatment. Because of the link between substance abuse and crime, treating substance abusing and dependent state prisoners while incarcerated has the potential to yield substantial economic benefits. In this paper, we simulate the lifetime costs and benefits of improving prison-based substance abuse treatment and post-release aftercare for a cohort of state prisoners. Our model captures the dynamics of substance abuse as a chronic disease; estimates the benefits of substance abuse treatment over individuals' lifetimes; and tracks the costs of crime and criminal justice costs related to policing, adjudication, and incarceration. We estimate net societal benefits and cost savings to the criminal justice system of the current treatment system and five policy scenarios. We find that four of the five policy scenarios provide positive net societal benefits and cost savings to the criminal justice system relative to the current treatment system. Our study demonstrates the societal gains to improving the drug treatment system for state prisoners.

Medication costs to private insurers of diversion of medications for attention-deficit hyperactivity disorder

BACKGROUND

The diversion of prescription stimulants for misuse, particularly those used in the treatment of attention-deficit hyperactivity disorder (ADHD), is potentially a significant problem for public health and for healthcare funding and delivery. Most prior research on the diversion of prescription stimulants for misuse, particularly those used in the treatment of ADHD, has focused on the 'end users' of diverted medications rather than the suppliers. Furthermore, little is known about the direct costs of diversion for third-party insurance payers in the US.

OBJECTIVES

The objectives of this study were to estimate the prevalence in the US of people whose private insurance paid costs for ADHD prescriptions that they gave or sold to another person (diversion), and to estimate medication costs of diversion to private insurers.

METHODS

Estimates are from a cross-sectional survey of respondents from two Internet survey panels targeting individuals aged 18-49 years in the civilian, noninstitutionalized US population, principally for those who filled prescriptions for ADHD medications in the past 30 days that were covered by private health insurance. Analysis weights were post-stratified to control totals from the Current Population Survey and National Health Interview Survey. Weighted prevalence rates and standard errors for diversion are reported, as are the costs of diverted pills using drug prices reported in the 2008 Thomson Reuters RED BOOK™. Sensitivity analyses were conducted that varied the cost assumptions for medications.

RESULTS

Among individuals aged 18-49 years whose private insurance paid some costs for ADHD medications in the past 30 days, 16.6% diverted medications from these prescriptions. Men aged 18-49 years for whom private insurance paid some costs of ADHD drugs in the past 30 days were more than twice as likely as their female counterparts to divert medications from these prescriptions (22.5% vs 9.1%; p = 0.03). After a pro-rated co-payment share was subtracted, the estimated value of diverted medications in a 30-day period was $US8.0 million. Lower- and upper-bound estimates were $US6.9 million to $US17 million, for a range of $US83 million to $US204 million annually. Overall, diversion accounted for about 3.6% of the total costs that private insurers paid for ADHD medications (range: 3.5-4.5%). The percentages varied by medication category, although relative differences were sensitive to inclusion of a pro-rated co-payment. A higher percentage of the costs of extended-release (XR) medications was lost to diversion compared with that for immediate-release (IR) medications.

CONCLUSIONS

Costs of ADHD medications paid for by private insurers that were lost to diversion were small relative to the total estimated medication costs and relative to total estimated healthcare costs for treating ADHD. Nevertheless, there may be significant cost savings for insurers if diversion can be reduced, particularly for XR medications. These findings represent a first step to informing policies to reduce diversion both in the interest of public health and for direct and indirect cost savings to insurers.

Conducting economic evaluations of screening and brief intervention for hazardous drinking: Methods and evidence to date for informing policy

ISSUES

Many policy review articles have concluded that alcohol screening and brief intervention (SBI) is both cost-effective and cost-beneficial. Yet a recent cost-effectiveness review for the United Kingdom's National Institute for Health and Clinical Excellence suggests that these conclusions may be premature.

APPROACH

This article offers a brief synopsis of the various types of economic analyses that may be applied to SBI, including cost analysis, cost-effectiveness analysis, cost-utility analysis, cost-benefit analysis and other types of economic evaluation. A brief overview of methodological issues is provided, and examples from the SBI evaluation literature are provided.

KEY FINDINGS, IMPLICATIONS AND CONCLUSIONS

The current evidence base is insufficient to draw firm conclusions about the cost, cost-effectiveness or cost-benefit of SBI and about the impact of SBI on health-care utilisation.[Cowell AJ, Bray JW, Mills MJ, Hinde JM. Conducting economic evaluations of screening and brief intervention for hazardous drinking: Methods and evidence to date for informing policy.

Costs of using motivational interviewing for problem drinking in the U.S. Air Force

Despite the popularity of motivational interviewing (MI) to address heavy drinking, limited evidence exists on the costs of using MI to address heavy drinking. This study examines the costs of using MI to address heavy drinking at four U.S. Air Force (USAF) bases. Clients were referred to and assessed at a base program to address their drinking as a result of an incident; those who were not alcohol dependent were invited to participate in the study. Participants consented and were randomly assigned to one of three intervention arms: individual MI (IMI), group MI (GMI), and Substance Abuse Awareness Seminar (SAAS). Three cost perspectives were taken: USAF, client, and the two combined. Data were collected from bases and public sources. The start-up cost per base ranged from $1340 to $2400 per provider staff member. Average implementation costs across bases were highest for the SAAS intervention ($148 per client).

Course of major depressive disorder and labor market outcome disruption

BACKGROUND

Major depressive disorder (MDD) has been found to be negatively associated with labor market outcomes. However, MDD has many different courses that are chronic or persistent, relapsing and remitting, or limited to a single lifetime episode. Such heterogeneity has been ignored in most past analyses.

AIMS OF THE STUDY

We examine the impact of heterogeneity in course of MDD on labor market outcomes.

METHODS

Wave I (2001-2002) respondents of the National Epidemiological Survey on Alcohol and Related Conditions - a nationally representative panel survey - were interviewed on average 3 years later (2004-2005). We categorized changes in MDD before and after wave I and before wave II into six courses: incident, recent remission, persistent remission, relapse, persistent depression, and no history of MDD. Odds ratios (ORs) and marginal effects of MDD transitions in multivariable multinomial regressions of labor market outcomes (being out of the labor force, being unemployed, working part-time, and working full-time -- the reference outcome) are reported.

RESULTS

Men and women who exhibited persistent remission (2 to 3 years) were equally likely to be in the labor force, employed, and working full-time, compared to those with no history of MDD (reference group). For men, recently remitted MDD (less than 1 year), compared to the reference group, increased the likelihood of being unemployed (3.2% higher probability of being unemployed conditional on being in the labor force; OR = 1.97, 95% confidence interval [CI] = 1.13--3.44) and working part-time (5.8% higher probability of working part-time conditional on being employed; OR = 1.75, 95% CI = 1.10-2.80). For women, no statistically significant effect for recent remission was found. The negative effects of incident onset, relapse, and persistence of MDD were found on some labor market outcomes for men and, to a lesser extent, for women.

DISCUSSION

Clinical treatment for depression should be coordinated and/or integrated with work-related interventions that help individuals who are recovering from depression to maintain their jobs. Such coordination will add to the value of clinical treatment for depression.

IMPLICATIONS FOR HEALTH POLICIES

The impact of MDD on labor market outcomes varies by course of illness. Past studies may have underestimated lost earnings due to mental illness because they did not distinguish between recent and persistent remission and thus did not account for lost earnings due to recent remission.

IMPLICATIONS FOR FURTHER RESEARCH

Further research is needed to understand why there are differential impacts for men and women and to make causal inferences on the relationships between MDD and labor market outcomes.

Psychiatric disorders and the labor market: an analysis by disorder profiles

BACKGROUND

A key societal cost of mental illness is its impact on the labor market. In examining the relationship between psychiatric disorders and the labor market, the literature to date either examines psychiatric disorders in broad classes or focuses on the impact of specific conditions.

AIMS OF THE STUDY

The aim is to examine the relationships among meaningful profiles of concurrent past year disorders and labor market outcomes by gender.

METHODS

Data are from the National Epidemiologic Survey on Alcohol and Related Conditions for 2001/2002 (NESARC), a representative sample of the noninstitutionalized population aged 18 or older residing in the United States. The analysis sample contains 18,429 women and 16,426 men (unweighted). We examined the relationship between profiles of psychiatric disorders and three labor market outcomes: labor force participation; employment, conditional on labor force participation; and working full-time conditional on being employed. Because no attempt was made to control for potential endogeneity between the labor market outcomes and the psychiatric profiles, we are unable to establish the causal direction of the associations estimated.

RESULTS

First, anxiety disorders among women appear to be associated with labor market outcomes (e.g., anxiety profile in employment outcome: OR=0.76, p<.05). Second, for employment among women large effects were seen for mood disorder and mood and anxiety; in contrast for men, these disorder profiles had significant associations with working full-time rather than employment. Third, for women, of the three labor market outcomes, employment status is particularly sensitive to the profiles of disorders. For men, no such pattern was found for any single labor market outcome.

DISCUSSION

Concurrent psychiatric disorder profiles affect men and women differently in the labor market. The greatest differences are in (i) the relationship between labor market outcomes and profiles exhibiting anxiety disorders, and (ii) which labor market outcomes are influenced. The main methodological limitation is that the approach does not attempt to assert a direction of causation between mental health conditions and the labor market outcomes. Unobserved heterogeneity and endogeneity are both possible and likely to some degree. Other limitations pertain to the data, which are cross-sectional and exclude some relatively rare disorders (e.g., schizophrenia).

IMPLICATIONS FOR HEALTH CARE PROVISION AND USE

The results may have significant implications for access to appropriate treatment, which may vary greatly by psychiatric disorder profile and by gender.

IMPLICATIONS FOR HEALTH POLICIES

In the United States, private third-party coverage for treatment is obtained either directly through working full-time at a medium to large firm or through a spouse being employed. The findings thus suggest that mental health policy may need to account for labor market policy.

IMPLICATIONS FOR FURTHER RESEARCH

Additional research is needed to disentangle the findings presented. For example, it is important to separate the influence of substance use disorders from mood disorder and uncover the pathways by which the different conditions in substance use disorders may influence the job market.

Assessing the impact of the national 'truth' antismoking campaign on beliefs, attitudes, and intent to smoke by race/ethnicity

OBJECTIVE

To examine racial/ethnic differences in the association between exposure to the 'truth' antismoking campaign and youth's beliefs and attitudes about cigarette companies and their intent to smoke.

DESIGN

The data are for 31,758 youth aged 12-17 from seven waves of the Legacy Media Tracking Survey (LMTS), conducted in the USA between December 1999 and July 2003. LMTS was designed to include sufficient proportions of African Americans (n=4631), Hispanics (n=6311), and Asians (n=2469) to assess tobacco countermarketing campaign associations in individual racial/ethnic groups. Separate belief and attitude indices were created. An indicator for the respondent not intending to smoke during the next year was created for non-smokers only, and models were estimated separately by ever-/never-smoking status.

RESULTS

Exposure to the truth campaign was positively associated with increased antitobacco beliefs and attitudes among youth overall. When analyzed by race/ethnicity, this association was statistically significant for white and African American youth. An examination of the individual belief and attitude items that composed the measurement indices suggests that different messages appealed to youth based on their race/ethnicity. Among never smokers, those exposed to the truth campaign had significantly higher odds of not intending to smoke. When analyzed separately by race/ethnicity, the estimates for African American youth were statistically significant and the estimates for white and Hispanic youth approached significance. Among ever smokers and across all racial/ethnic groups, those exposed to the truth campaign had significantly higher odds of not intending to smoke, and every racial/ethnic group had an odds ratio greater than one that was also statistically significant.

CONCLUSIONS

The findings suggest that the individual items comprising the indices may be less meaningful for some non-white groups of youth. Analyses of intention to smoke indicated that, among those who had never smoked, there were greater odds of not intending to smoke when examining all youth together without stratifying by race/ethnicity; however, a statistically significant effect was found only for the African American group when examining the effect by race/ethnicity. Among those who had ever smoked, a statistically significant effect was found for most racial/ethnic groups. This is a rich area for further research and is potentially critical to the success of future efforts to reach youth through behavior change messages.

The effect of alternative staff time data collection methods on drug treatment service cost estimates

Although a limited number of service cost estimates exist, no study has evaluated how differences in the method used to collect the staff time allocation across treatment services contribute to differences in service cost estimates. Three alternative data collection methods for estimating service-level costs in methadone treatment programs were evaluated: key informants, staff surveys, and staff diaries. We analyzed data from 25 methadone clinics across the United States. Results indicate that for the three primary services offered at methadone clinics-individual counseling, group counseling, and methadone dosing-no statistically significant differences exist in the mean estimates of costs per session across programs. Of the other five services analyzed, we found no statistically significant differences in two of the mean costs per session and a small but statistically significant difference in another service. We found large and statistically significant differences in mean costs for two services, initial patient assessment and initial medical services. Although there is no gold standard available to judge which method is the best to use, we concluded that the key informant method yields more reliable cost estimates compared with the staff methods and is less burdensome to both the treatment programs and to researchers. Our findings suggest that the key informant method is the preferred method for costing substance abuse treatment services.

Examining variation in treatment costs: a cost function for outpatient methadone treatment programs

OBJECTIVES

To estimate a hybrid cost function of the relationship between total annual cost for outpatient methadone treatment and output (annual patient days and selected services), input prices (wages and building space costs), and selected program and patient case-mix characteristics.

DATA SOURCES

Data are from a multistate study of 159 methadone treatment programs that participated in the Center for Substance Abuse Treatment's Evaluation of the Methadone/LAAM Treatment Program Accreditation Project between 1998 and 2000.

STUDY DESIGN

Using least squares regression for weighted data, we estimate the relationship between total annual costs and selected output measures, wages, building space costs, and selected program and patient case-mix characteristics.

PRINCIPAL FINDINGS

Findings indicate that total annual cost is positively associated with program's annual patient days, with a 10 percent increase in patient days associated with an 8.2 percent increase in total cost. Total annual cost also increases with counselor wages (p<.01), but no significant association is found for nurse wages or monthly building costs. Surprisingly, program characteristics and patient case mix variables do not appear to explain variations in methadone treatment costs. Similar results are found for a model with services as outputs.

CONCLUSIONS

This study provides important new insights into the determinants of methadone treatment costs. Our findings concur with economic theory in that total annual cost is positively related to counselor wages. However, among our factor inputs, counselor wages are the only significant driver of these costs. Furthermore, our findings suggest that methadone programs may realize economies of scale; however, other important factors, such as patient access, should be considered.

Formal Treatment, Self-Help, or No Treatment for Alcohol-Use Disorders? Evidence from the National Household Survey on Drug Abuse

OBJECTIVE

The purpose of this study was to examine further alcohol treatment choice by using data from a nationally representative sample of adults with alcohol-use disorders to test which of three models-sequential, multinomial, or nested best fit the data. The goals were to provide evidence about how this choice was made and to provide improved coefficient estimates, as well as to inform future analyses of treatment choice.

METHOD

Data from the 2000 National Household Survey of Drug Abuse include respondents ages 18-64 reporting symptoms consistent with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses of alcohol abuse or dependence. A nested multinomial framework is used to determine the preferred model and to estimate the effect of respondents' characteristics on the decisions to receive help and what kind of help to receive.

RESULTS

A sequential model, in which the choice of whether to receive help is unaffected by the level of satisfaction afforded by the alternatives, best fit the data. Older respondents had higher odds of both receiving help and choosing self-help, and those with a DSM-IV diagnosis of abuse had lower odds of receiving help but higher odds of entering self-help.

CONCLUSIONS

The decision to receive help for alcohol problems appears unaffected by the perceived differences between these two broad categories of alternatives: self-help or formal treatment. This result may indicate the need to provide more information on the full range of treatment options to those for whom self-help may not be sufficient.

The relationship between education and health behavior: some empirical evidence

Although researchers agree that more educated people typically engage in healthier behaviors, they have not uncovered the reason why. This paper considers several explanations, including future opportunity costs. Future opportunity costs represent any utility-improving future outcome that is affected by currently engaging in health-related behavior. This paper also examines whether there are degree effects in the health behaviors of binge drinking and smoking. Results suggest that future opportunity costs may affect smoking, although other interpretations cannot be ruled out. The results also find degree effects with regard to binge drinking.

Effects of diversion on adults with co-occurring mental illness and substance use: outcomes from a national multi-site study

This quasi-experimental non-equivalent comparison group study examines outcomes for participants in eight programs conducting criminal justice diversion for people with co-occurring serious mental illness and substance use disorders compared with jail detainees eligible for diversion, but who were processed through standard criminal justice methods without diversion. Nearly 2000 participants were interviewed at baseline, and 1500 at 3 month and 1300 at 12 month follow-up to baseline. In these interviews, outcome measures of re-arrest, mental health functioning, substance abuse, quality of life, and service utilization were obtained. Those diverted were more likely to have received mental health counseling, mental health medication, and mental health hospitalization than those not enrolled in a diversion program, but were equally likely to have received substance abuse counseling. Overall, the differences in proportions receiving services between the two groups were small, even when these differences were statistically significant. The effect associated with diversion differed somewhat across the individual sites. However, overall cross-site pooled analyses revealed no outcome differences between groups on measures of mental health symptoms, substance use, criminal justice recidivism, or quality of life. Although the immediate benefit of diversion as an access mechanism to community treatment is indicated in pooled cross-site results, such access was driven by more coercive (pre-booking and court) models and results suggest that effecting substantially greater access to services or services use did not occur. The findings also suggest that mental health, substance abuse, and criminal justice outcomes remain dependent on the treatment intervention received, perhaps moderated by type of diversion intervention, rather than on a generic and initial diversion event.

Deriving service costs for a clubhouse psychosocial rehabilitation program

This article (a) discusses "function cost," a concept to estimate costs where consumers are involved both in delivery and receipt of services; (b) develops a methodology for costing service units for psychosocial rehabilitation clubhouses; and (c) presents a case study of a clubhouse program. Using function cost to estimate the value of member time leads to costs being on average about 10% higher than when using opportunity cost. Because the case-study clubhouse is typical in key dimensions, the methods used here appear generalizable to other programs and should have utility for other rehabilitation-based services for individuals with mental illness.