Health care costs of primary care patients with recognized depression

Value-based pricing of cognitive behavioral therapy for depression in primary care: an economic evaluation

OBJECTIVES

Value-based pricing (VBP) determines product prices based on their perceived benefits. In healthcare, VBP prices medical technologies considering health outcomes and other relevant factors. This study applies VBP using economic evaluation to provider-patient communication, taking cognitive behavioral therapy (CBT) for adult primary care patients with depressive disorders as a case study.

METHODS

A 12-week decision-tree model was developed from the German social health insurance system's perspective, comparing CBT against the standard of care. The influence of an extended time horizon on VBP was assessed using a theoretical model and long-term data spanning 46 months.

RESULTS

Using a willingness-to-pay threshold of €88,000 per quality-adjusted life year gained, the base-case 50-minute compensation rate for CBT was €45. Assuming long-term effects of CBT significantly affected the value-based compensation, increasing it to €226.

CONCLUSIONS

This study showcases the potential of applying VBP to CBT. However, significant price variability is highlighted, contingent upon assumptions regarding CBT's long-term impacts.

A cross-sectional study of the relationship between depression status, health care coverage, and sexual orientation

Health care coverage is an important factor in receipt of behavioral healthcare. This study uses data from the New York City Community Health Survey to examine how sexual minority status impacts the relationship between depression status and having health care coverage. Approximately 10% of the sample (n = 9571; 47% 45+ years old; 35% White Non-Hispanic; 7% sexual minority) reported probable depression and low health care coverage. Compared to heterosexual participants, a greater proportion of sexual minority participants had low health care coverage (17% vs. 9%) and probable depression (19% vs. 9%). Logistic regression examining the association between probable depression status and health care coverage showed that those with probable depression have odds of low health care coverage that are were 3.08 times those who did not have probable depression; this relationship was not modified by sexual orientation. Continued research to understand the interplay of health care coverage, mental health, and sexual orientation is needed.

The reliability, validity and screening effect of the happiness index scale among inpatients in a general hospital

BACKGROUND

The Happiness Index Scale (HIS) is a newly developed scale by our group to screen for common psychological illnesses among general hospital inpatients. This study aimed to analyze the reliability, validity and screening effect of the HIS and to explore its clinical application.

METHODS

From April 1, 2021, to December 31, 2021, a total of 8405 continuous inpatients were enrolled from different departments of a large tertiary general hospital with 1385 inpatient beds in Guangzhou, Guangdong Province, China. Using a cross-sectional survey design, each participant was assessed with the Patient Health Questionnaire 9(PHQ-9), Generalized Anxiety Disorder 7 items(GAD-7), Athens Insomnia Scale (AIS), Columbia Suicide Severity Rating Scale (C-SSRS) and HIS within 24 h of admission. McDonald's ω coefficient, the Guttman split-half coefficient and the test-retest reliability coefficient were used to evaluate the reliability of the HIS and the construct validity and criterion validity of the validity tests. Scores on the PHQ-9, GAD-7, AIS, and C-SSRS were used as the gold standard tools to analyze the screening effect of the HIS.

RESULTS

The HIS exhibited very good reliability, with a McDonald's ω coefficient of 0.825, a Guttman split-half coefficient of 0.920 and a test-retest reliability coefficient of 0.745 (P < 0.05). Confirmatory factor analysis showed a satisfactory model fitting index with a χ²/df = 2.602, a root mean squared error of approximation (RMSEA) of 0.014, a standardized root mean square residual (SRMR) of 0.010, a comparative fit index (CFI) of 0.992, and a Tucker-Lewis index (TLI) of 0.983. The correlation coefficient between the total score of each dimension of the scale and the corresponding criterion was 0.854 ~ 0.949 (P < 0.001). The HIS showed a very good distinguishing effect. The average HIS score of inpatients who screened positive for psychological problems was significantly higher than that of inpatients who screened negative for psychological problems (t = 3790.619, P < 0.001). The effect size was very large (Cohens d = 2.695, 95% CI = 2.630 ~ 2.761). Approximately 90.2% of the positive and negative screening results of the HIS were matched with the gold standard tools, with a kappa value of 0.747 (P < 0.001). The screening effect test showed a sensitivity (true positive rate) of 92.9% and a specificity (true negative rate) of 89.5%.

CONCLUSION

The HIS exhibited satisfactory reliability and validity and a clinically meaningful screening effect with a much shorter version compared to the commonly used screening scales. Thus, it could potentially be useful as the first screening step to rule out psychological conditions for inpatients in general hospitals or to remind medical teams of further psychological concerns.

Do breast cancer survivors with a recent history of clinical depression report worse experiences with care? A retrospective cohort study using SEER-CAHPS data

PURPOSE

We examined whether breast cancer survivors' experiences with care differed by a recent history of clinical depression, and whether associations differed by race/ethnicity.

METHODS

Using the Epidemiology and End Results-Consumer Assessment of Healthcare Providers and Systems (SEER-CAHPS) dataset, we analyzed records of breast cancer survivors who completed a survey at least 12 months after their cancer diagnosis. We assessed clinical depression 12 months prior to survey completion using Medicare claims. We used separate multivariable logistic regressions to examine the associations between depression and excellent (vs. less than excellent) ratings of experiences with care (i.e., doctor communication, getting needed care, getting care quickly, getting prescription drugs, specialist and overall care). We also assessed interactions of depression by race/ethnicity. All models were adjusted for demographics and cancer prognostic and treatment factors.

RESULTS

Of the 2271 survivors, 7.6% were clinically depressed. After adjusting for covariates, survivors with clinical depression had lower odds of reporting excellent ratings of their ability to get needed care, care by their specialist, and overall care, compared to those without depression (AOR = 0.58, 95% CI: 0.40-0.84; AOR = 0.40, CI: 0.31-0.76; and AOR = 0.61, CI: 0.42-0.89, respectively). Among Hispanics, having depression was associated with higher odds of excellent ratings of one's ability to get needed care (AOR: 5.42, 95% CI: 1.02-28.81). No other statistically significant associations by race/ethnicity were found.

CONCLUSIONS

Breast cancer survivors with depression report poorer patient experiences with care. Further research is needed to understand complexities of ratings of experiences with care among survivors of diverse backgrounds.

IMPLICATIONS

Survivors with a recent history of clinical depression may benefit from additional supportive care services.

Improvements in Depression Outcomes Following a Digital Cognitive Behavioral Therapy Intervention in a Polychronic Population: Retrospective Study

Background

Digital mental health interventions have shown promise in reducing barriers to effective care for depression. Depression and related mental disorders are known to be highly comorbid with common chronic physical conditions, such as obesity and type 2 diabetes. While some research has explored the interaction dynamics of treating populations living with both mental and physical disorders, very little is known about such dynamics in digital care.

Objective

We aimed to examine the effectiveness of a 12-week, therapist-supported, app-based cognitive behavioral therapy program in improving symptoms of depression and anxiety. The studied population included adults with a heavy burden of chronic physical disease, including obesity and type 2 diabetes.

Methods

A total of 1512 participants with at least moderate depression were enrolled. The treatment cohort consisted of 831 (54.96%) participants who completed a follow-up assessment. The program included structured lessons and tools (ie, exercises and practices) and offered one-on-one weekly video counseling sessions with a licensed therapist for 12 weeks and monthly sessions thereafter. The clinically validated 8-item Patient Health Questionnaire (PHQ-8) and the 7-item Generalized Anxiety Disorder scale (GAD-7) were used to assess depression and anxiety, respectively. Linear mixed-effects modeling was employed to examine changes in depression and anxiety over time. Given correlation among various measures of program usage, a composite variable for depth of usage was used to analyze the correlation between usage and changes in depressive symptoms. Body weight changes from baseline were assessed primarily with digitally connected scales.

Results

Out of 831 participants in the treatment cohort, 74.5% (n=619) showed a clinically significant reduction in depressive symptom severity after 12 weeks, where follow-up PHQ-8 scores had shifted downward by at least one diagnostic category. In total, 67.5% (n=561) of the participants showed a reliable improvement in PHQ-8 scores as measured by the reliable change index. There was an average reduction of 5.9 (SD 5.2) points (P<.001) between baseline and follow-up. Greater program usage was correlated with greater likelihood of reliable improvement in depressive symptoms (odds ratio 1.3, 95% CI 1.1-1.5; P=.002). An exploratory analysis of body weight changes with a multilevel, mixed-effect model suggested that reliable improvement in depressive symptoms at follow-up was associated with significantly greater weight loss at 9 months (β=–1.11, P=.002).

Conclusions

The results provide further support that digital interventions can support clinically meaningful improvements in depression. Some form of synergy in treatment of comorbid depression and obesity or diabetes could be studied in future research. The study was limited by postintervention participant attrition as well as the retrospective observational study design.

Effect of antidepressant use on length of hospitalization in patients on anti-infective therapy

Compared to those without depression, acutely-ill patients with depression hospitalized for an infection usually have poor outcomes, including increased length of stay (LOS).

PURPOSE

The primary objective was to evaluate the LOS between patients receiving an anti-infective with and without any antidepressant use. Secondary objectives were to examine LOS based on acuity of care and age.

METHODS

Using a cross-sectional design, hospitalized adult patients who received anti-infective agents between January 1, 2017 and October 31, 2019 for ≥7 days were included. Univariate and multivariate analyses were conducted to determine statistical significance.

RESULTS

A total of 17,651 patient encounters were included in the study. Of all patient encounters, 5165 (29%) received antidepressants concurrently with anti-infectives, with mean age of 57 years ± 17.3. Patients receiving concurrent antidepressants experienced longer LOS compared with patients not receiving antidepressants [20 vs 16 days, 95% confident interval (CI): 3.98-5.18, p < 0.001]. Stratified by intensive care unit (ICU) admission during hospital encounters and age ≥ 65 years, patients receiving antidepressants had longer LOS (25 vs 18 days, CI: 5.63-8.61, p < 0.001, and 18 vs 15 days, CI: 2.39-4.04, p < 0.001, respectively). After controlling for gender and ethnicity, antidepressant use and ICU admission were independently associated with increased LOS.

CONCLUSION

Patients who received both an antidepressant and an anti-infective agent had significantly increased LOS, including those in the ICU and in the elderly population. Future studies are needed to assess the impact of concomitant antidepressant use on mortality and other clinical outcomes in patients hospitalized with an infection.

Does screening for depressive symptoms help optimize duloxetine use in knee OA patients with moderate pain? A cost-effectiveness analysis

OBJECTIVE

Duloxetine is an FDA-approved treatment for both osteoarthritis (OA) pain and depression, but uptake of duloxetine in knee OA management varies. We examined the cost-effectiveness of adding duloxetine to knee OA care with or without depression screening.

METHODS

We used the Osteoarthritis Policy Model, a validated computer microsimulation of knee OA, to examine the value of duloxetine for knee OA patients with moderate pain by comparing three strategies: 1) usual care (UC); 2) duloxetine for those who screen positive for depression on the Patient Health Questionnaire 9 (PHQ-9) + UC; and 3) universal duloxetine + UC. Outcomes included quality-adjusted life years (QALYs), lifetime direct medical costs, and incremental cost-effectiveness ratios (ICERs), discounted at 3% annually. Model inputs, drawn from published literature and national databases, included: annual cost of duloxetine, $721-$937; average pain reduction for duloxetine, 17.5 points on the WOMAC pain scale (0-100); likelihood of depression remission with duloxetine, 27.4%. We considered two willingness-to-pay (WTP) thresholds of $50,000/QALY and $100,000/QALY. We varied parameters related to the PHQ-9 and duloxetine's cost, efficacy, and toxicities to address uncertainty in model inputs.

RESULTS

The screening strategy led to an additional 17 QALYs per 1,000 subjects and increased costs by $289/subject (ICER=$17,000/QALY). Universal duloxetine led to an additional 31 QALYs per 1,000 subjects and $1,205/subject (ICER=$39,300/QALY). Under the majority of sensitivity analyses, universal duloxetine was cost-effective at the $100,000/QALY threshold.

CONCLUSION

Adding duloxetine to usual care for knee OA patients with moderate pain, regardless of depressive symptoms, is cost-effective at frequently-used WTP thresholds.

A Review of Psychiatric Comorbidity in Myasthenia Gravis

This study aimed to review studies focused on the affective comorbidities associated with myasthenia gravis and to determine the extent to which neuromuscular treatment modalities address non-somatic aspects of autoimmune myasthenia gravis. Depression, anxiety, and emotional hyperactivity can aggravate myasthenia gravis, hinder accurate diagnoses, and presumably influence overall health-related quality of life.

Studies were identified using PubMed Medline and Web of Science to assess the effects of psychological factors on myasthenia gravis, encompassing 49 years of research worldwide. After analysis, approximately 6,060 patients from 32 studies worldwide between 1971 and 2020 were included. Standard-of-care approaches to diagnosis and treatment continue to under-appreciate the prevalence or impact of mood disorders in myasthenia gravis.

The majority of studies evaluated demonstrated an association between myasthenia gravis and mood disorders. However, the initiative to detect and treat affective comorbidities probably remains suboptimal. Although treatments for the somatic effects of myasthenia gravis have evolved over the past century, the paradigm of clinical practice has yet to adequately address the management of psychological impacts on the disease. This review is hoped to raise the necessary awareness in this regard.

Psychosocial functioning in patients with treatment resistant depression

Background

Depression is a disorder that causes disability, with a profound adverse impact on all areas of psychosocial functioning. This is particularly true for those with treatment resistant depression (TRD). However, to date, no systematic assessments of psychosocial functioning for patients with TRD have been conducted.

Methods

In the present study, we used the Longitudinal Interval Follow-up Evaluation (LIFE) scale to measure psychosocial functioning in 92 patients with TRD. These patients met formal criteria for TRD and were part of a clinical trial examining the efficacy of lithium augmentation of nortriptyline.

Results

Clinicians rated this sample of patients as experiencing mild to moderate impairment in work-related activities, good to fair interpersonal relations, poor level of involvement in recreational activities, and mild impairment of ability to enjoy sexual activity. Patients and clinicians rated global social adjustment as poor.

Conclusions

Patients with formally defined TRD experience significant impairment in psychosocial functioning. In this sample a tendency existed for both clinicians and patients to assign more severely impaired global ratings when compared with ratings for specific functional areas.

The association of depression and painful physical symptoms–a review of the European literature

Objective:

The presence of painful physical symptoms may confound the diagnosis of major depressive disorder and may worsen patient prognosis. Epidemiological literature was reviewed to investigate the association between depression and painful physical symptoms.

Method:

MEDLINE and EMBASE database searches were conducted. Studies where a definable organic basis for pain was given were excluded. The search was unrestricted by language but limited to European studies and countries. After filters were applied, 70 eligible studies were reviewed.

Results:

The majority of studies reviewed showed an association between depression and painful physical symptoms. Over 40% of all studies examining the association between pain and depression were carried out in pain clinics in secondary care. Very few studies were conducted in psychiatric settings.

Conclusion:

The findings of this review suggest that painful physical symptoms may be an important part of the depressive syndrome. Although the relationship between depression and painful physical symptoms is not yet fully understood, findings suggest that diagnosis and treatment of depression should involve investigating and treating the full spectrum of symptoms (emotional and physical). Further research in psychiatric and generalist settings is needed to elucidate the relationship between depression and painful physical symptoms as experienced by patients and at the clinical level.

"Energy is a Finite Resource": Designing Technology to Support Individuals across Fluctuating Symptoms of Depression

While the HCI field increasingly examines how digital tools can support individuals in managing mental health conditions, it remains unclear how these tools can accommodate these conditions' temporal aspects. Based on weekly interviews with five individuals with depression, conducted over six weeks, this study identifies design opportunities and challenges related to extending technology-based support across fluctuating symptoms. Our findings suggest that participants perceive events and contexts in daily life to have marked impact on their symptoms. Results also illustrate that ebbs and flows in symptoms profoundly affect how individuals practice depression self-management. While digital tools often aim to reach individuals while they feel depressed, we suggest they should also engage individuals when they are less symptomatic, leveraging their energy and motivation to build habits, establish plans and goals, and generate and organize content to prepare for symptom onset.

Healthcare utilization and out-of-pocket expenditures associated with depression in adults: a cross-sectional analysis in Nepal

BACKGROUND

Despite attempts to improve universal health coverage (UHC) in low income countries like Nepal, most healthcare utilization is still financed by out-of-pocket (OOP) payments, with detrimental effects on the poorest and most in need. Evidence from high income countries shows that depression is associated with increased healthcare utilization, which may lead to increased OOP expenditures, placing greater stress on families. To inform policies for integrating mental healthcare into UHC in LMIC, we must understand healthcare utilization and OOP expenditure patterns in people with depression. We examined associations between symptoms of depression and frequency and type of healthcare utilization and OOP expenditure among adults in Chitwan District, Nepal.

METHODS

We analysed data from a population-based survey of 2040 adults in 2013, who completed the PHQ-9 screening tool for depression and answered questions about healthcare utilization. We examined associations between increasing PHQ-9 score and healthcare utilization frequency and OOP expenditure using negative binomial regression. We also compared utilization of specific outpatient service providers and their related costs among adults with and without probable depression, determined by a PHQ-9 score of 10 or more.

RESULTS

We classified 80 (3.6%) participants with probable depression, 70.9% of whom used some form of healthcare in the past year compared to 43.9% of people without probable depression. Mean annual OOP healthcare expenditures were $118 USD in people with probable depression, compared to $110 USD in people without. With each unit increase in PHQ-9 score, there was a 14% increase in total healthcare visits (95% CI 7-22%, p < 0.0001) and $9 USD increase in OOP expenditures (95% CI $2-$17; p < 0.0001). People with depression sought most healthcare from pharmacists (30.1%) but reported the greatest expenditure on specialist doctors ($36 USD).

CONCLUSIONS

In this population-based sample from Central Nepal, we identified dose-dependent increases in healthcare utilization and OOP expenditure with increasing PHQ-9 scores. Future studies should evaluate whether provision of mental health services as an integrated component of UHC can improve overall health and reduce healthcare utilisation and expenditure, thereby alleviating financial pressures on families.

Impact of the mental health and dynamic referral for oncology (MHADRO) program on oncology patient outcomes, health care utilization, and health provider behaviors: A multi-site randomized control trial

OBJECTIVE

The MHADRO assesses psychosocial and medical needs, provides tailored feedback reports, and connects patients to mental health providers. This study examined the MHADRO's effect on patient outcomes, health care utilization, and oncology provider documentation and behaviors.

METHODS

836 patients were part of a multi-site RCT and assessments were conducted at baseline, 2, 6 and 12 months.

RESULTS

The intervention group engaged in less emergency calls to providers. There were no differences in psychosocial outcomes at follow up assessments. Providers of patients in the intervention group were more likely to: document psychosocial symptoms and history; refer to psychosocial services; encourage support groups; seek psychological evaluations during visits. Patients who agreed to a mental health referral had decreased hospitalizations, increased mental health care interactions, and stronger ratings of counseling potential benefits. This group also reported increased psychosocial distress at all follow-up assessments.

CONCLUSION

The MHADRO may increase access to mental health care, lessen utilization, and improve providers' management of psychosocial needs, but does not appear to impact overall functioning over time.

PRACTICE IMPLICATIONS

Providers are encouraged to consider incorporating programs, like the MHADRO, into patient care as they may have the potential to impact screening and management of patients' psychosocial needs.

Depressive Symptoms, Lack of Physical Activity, and Their Combination Towards Health Care Utilisation Frequency

Depressive symptoms and lack of physical activity are independent factors that lead to higher health care utilisation, often occurring simultaneously. We aimed to assess the effects of depressive symptoms, lack of aerobic physical activity (PA), and the combination of those factors on the probability of using in- and outpatient health care services in men and women. Data from 15,770 people from the nationally representative Austrian Health Interview Survey (AT-HIS) were used. In analysis, depressive symptoms, adjusted for sociodemographic, health related, and lifestyle-related factors were associated with higher odds of outpatient health care utilisation (OR: 1.60; 95% CI: 1.19–2.14) in men and (OR: 2.10; 95%CI: 1.65–2.66) in women, and with higher odds of inpatient health care utilisation (OR: 1.52; 95% CI: 1.09–2.10) in men and (OR: 2.09; 95% CI: 1.64–2.68) in women. However, depressive symptoms were not associated with higher health care utilisation in the fully adjusted models. In men, co-existence of depressive symptoms and lack of health enhancing physical activity (HEPA) was associated with higher odds of using inpatient health care services, compared to the presence of only one or none of the factors. In conclusion, our results show that depressive symptoms are associated with more health care utilisation in both men and women and that the co-existence of both depressive symptoms and lack of HEPA elevated the odds for inpatient health care utilisation in men even more.

Prevalence of anxiety and depressive symptoms and their association with multimorbidity and demographic factors: a community-based, cross-sectional survey in Karachi, Pakistan

OBJECTIVE

This study aimed to estimate the prevalence of anxiety and depressive symptoms and their association with multimorbidity and the demographic characteristics of adults aged 30 years and above in Karachi, Pakistan.

DESIGN

Observational cross-sectional study.

STUDY SETTING AND PARTICIPANTS

The study was carried out among a general population aged 30 years and above residing in the Gulshan-e-Iqbal town of Karachi, Pakistan. The study participants were recruited using the systematic random sampling approach based on the inclusion criteria. The data collected from 2867 participants were analysed.

MAIN OUTCOME MEASURES

The primary outcome of the study was the prevalence of anxiety and depressive symptoms, measured with the Aga Khan University Anxiety Depression Scale. The secondary outcome was the association of anxiety and depressive symptoms with multimorbidity as well as with the sociodemographic characteristics of the participants, using binary logistic regression.

RESULTS

Out of 2867 individuals, 27.4% reported having anxiety and depressive symptoms. The multivariate logistic regression model revealed that the presence of multimorbidity (adjusted OR (AOR)=1.33, 95% CI 1.11 to 1.58), female gender (AOR=2.40, 95% CI 2.01 to 2.87), illiteracy (AOR=1.51, 95% CI 1.09 to 2.07), more children (AOR=0.74, 95% CI 0.59 to 0.93) and visiting a faith healer (AOR=2.29, 95% CI 1.82 to 2.88) were the significant factors associated with anxiety and depressive symptoms.

CONCLUSION

This study revealed a moderately high prevalence of anxiety and depressive symptoms among adults aged 30 years and above in Karachi, Pakistan. The key variables associated with anxiety and depressive symptoms were multimorbidity, female gender, lower level of education, more children and visiting faith healers.

Depression in Emergency Department Patients and Association With Health Care Utilization

BACKGROUND

Depression is one of the most common illnesses in the United States, with increased prevalence among people with lower socioeconomic status and chronic mental illness who often seek care in the emergency department (ED). We sought to estimate the rate and severity of major depressive disorder (MDD) in a nonpsychiatric ED population and its association with subsequent ED visits and hospitalizations.

METHODS

This prospective cohort study enrolled a convenience sample of English-speaking adults presenting to an urban academic medical center ED without psychiatric complaints between January 1, 2015, and September 21, 2015. Patients completed a computerized adaptive depression diagnostic screen (CAD-MDD) and dimensional depression severity measurement test (CAT-DI) via tablet computer. Primary outcomes included number of ED visits and hospitalizations assessed from index visit until January 1, 2016. Negative binomial regression modeling was performed to assess associations between depression, depression severity, clinical covariates, and utilization outcomes.

RESULTS

Of 999 enrolled patients, 27% screened positive for MDD. The presence of MDD conveyed a 61% increase in the rate of ED visits (incidence rate ratio [IRR] = 1.61, 95% confidence interval [CI] = 1.27 to 2.03) and a 49% increase in the rate of hospitalizations (IRR = 1.49, 95% CI = 1.06-2.09). For each 10% increase in MDD severity, there was a 10% increase in the relative rate of subsequent ED visits (IRR = 1.10, 95% CI = 1.04 to 1.16) and hospitalizations (IRR = 1.10, 95% CI = 1.02 to 1.18). Across the range of the severity scale there was over a 2.5-fold increase in the rate of ED visits and hospitalization rates.

CONCLUSIONS

Rates of depression were high among a convenience sample of English-speaking adult ED patients presenting with nonpsychiatric complaints and independently associated with increased risk of subsequent ED utilization and hospitalization. Standardized assessment tools that provide rapid, accurate, and precise classification of MDD severity have the potential to play an important role in identifying ED patients in need of urgent psychiatric resource referral.

The excess costs of depression: a systematic review and meta-analysis

AIMS

Major depressive disorders are highly prevalent in the world population, contribute substantially to the global disease burden and cause high health care expenditures. Information on the economic impact of depression, as provided by cost-of-illness (COI) studies, can support policymakers in the decision-making regarding resource allocation. Although the literature on COI studies of depression has already been reviewed, there is no quantitative estimation of depression excess costs across studies yet. Our aims were to systematically review COI studies of depression with comparison group worldwide and to assess the excess costs of depression in adolescents, adults, elderly, and depression as a comorbidity of a primary somatic disease quantitatively in a meta-analysis.

METHODS

We followed the PRISMA reporting guidelines. PubMed, PsycINFO, NHS EED, and EconLit were searched without limitations until 27/04/2018. English or German full-text peer-reviewed articles that compared mean costs of depressed and non-depressed study participants from a bottom-up approach were included. We only included studies reporting costs for major depressive disorders. Data were pooled using a random-effects model and heterogeneity was assessed with I² statistic. The primary outcome was ratio of means (RoM) of costs of depressed v. non-depressed study participants, interpretable as the percentage change in mean costs between the groups.

RESULTS

We screened 12 760 articles by title/abstract, assessed 393 articles in full-text and included 48 articles. The included studies encompassed in total 55 898 depressed and 674 414 non-depressed study participants. Meta-analysis showed that depression was associated with higher direct costs in adolescents (RoM = 2.79 [1.69-4.59], p < 0.0001, I² = 87%), in adults (RoM = 2.58 [2.01-3.31], p < 0.0001, I² = 99%), in elderly (RoM = 1.73 [1.47-2.03], p < 0.0001, I² = 73%) and in participants with comorbid depression (RoM = 1.39 [1.24-1.55], p < 0.0001, I² = 42%). In addition, we conducted meta-analyses for inpatient, outpatient, medication and emergency costs and a cost category including all other direct cost categories. Meta-analysis of indirect costs showed that depression was associated with higher costs in adults (RoM = 2.28 [1.75-2.98], p < 0.0001, I² = 74%).

CONCLUSIONS

This work is the first to provide a meta-analysis in a global systematic review of COI studies for depression. Depression was associated with higher costs in all age groups and as comorbidity. Pooled RoM was highest in adolescence and decreased with age. In the subgroup with depression as a comorbidity of a primary somatic disease, pooled RoM was lower as compared to the age subgroups. More evidence in COI studies for depression in adolescence and for indirect costs would be desirable.

Depressive Symptoms and Total Healthcare Costs: Roles of Functional Limitations and Multimorbidity

OBJECTIVES

Depressive symptoms can be both a cause and a consequence of functional limitations and medical conditions. Our objectives were to determine the association of depressive symptoms with subsequent total healthcare costs in older women after accounting for functional limitations and multimorbidity.

DESIGN

Prospective cohort study (Study of Osteoporotic Fractures [SOF]).

SETTING

Four US sites.

PARTICIPANTS

A total of 2508 community-dwelling women (mean age = 79.4 years) participating in the SOF year 10 (Y10) examination linked with their Medicare claims data.

MEASUREMENTS

At Y10, depressive symptoms were measured using the 15-item Geriatric Depression Scale (GDS) and functional limitations were assessed by number (range = 0-5) of impairments in performing instrumental activities of daily living. Multimorbidity was ascertained by the Elixhauser method using claims data for the 12 months preceding the Y10 examination. Total direct healthcare costs, outpatient costs, acute hospital stays, and skilled nursing facility during the 12 months following the Y10 examination were ascertained from claims data.

RESULTS

Annualized mean (SD) total healthcare costs were $4654 ($9075) in those with little or no depressive symptoms (GDS score = 0-1), $7871 ($14 534) in those with mild depressive symptoms (GDS score = 2-5), and $9010 ($15 578) in those with moderate to severe depressive symptoms (GDS score = 6 or more). After adjustment for age, site, self-reported functional limitations, and multimorbidity, the magnitudes of these incremental costs were partially attenuated (cost ratio = 1.34 [95% confidence interval {CI} = 1.14-1.59] for those with mild depressive symptoms, and cost ratio = 1.29 [95% CI = 0.99-1.69] for those with moderate to severe depressive symptoms vs women with little or no depressive symptoms).

CONCLUSION

Depressive symptoms were associated with higher subsequent healthcare costs attributable, in part, to greater functional limitations and multimorbidity among those with symptoms. Importantly, even mild depressive symptoms were associated with higher healthcare costs. J Am Geriatr Soc 67:1596-1603, 2019.

Healthcare cost, service use and mortality in major psychiatric disorders in Taiwan

BACKGROUND

We aimed to examine the differences in the cost distributions, service use, and mortality outcomes, across major psychiatric disorders in Taiwan.

METHOD

A national cohort of adult patients (n = 68,068) who had newly received a diagnosis of schizophrenia, bipolar disorder, and major depressive disorder (MDD) was identified from the National Health Insurance Research Database and followed for the subsequent three years. Variations in the 1-year and 3-year healthcare cost distributions and mortality outcomes were examined according to age group (18-64 years, ≥65 years) and diagnosis.

RESULTS

Regardless of age group, individuals with schizophrenia had the highest total and psychiatric healthcare costs. Healthcare costs for psychiatric services accounted for 84.25%, 60%, and 29.62% of the 1-year total healthcare costs for younger patients with a diagnosis of schizophrenia, bipolar disorder, and MDD, respectively. Psychiatric inpatient care costs constituted a major part of the 1-year psychiatric healthcare costs, e.g., 85.86% for schizophrenia patients aged 18-64 years, while psychiatric medication costs contributed to a relatively smaller part. For those older than 65 years, costs of other specialties for comorbid physical conditions were more prominent.

LIMITATIONS

The perspective of the current analysis was limited to healthcare services, and we were not able to analyse wider economic impacts.

CONCLUSIONS

Psychiatric inpatient care costs contributed to a significant share of psychiatric expenditures, emphasizing the need of developing strategies to reduce rehospitalisations. For those aged 65 years or older, efforts to improve interdisciplinary service care for comorbid physical conditions may be required.

Do Symptoms of Depression Interact with Substance Use to Affect HIV Continuum of Care Outcomes?

Few studies examine how depression and substance use interact to affect HIV control. In 14,380 persons with HIV (PWH), we used logistic regression and generalized estimating equations to evaluate how symptoms of depression interact with alcohol, cocaine, opioid, and methamphetamine use to affect subsequent retention in care, maintaining an active prescription for ART, and consistent virologic suppression. Among PWH with no or mild depressive symptoms, heavy alcohol use had no association with virologic suppression (OR 1.00 [0.95-1.06]); among those with moderate or severe symptoms, it was associated with reduced viral suppression (OR 0.80 [0.74-0.87]). We found no interactions with heavy alcohol use on retention in care or maintaining ART prescription or with other substances for any outcome. These results highlight the importance of treating moderate or severe depression in PWH, especially with comorbid heavy alcohol use, and support multifaceted interventions targeting alcohol use and depression.

Societal burden of adolescent depression, an overview and cost-of-illness study

BACKGROUND

Depression in adolescents is a serious problem to society because of the high prevalence rate, the high subjective burden of illness and negative (economic) consequences. Information regarding the economic burden of adolescent depression is scarce. The goal of this study is twofold. First, an overview of the literature on prevalence, burden of disease, and costs related to adult and adolescent depression is given. Second, a prevalence-based cost-of-illness study is being conducted.

METHODS

In this study a cost-of-illness study using a societal perspective was conducted using data of 56 clinically depressed Dutch adolescents aged 12-21. Bottom-up acquired costs were measured by means of cost questionnaires.

RESULTS

The calculations showed that clinically depressed adolescents referred to treatment cost the Dutch society €37.7 million a year. The calculated costs were higher when a more recent prevalence rate was used in a secondary analysis.

LIMITATIONS

Limitations of this study are that only older Dutch prevalence rates were available, a relatively small sample size was used and no long term costs could be calculated.

CONCLUSION

Even though the sample size is small, the calculated costs are indicative for the societal costs of adolescents with depression. Cost-effective prevention and intervention methods seem warranted to reduce these enormous costs.

The effects of Inquiry-Based Stress Reduction (IBSR) on mental health and well-being among a non-clinical sample

BACKGROUND

Mental problems are highly common among the general population. Mind-body interventions were found to be highly effective in treating them. The current study assessed the effect of Inquiry-Based Stress Reduction (IBSR) meditation on psychological parameters in a general population sample.

METHODS

Ninety-seven Participants enrolled in a 28-day workshop and completed a set of self-administered measures before and after the workshop. Outcome measures included Beck Depression Inventory-II (BDI-II), Quick Inventory of Depressive Symptomology-Self Report (QIDS-SR₁₆), Outcome Questionnaire OQ-45.2, The Quality of Life Inventory (QOLI), State-Trait Anxiety Inventory Form (STAI), State-Trait Anger Expression Inventory (STAXI) (State), Subjective Happiness Scale (SHS), Eating Attitudes Test (EAT).

RESULTS

BDI scale decreased significantly before and after the intervention. QIDS scale improved significantly from T1 to T2 (p < 0.001). Outcome questionnaire decreased significantly at T2. Quality of life scores improved significantly between T1 and T2 (p < 0.001). Anxiety state and trait scores decreased significantly after the intervention (p < 0.001) All the subscales of anger decreased significantly after the intervention (p < 0.001).Subjective happiness improved significantly (p < 0.001).

CONCLUSIONS

IBSR meditation improved various psychological scales among a general population sample. Further controlled studies should evaluate the clinical implementation of IBSR among the general population.

Economic burden of the therapeutic management of mental illnesses and its effect on household purchasing power

Cost or burden of illness studies for mental illnesses has helped define the magnitude of their negative effects on the household, community and national economy. Despite its many benefits, there is a paucity of these studies among Nigerians being managed for mental illnesses. This study was aimed at assessing the economic burden of mental illnesses and its effect on household purchasing power. The study was descriptive cross-sectional in design conducted among 284 out-patients with five categories of mental illnesses at the Neuropsychiatric Hospital, Aro recruited via a systematic sampling technique. Data collection was quantitative using a semi-structured interviewer-administered tool. Participants provided the actual direct costs and estimates of indirect costs incurred during their most recent inpatient admission and their first clinic visit after discharge. Parametric and non-parametric statistical tests were conducted on the direct and estimated indirect costs respectively after testing them for normality using the Q-Q plot with statistical significance determined at p<0.05. Almost 96% of respondents finance their healthcare costs by themselves or their family with >50% earning Collapse

Key Words Collapse

MESH Headings

• Adolescent
• Adult
• Aged
• Cost of Illness
• Costs and Cost Analysis
• Cross-Sectional Studies
• Family Characteristics
• Female
• Humans
• Male
• Mental Disorders/economics
• Mental Disorders/therapy
• Middle Aged

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Grants Collapse

Affiliation(s)

Afis A. Agboola Child and Adolescent Mental Health Unit, Federal Neuropsychiatric Hospital Aro, Abeokuta, Ogun state, South west, Nigeria
Oluwaseun T. Esan Department of Community Health, Faculty of Clinical Sciences, Obafemi Awolowo University, Ile-Ife, Osun State, South west, Nigeria
Oluwasegun T. Afolabi Department of Community Health, Faculty of Clinical Sciences, Obafemi Awolowo University, Ile-Ife, Osun State, South west, Nigeria
Taiwo A. Soyinka Department of Research and Training, Research Unit, Federal Neuropsychiatric Hospital Aro, Abeokuta, Ogun state, South west, Nigeria
Adedunmola O. Oluwaranti Residency Training Program, Federal Neuropsychiatric Hospital Aro, Abeokuta, Ogun state, South west, Nigeria
Adeniji Adetayo Residency Training Program, Federal Neuropsychiatric Hospital Aro, Abeokuta, Ogun state, South west, Nigeria

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Sickness absence indicating depressive symptoms of working population in South Korea

BACKGROUND

Sickness absence has been regarded as an important indicator of workers' health and work productivity. This study is aimed to evaluate the association between depressive symptoms and sickness absence in workers of South Korea.

METHODS

We used nationwide cross-sectional survey data from 2889 individuals in the working population aged over 19 years in South Korea. Depressive symptoms were measured using Patient Health Questionnaire-9 (PHQ-9). Those respondents who scored above 10 on PHQ-9 were regarded as having depressive symptoms. Sickness absence was considered a binary variable with an absence of at least 1 day in the past month. The survey instrument contained questions about sociodemographic factors, lifestyle, work-related factors, and chronic illnesses. Logistic regression models were used to find odds ratios and confidence intervals.

RESULTS

The prevalence of sickness absence was found to be overall 4.6%. The adjusted odds ratio of sickness absence with depressive symptoms (PHQ-9 score ≥ 10) was 3.63 (Confidence Interval: 2.13-6.20) after controlling of possible confounders. Compared to minimal depressive symptoms (PHQ-9 < 5), the differences between other types of severity of depressive symptoms (mild, moderate, and moderately severe) in terms of mean of all sickness absences were more significant.

LIMITATION

The sickness absence based on the memory of the respondent in this study may result in a recall bias.

CONCLUSIONS

Incidence of at least 1 day of sickness absence per month increased the risk of depressive symptoms after controlling for the possible confounding factors in general working population. It may be necessary to consider strategies for assessing depression in the workers who take sick leaves.

Estimating cost savings of pharmacogenetic testing for depression in real-world clinical settings

The burden of depression significantly impacts the patient, the health care system, and society, at large. Medication management guided by pharmacogenetics has been shown to increase therapeutic efficacy and improve symptoms in patients diagnosed with depression, but limited data are available on the cost savings of pharmacogenetic-guided interventions outside of psychiatric clinical specialties. Our study utilizes published health care costs and clinical patient outcome data to model the economic impact of pharmacogenetic-guided treatment for depression in a variety of clinical settings. Assuming a test cost of USD$2,000 for pharmacogenetic testing, the model predicts a savings of USD$3,962 annually per patient with pharmacogenetic-guided medication management.

The development and validation of Huaxi emotional-distress index (HEI): A Chinese questionnaire for screening depression and anxiety in non-psychiatric clinical settings

BACKGROUND

Depression and anxiety among general hospital patients are common and under-recognized in China. This study aimed toward developing a short questionnaire for screening depression and anxiety in non-psychiatric clinical settings, and to test its reliability and validity.

METHODS

The item pool which included 35 questions about emotional distress was drafted through a comprehensive literature review. An expert panel review and the first clinical test with 288 general hospital patients were conducted for the primary item selection. The second clinical test was performed to select the final item in 637 non-psychiatric patients. The reliability and validity of the final questionnaire were tested in 763 non-psychiatric patients, in which 211 subjects were interviewed by psychiatrists using Mini International Neuropsychiatric Interview (MINI). Multiple data analysis methods including principal components analysis (PCA), item response theory (IRT), and receiver operating characteristic (ROC) curve were used to select items and validate the final questionnaire.

RESULTS

The series selection of items resulted in a 9-item questionnaire, namely Huaxi Emotional-distress Index (HEI). The Cronbach's α coefficient of HEI was 0.90. The PCA results showed a unidimensional construct. The area under the ROC curve (AUC) was 0.88 when compared with MINI interview. Using the optimal cut-off score of HEI (≥11), the sensitivity and specificity were 0.880 and 0.766, respectively.

CONCLUSIONS

The HEI is considered as a reliable and valid instrument for screening depression and anxiety, which may have substantial clinical value to detect patients' emotional disturbances especially in the busy non-psychiatric clinical settings in China.

Depression and the Heart: A Systematic Overview of Definition, Measurement, Consequences and Treatment of Depression in Cardiovascular Disease

Depression is an independent risk factor in the pathogenesis of cardiovascular disease and it is a prevalent disorder after cardiovascular disease associated with negative outcome in terms of mortality and morbidity. It is a dangerous condition requiring adequate screening and treatment, however, it often remains undiagnosed and thus untreated. Non-psychiatric healthcare workers, like nurses, general practitioners, physiotherapists and cardiologists are the health providers most closely involved in the management of patients with cardiovascular disease. They can play an important role in screening cardiovascular patients for depressive symptoms and in referring them for treatment. The purpose of this article therefore is to provide an evidence-based framework, aiming to educate non-psychiatric healthcare providers on depressive disorder in the context of chronic cardiovascular disease. In this paper, an overview of the definition, prevalence and consequences of depression will be discussed. Moreover, an overview of measurement methods and treatment modalities for depression will be provided. In addition, a step-by-step guide is provided in order to help non-psychiatric healthcare providers in dealing with depressed patients.

Prevalence and Costs of Chronic Conditions in the VA Health Care System

Chronic conditions are among the most common causes of death and disability in the United States. Patients with such conditions receive disproportionate amounts of health care services and therefore cost more per capita than the average patient. This study assesses the prevalence among the Department of Veterans Affairs (VA) health care users and VA expenditures (costs) of 29 common chronic conditions. The authors used regression to identify the marginal impact of these conditions on total, inpatient, outpatient, and pharmacy costs. Excluding costs of contracted medical services at non-VA facilities, total VA health care expenditures in fiscal year 1999 (FY1999) were $14.3 billion. Among the 3.4 million VA patients in FY1999, 72 percent had 1 or more of the 29 chronic conditions, and these patients accounted for 96 percent of the total costs ($13.7 billion). In addition, 35 percent (1.2 million) of VA health care users had 3 or more of the 29 chronic conditions. These individuals accounted for 73 percent of the total cost. Overall, VA health care users have more chronic diseases than the general population.

A New Metric for Quantifying the Relative Impact of Risk Factors on Loss of Working Life Illustrated in a Population of Working Dogs

In a resource-limited world, organisations attempting to reduce the impact of health or behaviour issues need to choose carefully how to allocate resources for the highest overall impact. However, such choices may not always be obvious. Which has the biggest impact? A large change to a small number of individuals, or a small change to a large number of individuals? The challenge is identifying the issues that have the greatest impact on the population so potential interventions can be prioritised. We addressed this by developing a score to quantify the impact of health conditions and behaviour problems in a population of working guide dogs using data from Guide Dogs, UK. The cumulative incidence of different issues was combined with information about their impact, in terms of reduction in working life, to create a work score. The work score was created at population-level to illustrate issues with the greatest impact on the population and to understand contributions of breeds or crossbreeds to the workforce. An individual work deficit score was also created and means of this score used to illustrate the impact on working life within a subgroup of the population such as a breed, or crossbreed generation. The work deficit scores showed that those removed for behavioural issues had a greater impact on the overall workforce than those removed for health reasons. Additionally trends over time illustrated the positive influence of interventions Guide Dogs have made to improve their workforce. Information highlighted by these scores is pertinent to the effort of Guide Dogs to ensure partnerships are lasting. Recognising that the scores developed here could be transferable to a wide variety of contexts and species, most notably human work force decisions; we discuss possible uses and adaptations such as reduction in lifespan, quality of life and yield in production animals.

Physical Activity as a Nonpharmacological Treatment for Depression: A Review

Physical activity is increasingly being cited as an alternative to more traditional drug treatments for treating depression. Although an increasing amount of research has investigated this theory, much of the literature has been criticized from a methodological perspective. Given rising concern for the increasing costs of mental health care, it is timely and important to examine valid, reliable, and objective research findings on the potential role of physical activity as a low-cost non-pharmacological intervention for the treatment of depression. This article reviews cross-sectional, longitudinal, and randomized studies that investigated the role of physical activity in the prevention and alleviation of depression. The review found that although there is undoubtedly a need for more research with a greater emphasis on methodological strength, the scientific literature is generally supportive of the beneficial effects of aerobic and nonaerobic exercise on depression in clinically and nonclinically depressed adults. Implications for public health are discussed.

Detecting and Evaluating Depression Among Elderly Patients in Home Health

Among home health patients, depression is a debilitating and treatable psychiatric condition that often remains undiagnosed and reduces quality of life, social interactions, daily functioning, and treatment adherence. Untreated major depression increases functional decline; costly medical, emergency, and mental health visits; and reliance on disability or welfare. In the worst case, many patients decide that life is not worth living and attempt suicide. Screening and careful assessment are the keys to the detection and evaluation of depression. Scant literature exists to guide the evaluation and management of depressive disorders in home care. This article illustrates the evaluation and management of depression. The home care provider is in a key position to detect, evaluate, and intervene with depression and monitor its complications such as suicide risk. Evaluating depression is a professional nursing responsibility requiring judgment and the ability to understand subtle dynamics of loss, hopelessness, and emotional pain.

Future Directions for the Implementation and Dissemination of Statewide Developmental-Behavioral Pediatric Integrated Health Care

The integration of mental health and pediatric health care services has long been a goal for both research and practice. With the advent of federal policies developed to mandate clinical efficiency across the health care spectrum, this issue is becoming more salient. Applied literature on this topic is only recently emerging, however, and there are limited contextual examples to guide program development, research, and refinement. This article presents background information relevant to the development of such a program (the Center for Advancement of Youth). The cultural and organizational contexts for the project are discussed, with particular emphasis on models for cooperation among several institutions of varying size and scope. The implications for the future of tangible research in this area are also discussed, with attention to extending lessons learned to diverse settings motivated to integrate various aspects of health care service provision.

Integrating Telemental Healthcare with the Patient-Centered Medical Home Model

OBJECTIVE

The purpose of this article is to discuss how telemental healthcare and the patient-centered medical home (PCMH) can be integrated to improve the quality of mental healthcare available.

METHODS

This article outlines the components of a PCMH, and how the needs of this type of system of care can benefit from telemental healthcare.

RESULTS

The princples of PCMHs are being increasingly promoted in a variety of settings. In order to fulfill these principles, mental heathcare must be a integral part of the care provided to patients within the PCMH. The mental healthcare workforce is inadequate to provide care for patients, particularly in rural and high-poverty areas. Telemental healthcare provides a means to extend mental health services to the PCMHs using a variety of models.

CONCLUSIONS

Telemental healthcare offers unique opportunities to bridge the need for mental healthcare integration in the PCMH for all patients.

Spirituality and Religiousness are Associated With Fewer Depressive Symptoms in Individuals With Medical Conditions

BACKGROUND

The increased prevalence of depressive symptoms among adults diagnosed with chronic health issues has been largely documented.

OBJECTIVES

Research is needed to clarify the effect of religiousness/spirituality in relation to chronic health conditions and depression, to establish whether these variables can serve as protective factors.

METHODS

Self-report data from a nationwide study of spirituality and health were used. Individuals with at least 1 chronic illness (N = 1696) formed the subsample for this study. Religiousness/spirituality variables included frequency of church attendance, prayer, religious meaning, religious hope, general meaning, general hope, peace, and view of God. Other variables included depressive symptoms and demographics (age, gender, ethnicity, and education).

RESULTS

A series of hierarchical regression analyses revealed that chronic conditions were consistently associated with more depressive symptoms. Greater religiousness/spirituality was significantly associated with fewer depressive symptoms, contributing 16% of the variance above demographics and the number of chronic illnesses. The religiousness/spirituality variables conferring the greatest protection against depression were psychospiritual variables (general meaning and general hope, followed by peace). Also significant but making a smaller contribution to less depression were church attendance, religious meaning, religious hope, and positive view of God. Only prayer did not relate significantly to less depression.

CONCLUSION

Maintaining a sense of spirituality or religiousness can benefit well-being of individuals diagnosed with a chronic health condition, especially having meaning, maintaining hope, and having a sense of peace. Patients could potentially benefit from being offered the resources that support their spiritual/religious practices and beliefs as they cope with chronic illness.

Depression-related treatment and costs in Germany: Do they change with comorbidity? A claims data analysis

BACKGROUND

Existing diverse bottom-up estimations of direct costs associated with depression in Germany motivated a detailed patient-level analysis of depression-related treatment (DRT), -costs (DRC) and Comorbidity.

METHODS

A large sickness fund's claims data was used to retrospectively identify patients aged 18-65 years with new-onset depression treatment between January 1st and February 15th 2010, and follow them until December 31st 2010, describe DRT, estimate associated DRC, and predict DRC with a generalised linear model.

RESULTS

A total of 18,139 patients were analysed. Mean direct DRC were €783. Predictors of DRC regarding psychiatric comorbidities were: "Delusion, psychotic disorders and personality disorders" (DRC-ratio 1.72), "Alcohol/drug addiction" (1.82), "abuse of alcohol/drugs" (1.57). Predictors of DRC regarding medical comorbidities were: "Rheumatoid arthritis" (0.77), "atherosclerosis" (0.65), "pregnancy" (0.66), and "Osteoarthritis" (1.87). Of all patients, 60.8% received their most intense/specialised DRT from a general practitioner, a medical specialist (23.7%), a psychotherapist (8.0%), a medical specialist and psychotherapist (2.9%), or in hospital (4.6%). Serious psychiatric comorbidity nearly tripled depression-related hospitalisation rates.

LIMITATIONS

Seasonal affective disorder and missing psychiatric outpatient clinic data must be considered.

CONCLUSIONS

Estimated DRC are significantly below the assessment of the German national guideline. Differing definitions of observation period and cost attribution might explain differing German DRC results. Signs of hospital psychiatric comorbidity bias indicate overestimation of hospital DRC. Identified associations of DRC with certain medical diseases in older adults warrant further research. Up to one quarter of patients with severe depression diagnosis might lack specialist treatment.

Urinary phthalate metabolites and depression in an elderly population: National Health and Nutrition Examination Survey 2005-2012

Previous animal studies have demonstrated that phthalate exposure is associated with depression-like behaviors. However, no human study has explored this relationship. We explored the association between urinary phthalate metabolite concentrations and depression in a nationally representative sample of the U.S. elderly population. We analyzed 2030 participants aged 60 years or older with available data on phthalates and depression from the 2005 to 2012 National Health and Nutrition Examination Survey (NHANES). We selected 10 urinary phthalate metabolites with a weighted detection rate >60%. Depression was defined as a 9-item Patient Health Questionnaire score ≥10. The models were adjusted for age, sex, race/ethnicity, education level, income-to-poverty ratio, health insurance coverage, marital status, smoking status, alcohol consumption, moderate physical activity, body mass index, comorbidity status, NHANEs cycle, and urinary creatinine levels. One-unit increases in log-transformed mono-(3-carboxypropyl) phthalate (MCPP) (odds ratio [OR]=1.24, 95% confidence interval [CI]=1.02-1.52) and mono(carboxynonyl) phthalate (MCNP) (OR=1.42, 95% CI=1.15-1.75) were positively associated with depression. When we stratified the urinary phthalate metabolites into quartiles, the highest quartiles (Q4) of MCNP (OR=2.57, 95% CI=1.25-5.27) and mono-n-butyl phthalate (MBP) (OR=2.40, 95% CI=1.10-5.22) were associated with depression compared with the lowest quartiles (Q1). Concentrations of urinary phthalate metabolites MCPP, MCNP, and MBP were positively associated with the risk of depression in a representative sample of the U.S. elderly population. However, the present cross-sectional study is hypothesis generating and the associations need to be investigated through further longitudinal studies.

Bridging the gap: determinants of undiagnosed or untreated urinary incontinence in women

BACKGROUND

More than a third of middle-aged or older women suffer from urinary incontinence, but less than half undergo evaluation or treatment for this burdensome condition. With national organizations now including an assessment of incontinence as a quality performance measure, providers and health care organizations have a growing incentive to identify and engage these women who are undiagnosed and untreated.

OBJECTIVE

We sought to identify clinical and sociodemographic determinants of patient-provider discussion and treatment of incontinence among ethnically diverse, community-dwelling women.

STUDY DESIGN

We conducted an observational cohort study from 2003 through 2012 of 969 women aged 40 years and older enrolled in a Northern California integrated health care delivery system who reported at least weekly incontinence. Clinical severity, type, treatment, and discussion of incontinence were assessed by structured questionnaires. Multivariable regression evaluated predictors of discussion and treatment.

RESULTS

Mean age of the 969 participants was 59.9 (±9.7) years, and 55% were racial/ethnic minorities (171 black, 233 Latina, 133 Asian or Native American). Fifty-five percent reported discussing their incontinence with a health care provider, 36% within 1 year of symptom onset, and with only 3% indicating that their provider initiated the discussion. More than half (52%) reported being at least moderately bothered by their incontinence. Of these women, 324 (65%) discussed their incontinence with a clinician, with 200 (40%) doing so within 1 year of symptom onset. In a multivariable analysis, women were less likely to have discussed their incontinence if they had a household income < $30,000/y vs ≥ $120,000/y (adjusted odds ratio [AOR], 0.49, 95% confidence interval [CI], 0.28-0.86) or were diabetic (AOR, 0.71, 95% CI, 0.51-0.99). They were more likely to have discussed incontinence if they had clinically severe incontinence (AOR, 3.09, 95% CI, 1.89-5.07), depression (AOR, 1.71, 95% CI, 1.20-2.44), pelvic organ prolapse (AOR, 1.98, 95% CI, 1.13-3.46), or arthritis (AOR, 1.44, 95% CI, 1.06-1.95). Among the subset of women reporting at least moderate subjective bother from incontinence, black race (AOR, 0.45, 95% CI, 0.25-0.81, vs white race) and income < $30,000/y (AOR, 0.37, 95% CI, 0.17-0.81, vs ≥ $120,000/y) were associated with a reduced likelihood of discussing incontinence. Those with clinically severe incontinence (AOR, 2.93, 95% CI, 1.53-5.61, vs low to moderate incontinence by the Sandvik scale) were more likely to discuss it with a clinician.

CONCLUSION

Even in an integrated health care system, lower income was associated with decreased rates of patient-provider discussion of incontinence among women with at least weekly incontinence. Despite being at increased risk of incontinence, diabetic women were also less likely to have discussed incontinence or received care. Findings provide support for systematic screening of women to overcome barriers to evaluation and treatment.

Cost-effectiveness of integrated collaborative care for comorbid major depression in patients with cancer

OBJECTIVES

Comorbid major depression is associated with reduced quality of life and greater use of healthcare resources. A recent randomised trial (SMaRT, Symptom Management Research Trials, Oncology-2) found that a collaborative care treatment programme (Depression Care for People with Cancer, DCPC) was highly effective in treating depression in patients with cancer. This study aims to estimate the cost-effectiveness of DCPC compared with usual care from a health service perspective.

METHODS

Costs were estimated using UK national unit cost estimates and health outcomes measured using quality-adjusted life-years (QALYs). Incremental cost-effectiveness of DCPC compared with usual care was calculated and scenario analyses performed to test alternative assumptions on costs and missing data. Uncertainty was characterised using cost-effectiveness acceptability curves. The probability of DCPC being cost-effective was determined using the UK National Institute for Health and Care Excellence's (NICE) cost-effectiveness threshold range of £ 20,000 to £ 30,000 per QALY gained.

RESULTS

DCPC cost on average £ 631 more than usual care per patient, and resulted in a mean gain of 0.066 QALYs, yielding an incremental cost-effectiveness ratio of £ 9549 per QALY. The probability of DCPC being cost-effective was 0.9 or greater at cost-effectiveness thresholds above £ 20,000 per QALY for the base case and scenario analyses.

CONCLUSIONS

Compared with usual care, DCPC is likely to be cost-effective at the current thresholds used by NICE. This study adds to the weight of evidence that collaborative care treatment models are cost-effective for depression, and provides new evidence regarding their use in specialist medical settings.

Predicting Depression among Patients with Diabetes Using Longitudinal Data. A Multilevel Regression Model

INTRODUCTION

This article is part of the Focus Theme of Methods of Information in Medicine on "Big Data and Analytics in Healthcare".

BACKGROUND

Depression is a common and often undiagnosed condition for patients with diabetes. It is also a condition that significantly impacts healthcare outcomes, use, and cost as well as elevating suicide risk. Therefore, a model to predict depression among diabetes patients is a promising and valuable tool for providers to proactively assess depressive symptoms and identify those with depression.

OBJECTIVES

This study seeks to develop a generalized multilevel regression model, using a longitudinal data set from a recent large-scale clinical trial, to predict depression severity and presence of major depression among patients with diabetes.

METHODS

Severity of depression was measured by the Patient Health Questionnaire PHQ-9 score. Predictors were selected from 29 candidate factors to develop a 2-level Poisson regression model that can make population-average predictions for all patients and subject-specific predictions for individual patients with historical records. Newly obtained patient records can be incorporated with historical records to update the prediction model. Root-mean-square errors (RMSE) were used to evaluate predictive accuracy of PHQ-9 scores. The study also evaluated the classification ability of using the predicted PHQ-9 scores to classify patients as having major depression.

RESULTS

Two time-invariant and 10 time-varying predictors were selected for the model. Incorporating historical records and using them to update the model may improve both predictive accuracy of PHQ-9 scores and classification ability of the predicted scores. Subject-specific predictions (for individual patients with historical records) achieved RMSE about 4 and areas under the receiver operating characteristic (ROC) curve about 0.9 and are better than population-average predictions.

CONCLUSIONS

The study developed a generalized multilevel regression model to predict depression and demonstrated that using generalized multilevel regression based on longitudinal patient records can achieve high predictive ability.

Guideline concordant detection and management of depression among Alaska Native and American Indian people in primary care

BACKGROUND

A tribal health organization in Alaska implemented a primary care depression screening, detection and management initiative amongst 55,000 Alaska Native/American Indian people (AN/AIs).

OBJECTIVES

(a) To describe the proportion of AN/AIs screening positive for depression with depression noted or diagnosed and proportion with guideline concordant management and (b) to assess whether management varied by patient and provider factors.

RESEARCH DESIGN

Secondary analysis of electronic and paper medical record information of 400 AN/AIs.

MEASURES

Provider variables, patient demographics and patient clinical factors were electronically queried. Manual chart audits assessed depression notation, diagnoses and management within 12 weeks of positive screening. Multilevel ordinal logistic modelling assessed management by patient and provider factors.

RESULTS

A depression diagnosis was present in 141 (35%) charts and 151 (38%) had depressive symptoms noted. Detection was higher among AN/AIs with moderate and severe depression (p<0.001). In total, 258 patients (66%) received guideline concordant management, 32 (8%) had some management, and 110 (28%) received no management. Younger patient age and increased provider tenure increased odds of management.

CONCLUSIONS

Most AN/AIs screening positive for depression received initial guideline concordant management. Additional outreach to older patients and additional support for providers newer to practices appears warranted.

Patient-reported depression measures in cancer: a meta-review

The patient-reported depression measures that perform best in oncology settings have not yet been identified. We did a meta-review to integrate the findings of reviews of more than 50 depression measures used in adults with, or recovering from, any type of cancer. We searched Medline, PsycINFO, Embase, and grey literature from 1999 to 2014 to identify 19 reviews representing 372 primary studies. 11 reviews were rated as being of high quality (defined as meeting at least 20 criteria in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement). The Hospital Anxiety Depression Scale (HADS) was the most thoroughly evaluated measure, but was limited by cutpoint variability. The HADS had moderate screening utility indices and was least recommended in advanced cancer or palliative care. The Beck Depression Inventory was more generalisable across cancer types and disease stages, with good indices for screening and case finding. The Center for Epidemiologic Studies Depression Scale was the best-weighted measure in terms of responsiveness. This meta-review provides a comprehensive overview of the strengths and limitations of available depression measures. It can inform the choice of the best measure for specific settings and purposes.

Comorbidity of depression with physical disorders: research and clinical implications

Depression is prevalent in patients with physical disorders, particularly in those with severe disorders such as cancer, stroke, and acute coronary syndrome. Depression has an adverse impact on the courses of these diseases that includes poor quality of life, more functional impairments, and a higher mortality rate. Patients with physical disorders are at higher risk of depression. This is particularly true for patients with genetic and epigenetic predictors, environmental vulnerabilities such as past depression, higher disability, and stressful life events. Such patients should be monitored closely. To appropriately manage depression in these patients, comprehensive and integrative care that includes antidepressant treatment (with considerations for adverse effects and drug interactions), treatment of the physical disorder, and collaborative care that consists of disease education, cognitive reframing, and modification of coping style should be provided. The objective of the present review was to present and summarize the prevalence, risk factors, clinical correlates, current pathophysiological aspects including genetics, and treatments for depression comorbid with physical disorders. In particular, we tried to focus on severe physical disorders with high mortality rates, such as cancer, stroke, and acute coronary syndrome, which are highly comorbid with depression. This review will enhance our current understanding of the association between depression and serious medical conditions, which will allow clinicians to develop more advanced and personalized treatment options for these patients in routine clinical practice.

Shared neurobiological pathways between type 2 diabetes and depressive symptoms: a review of morphological and neurocognitive findings

Type 2 diabetes (T2D) patients are twice as likely to experience depressive symptoms than people without T2D, resulting in greater economic burden, worse clinical outcomes, and reduced quality of life. Several overlapping pathophysiological processes including hypothalamic-pituitary-adrenal axis hyperactivity, sympathetic nervous system activation, and elevated pro-inflammatory biomarkers are recognized as playing a role between T2D and depressive symptoms. However, other neurobiological mechanisms that may help to further link these comorbidities have not been extensively reviewed. Reduced neuroplasticity in brain regions sensitive to stress (e.g., hippocampus) may be associated with T2D and depressive symptoms. T2D patients demonstrate reduced neuroplasticity including morphological/volumetric abnormalities and subsequent neurocognitive deficits, similar to those reported by patients with depressive symptoms. This review aims to summarize recent studies on morphological/volumetric abnormalities in T2D and correlated neurocognitive deficits. Modifying factors that contribute to reduced neuroplasticity will also be discussed. Integrating reduced neuroplasticity with other biological correlates of T2D and depressive symptoms could enhance future therapeutic interventions and further disentangle the bidirectional associations between these comorbidities.

Depressive symptoms and access to mental health care in women screened for postpartum depression who lose health insurance coverage after delivery: findings from the Translating Research into Practice for Postpartum Depression (TRIPPD) effectiveness study

OBJECTIVE

To determine the impact of losing health insurance coverage on perceived need for and access to mental health care in women screened for postpartum depression (PPD) in primary care settings.

PATIENTS AND METHODS

The study sample included 2343 women enrolled in a 12-month, multisite, randomized trial that compared clinical outcomes of a comprehensive PPD screening and management program with usual care (March 1, 2006, through August 31, 2010). Screening for PPD occurred at the first postpartum visit (5-12 weeks) using the Edinburgh Postnatal Depression Scale followed by the 9-item Patient Health Questionnaire. Insurance status during the prenatal period, at delivery, and during the first postpartum year and perceived need for and access to mental health care during the first postpartum year were assessed via questionnaires completed by individual patients and participating practices.

RESULTS

Rates of uninsured increased from 3.8% during pregnancy and delivery (n=87 of 2317) to 10.8% at the first postpartum visit (n=253 of 2343) and 13.7% at any subsequent visit to the practice after 2 months post partum (n=226 of 1646) (P<.001, both comparisons vs baseline). For patients with data on insurance type during follow-up, insurance loss occurred primarily in Medicaid beneficiaries. Nine-item Patient Health Questionnaire scores and self-reported need for mental health care did not differ significantly between patients who remained insured and those who lost insurance during the first postpartum year. However, of patients who reported the need for mental health care, 61.1% of the uninsured (n=66 of 108) vs 27.1% of the insured (n=49 of 181) reported an inability to obtain mental health care (P<.001).

CONCLUSION

Loss of insurance during the first postpartum year did not significantly affect depressive symptoms or perceived need for mental health care but did adversely affect self-reported ability to obtain mental health care.

The Effect of Ginkgo biloba and Camellia sinensis Extracts on Psychological State and Glycemic Control in Patients with Type 2 Diabetes Mellitus

Interest in finding natural antioxidants for use in food or medical materials to prevent free radical imbalance has increased considerably over the past years. The aim of this research was to evaluate changes in glycemic control and psychological state of patients with type 2 diabetes mellitus (T2DM) after use of antioxidant plant preparations. Fifty-six patients with T2DM were randomly allocated to receive standardized Ginkgo biloba L. leaves dry extract, green tea dry extract, or placebo capsules. Diabetes glycemic control measured as glycated hemoglobin (HbA1c) level, antioxidant state and psychological data were evaluated at baseline, after 9 and 18 months of using either antioxidant preparations or placebo. The level of perceived stress lowered significantly after 9 months ( p=0.038) and 18 months ( p=0.030), and the psychological aspect of quality of life significantly improved after 18 months ( p=0.019) of use of G. biloba extract. No significant differences were detected after using green tea extract. In patients using placebo, significant lowering of HbA1c level was observed after 18 months ( p=0.017). In conclusion, antioxidant G. biloba leaf extract exhibited a mild effect on psychological state and a trend of improving glycemic control in patients with type 2 diabetes mellitus.

Potentially traumatic events and serious life stressors are prospectively associated with frequency of doctor visits and overnight hospital visits

OBJECTIVE

Cumulative lifetime exposure to potentially traumatic events and serious life stressors has been linked with both mental and physical health problems; however, less is known about the association between exposure to potentially traumatic events and serious life stressors with health care use. We investigated whether a higher number of potentially traumatic events and serious life stressors were prospectively associated with an increased number of doctor visits and nights spent in the hospital.

METHODS

Participants were drawn from the Health and Retirement Study, a prospective and nationally representative study of adults aged 50+ in the United States (n=7168). We analyzed the data using a generalized linear model with a gamma distribution and log link.

RESULTS

A higher number of potentially traumatic events and serious life stressors were associated with an increased number of doctor visits and nights spent in the hospital. On a 10-point scale, each additional potentially traumatic event or serious life stressor was associated with an 8% increase in doctor visits after controlling for sociodemographic factors (RR=1.08, 95% CI=1.06-1.11; p<.001). Each additional potentially traumatic event or serious life stressor was also associated with an 18% increase in the number of nights spent in the hospital after controlling for sociodemographic factors (RR=1.18, 95% CI=1.10-1.27; p<.001).

CONCLUSION

Exposure to potentially traumatic events and serious life stressors is associated with increased doctor visits and nights spent in the hospital, which may have important implications for the current standard of care.

Impact of mindfulness-based cognitive therapy on health care utilization: a population-based controlled comparison

OBJECTIVE

Elevated rates of mood and anxiety disorders among high utilizers of health care have been suggested as one driver of increased service use. We compared the impact of Mindfulness Based Cognitive Therapy (MBCT), a structured group treatment, on the rates of health care utilization with matched control participants receiving non-MBCT group therapy.

METHODS

Using Ontario health administrative data, we created a retrospective cohort of population-based patients receiving MBCT and an age- and gender-matched (3:1) cohort of non-MBCT group therapy controls. Subjects were recruited between 2003 and 2010 and stratified according to high/low rates of primary care utilization, with the high utilization cohort being the cohort of interest. The primary outcome was a reduction in an aggregate measure of non-mental health utilization comprising Emergency Department, non-mental health primary care, and non-psychiatrist specialist visits.

RESULTS

There were 10,633 MBCT recipients, 4851 (46%) of whom were high utilizers. The proportion of high utilizers was 13,274 (45%, N=29,795) for non-MBCT group therapy controls. Among high utilizers, there was a significant reduction in non-mental health utilization among MBCT recipients compared to non-MBCT group therapy recipients (0.55 (0.21-0.89)) suggesting that for every two MBCT patients treated, there is a reduction in 1 non-mental health visit.

CONCLUSION

Among high utilizers of primary care, MBCT reduced non-mental health care utilization 1year post-therapy compared to non-MBCT, group therapy controls. The reductions suggest that MBCT, an established treatment modality for a variety of mental illnesses, has the added benefit of reducing distress-related high health care utilization.