Adequacy of treatment for serious mental illness in the United States

Clinical differences among patients treated for mental health problems in general medical and specialty mental health settings in the National Comorbidity Survey Replication

OBJECTIVE

General medical (GM) treatments for mental health disorders are less likely than specialty mental health (SMH) treatments to be adequate. We explored whether differences in the clinical characteristics of patients treated in each sector (GM-only or SMH-only) or in both sectors (GM+SMH) may help to explain this finding.

METHOD

We analyzed data from the National Comorbidity Survey Replication (NCS-R), a nationally representative household survey of 5692 English-speaking adult household residents that was carried out in 2001-2003. The NCS-R used a fully structured diagnostic interview to assess DSM-IV disorders, including mood, anxiety, impulse control and substance use disorders. We classified disorders in terms of a three-category severity gradient (serious, moderate and mild) based on information about clinically significant distress and role impairment. We collected self-report data on chronic physical conditions, sociodemographics and type of treatment received for emotional and substance use problems in the 12 months before the interview.

RESULTS

Patients who received GM+SMH treatment had more severe mental disorders and a higher prevalence of mood and anxiety disorders than patients who received treatment in only one of the two sectors. Patients seen in the GM-only and GM+SMH sectors had more chronic physical conditions than patients seen in the SMH-only sector.

CONCLUSION

Patient characteristics may partially explain the lower intensity and adequacy of GM treatment.

Co-location of health care for adults with serious mental illness and HIV infection

This study describes persons with serious mental illness and comorbid HIV infection and examines the effect of co-location of mental health and HIV care on satisfaction, service utilization, and appropriateness of care. One hundred and eighteen subjects completed interviews and gave blood samples; medical records were abstracted. Most reported few barriers to care and satisfaction with mental health and HIV treatment. Co-location of mental health and HIV care did not influence satisfaction with care, utilization of services, or appropriateness of care. This report challenges the notion that persons with serious mental illnesses receive inadequate health care and that they have minimal capacity for illness management. These subjects may be benefiting from increased funding for, and attention to, persons with HIV infection.

Quality of care for depressed elders in post-acute care: variations in needs met through services

This paper addresses quality of post-acute care for older adults going home after hospitalization for depression. Quality was conceptualized and assessed in terms of services received for four domains of need: psychiatric, medical, functional, and psychosocial. At discharge, needs for care was assessed using medical records, standardized instruments, and patient interviews; quality of care was assessed by whether or not needs were met by services through the first 6 weeks of post-acute care. Quality of care varied across type of need: psychiatric needs were most likely, and psychosocial needs were least likely, to be met. Urban elders received better psychiatric care than did rural elders. Elders in worse physical health received better medical and psychosocial care, but poorer psychiatric care. Elders with psychoses and living with others had better care for functional dependencies. The competing demands perspective suggests that medical illness may take priority over psychiatric care.

Rurality, gender, and mental health treatment

Mental health problems are common and costly, yet many individuals with these problems either do not receive care or receive care that is inadequate. Gender and place of residence contribute to disparities in the use of mental health services. The objective of this study was to identify the influence of gender and rurality on mental health services utilization by using more sensitive indices of rurality. Pooled data from 4 panels of the Medical Expenditure Panel Survey (1996-2000) yielded a sample of 32,219 respondents aged 18 through 64. Variables were stratified by residence using rural-urban continuum codes. We used logistic and linear regression to model effects of gender and rurality on treatment rates. We found that rural women are less likely to receive mental health treatment either through the general healthcare system or through specialty mental health systems when compared to women in metropolitan statistical areas (MSA) or urbanized non-MSA areas. Rural men receive less mental health treatment than do rural women and less specialty mental health treatment than do men in MSAs or least rural non-MSA areas. Reported mental health deteriorates as the level of rurality increases. There is a considerable unmet need for mental health services in most rural areas. The general health sector does not seem to contribute remarkably to mental health services for women in these areas.

What should non-US behavioral health systems learn from the USA?: US behavior health services trends in the 1980s and 1990s

Several countries, such as the USA, inadvertently created a different behavioral health payment system from the rest of medicine through the introduction of diagnostic-related group exemptions for psychiatric care. This led to isolation in the administration and delivery of care for patients with mental health and substance abuse disorders from other medical services with significant, yet unintended, consequences. To insure an efficient and effective health-care system, it is necessary to recognize the problems introduced by segregating behavioral health from the rest of medical care. In this review, the authors assess trends in behavioral health services during the last two decades in the USA, a period in which independently managed behavioral health care has dominated administrative practices. During this time, behavioral health has been an easy target for aggressive cost cutting measures. There have been no clinically significant improvements in the number of adults receiving minimally adequate treatment or in the percentage of the population with behavior health problems receiving psychiatric care with the possible exception of depression. While decreased spending for behavioral health services has been well documented during this period, these savings are offset by costs shifted to greater medical service use with a net increase in the total cost of health care. Targeting behavioral health for reduction in health-care spending through independent management, starting with diagnostic procedure code or diagnostic-related group exemption may not be the wisest approach in addressing the increasing fiscal burden that medical care is placing on the national economy.

Patterns of HIV care for patients with serious mental illness

Individuals with serious mental illness are at higher risk for HIV than are members of the general population. Although studies have shown that individuals with serious mental illness experience less adequate care and worse physical health outcomes than comparable patients without serious mental illness, little is known about HIV care among individuals with serious mental illness who become infected with HIV. In the present study, we describe patterns of highly active antiretroviral treatment (HAART) use and physician monitoring received by 154 patients with serious mental illness infected with HIV. Participants were recruited from mental health agencies in Los Angeles, California. Data from 762 HIV-only patients from a separate Western U.S. probability sample were used for comparison. High proportions of serious mental illness patients with HIV in our sample appeared to be receiving adequate HIV care. Fifty-one percent of all serious mental illness patients with serious mental illness with HIV were taking HAART, and the majority received close monitoring of their CD4 counts (84%) and viral loads (82%) throughout a 1-year period. HAART use and patterns of CD4 count and viral load monitoring did not differ significantly between patients with both serious mental illness and HIV, and patients with HIV only (all p > 0.05). Specialized programs providing assistance to serious mental illness populations with HIV may be helping to narrow health care disparities as a result of having serious mental illness.

Trapped in transition: The complex young adult patient

The transition from adolescence to adulthood is filled with new responsibilities, rights, and roles. As such, it can be a difficult period for the individual to navigate, and is only complicated by the presence of complex psychiatric illness. When these factors coincide, what can result is social and psychiatric disability. This article examines unique obstacles and considerations in the care of the complex young adult patient as illustrated by case vignettes from a specialty unit devoted to the care of this population. In the process, specific strategies useful in engaging, assessing, and treating this cohort are put forth.

Length of stay, admission types, psychiatric diagnoses, and the implications of stigma in African Americans in the nationwide inpatient sample

African Americans purportedly have a higher prevalence of mental illnesses but are often misdiagnosed and less likely to seek treatment. Delayed treatment has been associated with the stigma related to these disorders. The demographic characteristics, length of stay, most prevalent psychiatric diagnoses, and hospital admissions of African Americans were compared to other U.S. populations using a nationwide sample (N = 4,474,732). African American participants were younger, had significantly longer lengths of stay, and were admitted more often through the emergency room than the other groups in this sample. Psychosis, alcohol/drug dependence, and depressive neurosis were the most prevalent psychiatric diagnoses reported for African American participants. Research is needed to explain these results so that strategies can be instituted to improve the poor mental health outcomes often observed in African American populations.

Unmet need for the treatment of depression in Atlantic Canada

OBJECTIVE

Most people with depression do not receive treatment, even though effective interventions are available. Population-based data can assist health service planners to improve access to mental health services. This study aimed to examine the determinants of untreated depression in Canada's Atlantic provinces.

METHOD

This study used data from the Canadian Community Health Survey Cycle 1.1. Logistic regression models explored the prevalence of depression and associated patterns of mental health service use among population subgroups.

RESULTS

Of the respondents, 7.3% experienced major depression in the previous year, as measured by the Composite International Diagnostic Interview Short Form. Individuals with the following characteristics were at increased risk for depression: female sex; widowed, separated, or divorced marital status; low income; and 2 or more comorbid medical conditions. Only 40% of respondents with probable depression reported any consultation about their condition with a general practitioner or mental health specialist. Less than one-quarter of Atlantic Canadians with depression reported receiving levels of care consistent with practice guidelines. Vulnerable groups, including older individuals, people with low levels of education, and those living in rural areas, were significantly less likely to receive treatment in either primary or specialty care.

CONCLUSIONS

These findings suggest inequitable access to services and the need to target interventions to at-risk populations by raising awareness among the public and health care providers. Health systems in the Atlantic region must work toward achieving consistent longitudinal care for a larger proportion of individuals suffering from depression by studying the underlying factors for service use among underserved groups.

Perceived need for mental health treatment in a nationally representative Canadian sample

OBJECTIVE

The optimal method of determining how many people in the general population need help for emotional problems remains unclear. This study aimed to examine the prevalence and correlates of self-perceived need for mental health services (that is, help seeking and perceived need) in a large, population-based sample.

METHODS

Data came from the Canadian Community Health Survey 1.2 (n = 36,816, respondent age 15 years and over, and response rate 77%). Respondents were asked whether they had sought help in the past year from any professional for emotional problems and whether they felt they needed help for emotional symptoms but had not sought treatment. The Composite International Diagnostic Interview (CIDI) was used to make DSM-IV mental disorder diagnoses.

RESULTS

The past-year prevalences of help seeking and perceived need were 8.7% and 2.9%, respectively. After adjusting for the presence of DSM-IV disorders assessed in the survey, sociodemographic factors, illness severity, social supports, and the presence of physical health conditions were associated with help seeking and perceived need. Independent of DSM diagnoses, sociodemographics, and social supports, perceived need and help seeking were associated with increased levels of distress, disability, and suicidal ideation and attempts.

CONCLUSIONS

This study illustrates that, in addition to the presence of a DSM diagnosis, the respondent's self-perceived need for mental health treatment is important in the assessment of need for mental health services in the community.

The relation between perceived need for mental health treatment, DSM diagnosis, and quality of life: a Canadian population-based survey

OBJECTIVES

Prevalence estimates of mental disorders were designed to provide an indirect estimate of the need for mental health services in the community. However, recent studies have demonstrated that meeting criteria for a DSM-based disorder does not necessarily equate with need for treatment. The current investigation examined the relation between self-perceived need for mental health treatment and DSM diagnosis, with respect to quality of life (QoL) and suicidal ideation.

METHODS

Data came from an Ontario population-based sample of 8116 residents (aged 15 to 64 years). The University of Michigan Composite International Diagnostic Interview was used to diagnose mood, anxiety, substance use, and bulimia disorder according to DSM-III-R criteria. We categorized past-year help seeking for emotional symptoms and (or) perceiving a need for treatment without seeking care as self-perceived need for treatment. We used a range of variables to measure QoL: self-perception of mental health status, a validated instrument that measured well-being, and restriction of activities (current, past 30 days, and long-term).

RESULTS

Independent of subjects' meeting criteria for a DSM-III-R diagnosis, self-perceived need for treatment was significantly associated with poor QoL (on all measures) and past-year suicidal ideation.

CONCLUSIONS

Self-perceived need for mental health treatment, in addition to DSM diagnosis, may provide valuable information for estimating the number of people in the population who need mental health services. The relation between self-perceived need for treatment and objective measures of treatment need requires future study.

Health services use in women with a history of bulimia nervosa or binge eating disorder

OBJECTIVE

The current study examined health services use during the past 12 months in a sample of young women with a history of an adolescent eating disorder (bulimia nervosa [BN] or binge eating disorder [BED]).

METHOD

A community sample of 1,582 young women (mean age = 21.5 years) was classified, based on a screening interview (and, for eating disorder diagnosis, confirmatory diagnostic interview), into one of three groups: BN or BED (n = 67), other psychiatric disorder (n = 443), and no adolescent psychiatric disorder (n = 1,072).

RESULTS

A history of BN/BED in adolescence was associated with elevated health services use, but this was a general effect associated with having a psychiatric disorder, not an effect specific to the diagnosis of an eating disorder. Total service days, outpatient psychotherapy visits, and emergency department visits were elevated in the combined group of BN/BED and other psychiatric disorder participants relative to the healthy comparison group. The women with BN/BED did not differ significantly from the women with a non-eating-related psychiatric disorder in the use of these services.

DISCUSSION

The similarity of health services use in young women with BN or BED and those with other psychiatric disorders underscores the clinical and economic impact of these eating disorders.

Addictive disorders

In conclusion, complex medical and psychiatric comorbidity is com-mon in individuals with substance use disorders. It is important to assess comorbidity because of the implications for prevention and treatment. Studies of the neurobiology of substance use and psychiatric disorders are accumulating rapidly and informing treatment development. Information about the prevention and treatment of infectious diseases and other medical conditions associated with substance use disorders also is growing, and it is important that patients are able to benefit from this. The articles in this issue provide state-of-the-art information about several issues related to comorbidity in substance use disorders.

Gaps in accessing treatment for anxiety and depression: Challenges for the delivery of care

Epidemiological studies have identified high prevalence rates of anxiety and depression in North America [e.g., J. of Nerv. Ment. Dis. 182 (1994) 290]. However, only a small percentage of these individuals access effective treatment. The undertreatment of anxiety and depression is a major public health issue and is associated with significant personal, social, and economic burden. This article describes the existing discrepancy between prevalence of anxiety and depression and access to effective treatment for adults and children, the contributors to this discrepancy, and suggests various means through which access to effective treatment may be enhanced. We begin with a brief overview of the prevalence and associated personal, societal, and systemic burdens of anxiety and depression. This is followed by a review of current rates of access to treatment and possible individual, provider, and systemic barriers to accessing treatment. Recommendations for bridging the gap between the high rates of these disorders and limited accessibility of effective care are then presented.

Geographical variation in acute psychiatric admissions within New York City 1990-2000: growing inequalities in service use?

The paper analyses geographical variations in use of acute psychiatric inpatient services within New York City and how these have changed from 1990 to 2000. We review literature suggesting reasons for the variations observed. Data from the New York State Department of Health Statewide Planning Research and Cooperative System were combined with population census data to produce age standardized ratio indicators of admissions and of bed days, as measures of use of general hospitals for psychiatric conditions, by males aged 15-64, in Zip Code Areas of New York City, in 1990 and 2000. Geographical variations in hospital use were related to proximity to general hospitals with psychiatric beds and to socio-economic status of local populations (as recorded in the 1990 and 2000 population censuses). Areas close to psychiatric hospitals areas show high admission levels. Controlling for this, Zip Code Areas with higher concentrations of poverty, of African American residents or of persons living alone were associated with relatively high admission ratios. These relationships vary somewhat between diagnostic groups. Area inequalities in standardized admission ratios persisted and widened between 1990 and 2000, and the highest hospital admission ratios were increasingly concentrated where social and economic disadvantage was greatest. Various possible reasons for this trend are explored. We conclude that increasing intensity of poverty in disadvantaged areas is not likely to provide an explanation and that the trends are more likely to result from changes in hospital management and funding affecting access to hospital services.

Adjustment to antidepressant utilization rates to account for depression in remission

Conventional estimates of antidepressant (AD) utilization in major depressive syndrome (MDS) have been low, but this may be partially because ongoing AD use by individuals with resolved MDS is not included. Valid estimates of AD utilization should include this ongoing use for MDS, but this is difficult since most surveys do not collect data on the reason for taking ADs. Only a proportion (f(dep)) of the nondepressed (nMDS) population taking ADs does so for depression. Published studies have not reported this proportion, and data required to estimate f(dep) are not usually available from surveys. The current study was performed to (1) estimate f(dep) by employing information on past history of depression, and (2) use the estimate to obtain an "adjusted" AD utilization rate, including resolved MDS subjects taking ADs. Data were collected in Calgary in 1998 and 1999 by random-digit dial telephone interview from consenting adults aged 18+ years. MDS was assessed using the Composite International Diagnostic Interview Short Form for Major Depression (CIDI-SFMD). Data were gathered on current medications, past depression, and current chronic physical illness. Of 2,542 respondents, 17.1% had MDS as defined by the CIDI-SFMD. A total of 20.2% of MDS and 3.2% of nMDS subjects were taking ADs. Of nMDS individuals taking ADs, 70.6% reported past depression (f(dep) = 70.6%). An "adjusted" AD utilization rate including this group was 28.2%. Physical illnesses that can be treated with ADs affected only 30.0% of nMDS subjects without past depression taking ADs. This study suggests that most individuals without active depression taking ADs do so for depression. AD utilization rates that ignore this group may be unrealistically low. AD use among nMDS subjects without previous depression is probably not primarily for physical illnesses. Limitations include the use of a brief predictive instrument for MDS, and self-report of past depression.

Comorbid mental disorders account for the role impairment of commonly occurring chronic physical disorders: results from the National Comorbidity Survey

Most health and work productivity studies have focused on individual conditions without considering comorbidity. We illustrate the implication of this neglect by examining the effects of comorbid mental disorders on role impairment (number of sickness absence and work cut-back days in the past month) among people with chronic physical disorders. A nationally representative household survey of 5877 respondents assessed current mental and physical disorders and role impairments. Four physical disorders were sufficiently common to be studied: hypertension, arthritis, asthma, and ulcers. All 4 physical disorders were associated with significant role impairments in bivariate analyses. However, further analysis showed that these impairments were almost entirely confined to cases with comorbid mental disorders. Effectiveness trials in workplace samples are needed to evaluate the cost-effectiveness of treating comorbid mental disorders among workers with chronic physical disorders.

Delays in initial treatment contact after first onset of a mental disorder

OBJECTIVE

To examine nationally representative patterns and predictors of delays in contacting a professional after first onset of a mental disorder.

DATA SOURCES

The National Comorbidity Survey, a nationally representative survey of 8,098 respondents aged 15-54.

STUDY DESIGN

Cross-sectional survey.

DATA COLLECTION

Assessed lifetime DSM-III-R mental disorders using a modified version of the Composite International Diagnostic Interview (CIDI). Obtained reports on age at onset of disorders and age of first treatment contact with each of six types of professionals (general medical doctors, psychiatrists, other mental health specialists, religious professionals, human services professionals, and alternative treatment professionals). Used Kaplan-Meier (KM) curves to estimate cumulative lifetime probabilities of treatment contact after first onset of a mental disorder. Used survival analysis to study the predictors of delays in making treatment contact.

PRINCIPAL FINDINGS

The vast majority (80.1 percent) of people with a lifetime DSM-III-R disorder eventually make treatment contact, although delays average more than a decade. The duration of delay is related to less serious disorders, younger age at onset, and older age at interview. There is no evidence that delay in initial contact with a health care professional is increased by earlier contact with other non-health-care professionals.

CONCLUSIONS

Within the limits of recalling lifetime events, it appears that delays in initial treatment contact are an important component of the larger problem of unmet need for mental health care. Interventions are needed to decrease these delays.

Considering schizophrenia from a prevention perspective

Schizophrenia is a serious mental illness that causes major disability and psychosocial impairment. Recent advances in the neurosciences are prompting considerations of schizophrenia from a preventive perspective. An overview of the literature is provided on two important aspects of the development of a prevention orientation in schizophrenia research: elucidation of potential causal risk factors for schizophrenia and research on risk markers. Risk factors for schizophrenia include, but are not limited to, family history, older paternal age, velo-cardio-facial syndrome, maternal infections during pregnancy, pregnancy and delivery complications, and social adjustment difficulties in childhood and adolescence. Potential risk markers include structural brain pathology, minor physical anomalies and dermatoglyphic abnormalities, neurocognitive deficits, eye-tracking dysfunction, certain electrophysiologic findings, and olfactory identification deficits. Several early efforts at indicated preventive interventions targeting individuals at particularly high risk for developing the disorder are discussed. The preventive medicine and public health disciplines may have a role in future research and interventions that apply a preventive perspective to schizophrenia and other mental illnesses. Like any other chronic medical condition, schizophrenia can be considered from a preventive perspective.

The National Comorbidity Survey Replication (NCS-R): background and aims

The National Comorbidity Survey Replication (NCS-R) is a new nationally representative community household survey of the prevalence and correlates of mental disorders in the US. The NCS-R was carried out a decade after the original NCS. The NCS-R repeats many of the questions from the NCS and also expands the NCS questioning to include assessments based on the more recent Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostics system (American Psychiatric Association, 1994). The NCS-R was designed to (1) investigate time trends and their correlates over the decade of the 1990s and (2) expand the assessment of the prevalence and correlates of mental disorders beyond the assessment in the baseline NCS in order to address a number of important substantive and methodological issues that were raised by the NCS. This paper presents a brief review of these aims.

Reducing the burden of affective disorders: is evidence-based health care affordable?

BACKGROUND

Affective disorders remain the leading cause of disability burden despite the availability of efficacious treatment. A wider dissemination of evidence-based health care is likely to impact this burden, however the affordability of such a strategy at the population level is unknown. This study calculated the cost-effectiveness of evidence-based health care for depression, dysthymia and bipolar disorder in the Australian population, and determined whether it was affordable, based on current mental health-related expenditure and outcomes for these disorders.

METHODS

Cost-effectiveness was expressed in costs per years lived with disability (YLDs) averted, a population health summary measure of disability burden. Data from the Australian National Survey of Mental Health and Wellbeing, in conjunction with published randomized trials and direct cost estimates, were used to estimate the 1-year costs and YLDs averted by current health care services, and costs and outcomes for an optimal strategy of evidence-based health care.

RESULTS

Current direct mental health-related health care costs for affective disorders in Australia were 615 million dollars (1997-98 Australian dollars). This treatment averted just under 30,000 YLDs giving a cost-effectiveness ratio of 20,633 dollars per YLD. Outcome could be increased by nearly 50% at similar cost with implementation of an evidence-based package of optimal treatment, halving the cost-effectiveness ratio to 10,737 dollars per YLD.

LIMITATIONS

The method to estimate YLDs averted from the literature requires replication. The costs of implementing evidence-based health care have not been estimated.

CONCLUSIONS

Evidence-based health care for affective disorders should be encouraged on both efficacy and efficiency grounds.

Distinguishing between first-admission schizophreniform disorder and schizophrenia

BACKGROUND

The validity of schizophreniform disorder remains controversial. Past research suggests that cases of schizophreniform disorder may be: (1). atypical cases of affective disorders, (2). cases of schizophrenia in early course, or (3). a heterogeneous group of disorders including a subgroup with benign course and outcome which maintains this diagnosis in the long term.

METHOD

We tested the validity of the schizophreniform disorder diagnosis by comparing the socio-demographic and baseline clinical characteristics, 24-month course and outcome, and 6- and 24-month research diagnoses of 34 cases initially diagnosed with schizophreniform disorder, and 128 cases with schizophrenia, drawn from a cohort of 628 first-admission patients in the Suffolk County Mental Health Project.

RESULTS

Compared to patients with schizophrenia, those with schizophreniform disorder were more likely to remit fully by 6 months and retain this status by 24 months. Only about half of the patients with schizophreniform disorder were re-diagnosed with schizophrenia or schizoaffective disorder at 24-month follow-up, 13% were re-diagnosed with affective disorders and 19% retained the diagnosis of schizophreniform disorder. In contrast, 92% of cases with a baseline diagnosis of schizophrenia retained this diagnosis at 24-month follow-up. The findings were similar in comparisons with schizophrenia patients having onset of symptoms within 6 months of hospitalization.

CONCLUSIONS

Schizophreniform disorder is a heterogeneous category, which includes a small group with benign psychotic disorders who maintain this diagnosis over at least 24 months. Better delineation of this subgroup has important treatment implications.

The prevalence of treated and untreated mental disorders in five countries

We analyzed survey data from Canada, Chile, Germany, The Netherlands, and the United States to study the prevalence and treatment of mental and substance abuse disorders. Total past-year prevalence estimates range between 17.0 percent (Chile) and 29.1 percent (U.S.). Many cases are mild. Although disorder severity is strongly related to treatment, one- to two-thirds of serious cases receive no treatment each year. Most treatment goes to minor and mild cases. Undertreatment of serious cases is most pronounced among young poorly educated males. Outreach is needed to reduce barriers to care among serious cases and young people at risk of serious disorders.

Patterns and correlates of contacting clergy for mental disorders in the United States

OBJECTIVE

To present nationally representative data on the part played by clergy in providing treatment to people with mental disorders in the United States.

DATA SOURCES

The National Comorbidity Survey (NCS), a nationally representative general population survey of 8,098 respondents ages 15-54.

STUDY DESIGN

Cross-sectional survey.

DATA COLLECTION

A modified version of the Composite International Diagnostic Interview was used to assess DSM-III-R mental disorders. Reports were obtained on age of onset of disorders, age of first seeking treatment, and treatment in the 12 months before interview with each of six types of professionals (clergy, general medical physicians, psychiatrists, other mental health specialists, human services providers, and alternative treatment providers).

PRINCIPAL FINDINGS

One-quarter of those who ever sought treatment for mental disorders did so from a clergy member. Although there has been a decline in this proportion between the 1950s (31.3 percent) and the early 1990s (23.5 percent), the clergy continue to be contacted by higher proportions than psychiatrists (16.7 percent) or general medical doctors (16.7 percent). Nearly one-quarter of those seeking help from clergy in a given year have the most seriously impairing mental disorders. The majority of these people are seen exclusively by the clergy, and not by a physician or mental health professional.

CONCLUSIONS

The clergy continue to play a crucial role in the U.S. mental health care delivery system. However, interventions appear to be needed to ensure that clergy members recognize the presence and severity of disorders, deliver therapies of sufficient intensity and quality, and collaborate appropriately with health care professionals.

Bias in mental health assessment and intervention: theory and evidence

A recent surgeon general's report and various studies document racial and ethnic disparities in mental health care, including gaps in access, questionable diagnostic practices, and limited provision of optimum treatments. Bias is a little studied but viable explanation for these disparities. It is important to isolate bias from other barriers to high-quality mental health care and to understand bias at several levels (practitioner, practice network or program, and community). More research is needed that directly evaluates the contribution of particular forms of bias to disparities in the area of mental health care.

The economic burden of depression and the cost-effectiveness of treatment

Cost-of-illness research has shown that depression is associated with an enormous economic burden, in the order of tens of billions of dollars each year in the US alone. The largest component of this economic burden derives from lost work productivity due to depression. A large body of literature indicates that the causes of the economic burden of depression, including impaired work performance, would respond both to improvement in depressive symptomatology and to standard treatments for depression. Despite this, the economic burden of depression persists, partly because of the widespread underuse and poor quality use of otherwise efficacious and tolerable depression treatments. Recent effectiveness studies conducted in primary care have shown that a variety of models, which enhance care of depression through aggressive outreach and improved quality of treatments, are highly effective in clinical terms and in some cases on work performance outcomes as well. Economic analyses accompanying these effectiveness studies have also shown that these quality improvement interventions are cost efficient. Unfortunately, widespread uptake of these enhanced treatment programmes for depression has not occurred in primary care due to barriers at the level of primary care physicians, healthcare systems, and purchasers of healthcare. Further research is needed to overcome these barriers to providing high-quality care for depression and to ultimately reduce the enormous adverse economic impact of depression disorders.

A framework for describing the impact of antidepressant medications on population health status

BACKGROUND

In the absence of strategies for primary prevention, public health initiatives for major depression have generally focused on secondary and tertiary strategies such as case-finding, public and professional education and disease management. Much emphasis has been placed on low reported rates of antidepressant utilization. In principle, increased rates of treatment utilization should lead to improved mental health status at the population level. However, methods for relating antidepressant utilization to population health status have not been described.

METHODS

An incidence-prevalence model was developed using data from a Canadian national survey, supplemented by parameter estimates from literature reviews. The lifetime sick-day proportion (LSP) was used to approximate point prevalence.

RESULTS

Mathematical simulations using this model produced reasonable approximations of point prevalence for major depression. The model suggests that an improved rate of treatment utilization may not, in itself, lead to substantially reduced prevalence. Reducing the rate of relapse in those with highly recurrent disorders, which can be accomplished by long-term antidepressant treatment, is predicted to have a more substantial impact on population health status.

CONCLUSIONS

The model presented here offers a framework for describing the impact of antidepressant treatment on population health status. Mathematical models may assist with decision-making and priority setting in the public health sphere, as illustrated by the model presented here, which challenges some commonly held assumptions.