General medical and specialty mental health service use for major depression

Health system use among patients with mental health conditions in a community based sample in Toronto, Canada: A retrospective cohort study

Objective

To identify hospital and primary care health service use among people with mental health conditions or addictions in an integrated primary-secondary care database in Toronto, Ontario.

Method

This was a retrospective cohort study of adults with mental health diagnoses using data from the Health Databank Collaborative (HDC), a primary care-hospital linked database in Toronto. Data were included up to March 31^st 2019. Negative binomial and logistic regression were used to evaluate associations between health care utilization and various patient characteristics and mental health diagnoses.

Results

28,482 patients age 18 or older were included. The adjusted odds of at least one mental health diagnosis were higher among younger patients (18–30 years vs. 81+years aOR = 1.87; 95% CI:1.68–2.08) and among female patients (aOR = 1.35; 95% CI: 1.27–1.42). Patients with one or more mental health diagnoses had higher adjusted rates of hospital visits compared to those without any mental health diagnosis including addiction (aRR = 1.74, 95% CI: 1.58–1.91) and anxiety (aRR = 1.28, 95% CI: 1.23–1.32). 14.5% of patients with a psychiatric diagnosis were referred to the hospital for specialized psychiatric services, and 38% of patients referred were eventually seen in consultation. The median wait time from the date of referral to the date of consultation was 133 days.

Conclusions

In this community, individuals with mental health diagnoses accessed primary and hospital-based health care at greater rates than those without mental health diagnoses. Wait times for specialized psychiatric care were long and most patients who were referred did not have a consultation. Information about services for patients with mental health conditions can be used to plan and monitor more integrated care across sectors, and ultimately improve outcomes.

Treatment of Veterans with Psychiatric Diagnoses Nationally in the Veterans Health Administration: A Comparison of Service Delivery by Mental Health Specialists and Other Providers

Patients with psychiatric disorders are treated by both mental health specialists and non-specialists. We use national data from the Veterans Health Administration to evaluate changing proportions of patients seen exclusively by non-specialists during the study year (FY 2012) limit as well as differences in socio-demographic, clinical and service use characteristics. There has been a five-fold increase in veterans with mental disorders seen by non-specialists over 20 years from 7 to 38%, findings similar to those in non-VA settings. Veterans treated by mental health specialists were younger, more likely to have been homeless and disabled, and had more severe and more numerous psychiatric diagnoses. There is a need to maintain specialty services and to strengthen non-specialty care through education and research.

Depression Treatment Status of Economically Disadvantaged African American Older Adults

Background: It is known that depression remains largely untreated in underserved communities. Hence, it is desirable to gain more knowledge on the prevalence and correlates of untreated depression among African-American (AA) older adults in economically disadvantaged areas. This knowledge may have the public health benefit of improving detection of AA older adults with depression who are at high risk of not receiving treatment, thereby reducing this health disparity. Objective: To study health and social correlates of untreated depression among AA older adults in economically disadvantaged areas. Methods: Between 2015 and 2018, this cross-sectional survey was conducted in South Los Angeles. Overall, 740 AA older adults who were 55+ years old entered this study. Independent variables were age, gender, living arrangement, insurance type, educational attainment, financial strain, chronic medical conditions, and pain intensity. Untreated depression was the dependent variable. Logistic and polynomial regression models were used to analyze these data. Results: According to the polynomial regression model, factors such as number of chronic medical conditions and pain intensity were higher in individuals with depression, regardless of treatment status. As our binary logistic regression showed, age, education, and number of providers were predictive of receiving treatment for depression. Conclusion: Age, educational attainment, number of providers (as a proxy of access to and use of care) may be useful to detect AA older adults with depression who are at high risk of not receiving treatment. Future research may focus on decomposition of the role of individual-level characteristics and health system-level characteristics that operate as barriers and facilitators to AA older adults receiving treatment for depression.

Mental Health Service Utilization in Depressed Canadian Armed Forces Personnel

BACKGROUND

Major depression is prevalent, impactful, and treatable in military populations, but not all depressed personnel seek professional care in a given year. Care-seeking patterns (including the use of primary vs. specialty care) and factors associated with the likelihood of mental health service utilization in depressed military personnel are poorly understood.

METHODS

Our sample included 520 Regular Force respondents to the 2013 Canadian Forces Mental Health Survey. All study participants had past-year major depression. Subjects reported whether they had spoken about their mental health with at least one health professional in the past 12 months. We used multivariate Poisson regression to explore factors associated with past-year mental health service use.

RESULTS

Three-quarters of Canadian military personnel with past-year depression had sought mental health care in the previous 12 months. Among care-seeking personnel, 70% had seen a psychologist or psychiatrist, while 5% had exclusively received care from a primary care physician. Belief in the effectiveness of mental health care was the factor most strongly associated with care seeking. Female gender, functional impairments, and psychiatric comorbidities were also associated with care seeking. Surprisingly, stigma perceptions had no independent association with care seeking.

CONCLUSIONS

The proportion of depressed Canadian Armed Forces personnel who seek professional care and who access specialty mental health care is higher than in most other populations. However, an important minority of patients are not accessing health services. Efforts to further increase mental health service utilization in the Canadian military should continue to target beliefs about the effectiveness of mental health care.

Trajectories of antidepressant medication use in individuals before and after being granted disability pension due to common mental disorders- a nationwide register-based study

BACKGROUND

Early retirement caused by disability pension (DP) due to common mental disorders (CMDs) is frequent in European countries. Inadequate treatment, e.g., suboptimal antidepressant (AD) medication before DP can be crucial in such DP. This explorative study aimed to disentangle trajectories of AD based on defined daily dose (DDD) before and after granted DP, and to characterize the trajectories by socio-demographics and medical factors.

METHODS

All 4642 individuals in Sweden aged 19-64 with incident DP due to CMD in 2009-2010 were included. Trajectories of annual DDDs of AD were analysed over a 6-year period by a group-based trajectory method. Associations between socio-demographic or medical factors and different trajectories were estimated by chi2-test and multinomial logistic regression.

RESULTS

Five trajectories of ADs were identified. Three groups, comprising 34%, 34%, and 21% of the cohort, had constant AD levels before and after DP with mean annual DDDs of 29, 234, and 580, respectively. Two groups, each including 6% of the cohort, had increasing levels of DDDs, levelling off at around 1150 and 785 DDDs after DP. Particularly age, outpatient care due to mental diagnoses and DP diagnoses were significantly associated with different trajectories (p < 0.05). All the groups had a larger proportion of older individuals (> 50%, 45-64 years), except for the 'increasing low' group, where younger individuals were in majority (> 60%, 18-44 years), who more frequently exited labour market due to 'anxiety disorders', with lower education and more specialised healthcare before DP than the other groups.

CONCLUSION

The heterogeneity among the five trajectory groups was partly explained by age, the severity of the mental disorder and the DP diagnoses. DDDs of ADs, though on different levels, varied marginally before and after granted DP in the majority. Moreover, AD levels were very low in one third of the individuals. Early identification and focus on the 'increasing low' group might be important in order to identify individuals at risk for further increase in annual DDDs of ADs even after granted DP, and might also contribute in prevention of DP. Further detailed research regarding different groups is warranted.

Trajectories and characteristics of functional impairment before and after suicide attempt in young adults - a nationwide register-based cohort study

BACKGROUND

Despite high rates of youth suicide attempt, little is known about patterns of functional impairment in terms of sickness absence and disability pension (SA/DP) before and after an attempt. The aim was to identify SA/DP trajectories among young adults with or without suicide attempt and to describe associations of socio-demographic and clinical factors with such trajectories.

METHODS

This is a population-based cohort study of 5385 individuals aged 25-40 years with a first suicide attempt during 2007-2009. One control for each case without suicide attempt was matched by socio-demographic factors. Trajectories of annual SA/DP months over an eight-year period were analysed by group-based trajectory modelling. Associations between socio-demographic and clinical factors with trajectory groups were estimated by chi²-test and multinomial logistic regression.

RESULTS

Two groups of suicide attempters had low SA/DP levels over time (62%). One group had constantly high SA/DP levels (16%). The remaining two groups had increased SA/DP initially, which then decreased at different time points. Socio-demographic and clinical factors were associated with different trajectories (R² = 0.44). Suicide attempters with low levels of SA/DP were likely to be unemployed whereas a larger proportion of those with high levels of SA/DP had psychiatric health care before the suicide attempt, particularly due to schizophrenia and non-affective psychoses or personality disorders.

CONCLUSIONS

Young suicide attempters even with no/low levels of SA/DP were likely to be marginalised at the labour market. Schizophrenia/non-affective psychoses and personality disorders were important clinical factors for differentiating the levels of SA/DP among young suicide attempters.

The 12-month prevalence of depression and health care utilization in the general population of Latvia

BACKGROUND

This cross-sectional study aims to assess the 12-month prevalence of major and minor depression in the Latvian population, and to evaluate associated health care utilization.

METHODS

Trained interviewers conducted face-to-face interviews with a multistage stratified probability sample of the Latvian general population, ages 15-64 (n=3003). Participants were interviewed using the depression module of the Mini International Neuropsychiatric Interview. Self-reported health care utilization and somatic illness were also assessed. Multinomial logistic regressions were applied.

RESULTS

The 12-month prevalence of major depression was 7.9% (95%CI 7.0-8.9), while for minor depression it was 7.7% (95%CI 6.8-8.7). We did not find a substantial difference in the relative risk ratio (RRR 1.7 for female) for having major depression by gender. RRR of having major depression was higher for those who had used healthcare services six or more times (RRR 2.0), those who had three or more somatic disorders during the past 12 months (RRR 2.3), those who perceived their health status as being below average (RRR 8.3), and those who were occasional smokers (RRR 3.0). RRR of having minor depression was increased for those who had at least three somatic disorders (RRR 2.3), those who received disability pension (RRR 1.9), and those who perceived their health status to be below average (RRR 3.0).

LIMITATIONS

The study was cross-sectional. Other psychiatric comorbidity was not assessed.

CONCLUSIONS

This is the first population based study reporting the 12-month prevalence of depression in Latvia. Certain factors associated with depression have been found.

Gender-related patterns and determinants of recent help-seeking for past-year affective, anxiety and substance use disorders: findings from a national epidemiological survey

AIMS

To examine: (1) gender-specific determinants of help-seeking for mental health, including health professional consultation and the use of non-clinical support services and self-management strategies (SS/SM) and; (2) gender differences among individuals with unmet perceived need for care.

METHOD

Analyses focused on 689 males and 1075 females aged 16-85 years who met ICD-10 criteria for a past-year affective, anxiety or substance use disorder in an Australian community-representative survey. Two classifications of help-seeking for mental health in the previous year were created: (1) no health professional consultation or SS/SM, or health professional consultation, or SS/SM only, and; (2) no general practitioner (GP) or mental health professional consultation, or GP only consultation, or mental health professional consultation. Between- and within-gender help-seeking patterns were explored using multinomial logistic regression models. Characteristics of males and females with unmet perceived need for care were compared using chi-square tests.

RESULTS

Males with mental or substance use disorders had relatively lower odds than females of any health professional consultation (adjusted odds ratio [AOR] = 0.46), use of SS/SM only (AOR = 0.59), and GP only consultation (AOR = 0.29). Notably, males with severe disorders had substantially lower odds than females of any health professional consultation (AOR = 0.29) and GP only consultation (AOR = 0.14). Most correlates of help-seeking were need-related. Many applied to both genders (e.g., severity, disability, psychiatric comorbidity), although some were male-specific (e.g., past-year reaction to a traumatic event) or female-specific (e.g., past-year affective disorder). Certain enabling and predisposing factors increased the probability of health professional consultation for both genders (age 30+ years) or for males (unmarried, single parenthood, reliance on government pension). Males with unmet perceived need for care were more likely to have experienced a substance use disorder and to want medicine or tablets or social intervention, whereas their females peers were more likely to have experienced an anxiety disorder and to want counselling or talking therapy. For both genders, attitudinal/knowledge barriers to receiving the types of help wanted (e.g., not knowing where to get help) were more commonly reported than structural barriers (e.g., cost).

CONCLUSIONS

Findings suggest a need to address barriers to help-seeking in males with severe disorders, and promote GP consultation. Exploring gender-specific attitudinal/knowledge barriers to receiving help, and the types of help wanted, may assist in designing interventions to increase consultation. Mental health promotion/education efforts could incorporate information about the content and benefits of evidence-based treatments and encourage males to participate in other potentially beneficial actions (e.g., physical activity).

Effects of Prefracture Depressive Illness and Postfracture Depressive Symptoms on Physical Performance After Hip Fracture

OBJECTIVES

To compare the effect of prefracture depressive illness and postfracture depressive symptoms on changes in physical performance after hip fracture.

DESIGN

Longitudinal observational cohort.

SETTING

Baltimore metropolitan area.

PARTICIPANTS

Older adults with hip fracture (N = 255).

MEASUREMENTS

Prefracture depressive illness (from medical records) at baseline and postfracture depressive symptoms at 2 months (using the Center for Epidemiologic Studies Depression Scale) were measured. Physical performance was measured 2, 6, and 12 months after fracture using the Short Physical Performance Battery (SPPB), a composite metric of functional status with a score ranging from 0 to 12. Weighted estimating equations were used to assess mean SPPB over time, comparing participants with and without prefracture depressive illness and subjects with and without postfracture depressive symptoms.

RESULTS

Participants with prefracture depressive illness had an SPPB increase of 0.4 units (95% confidence interval (CI) = -0.5-1.3) from 2 to 6 months, smaller than the increase of 1.0 SPPB unit (95% CI = 0.4-1.6) in those without prefracture depressive illness. Participants with postfracture depressive symptoms had an SPPB increase of 0.2 units (95% CI = -1.0-1.5) from 2 to 12 months, and those without postfracture depressive symptoms had a larger increase of 1.2 units (95% CI = 0.6-1.8) over the same period. Nevertheless, prefracture depressive illness and postfracture depressive symptoms were not significantly associated with SPPB.

CONCLUSIONS

Neither prefracture depressive illness nor postfracture depressive symptoms were significantly associated with changes in physical performance after hip fracture, but the magnitude of estimates suggested possible clinically meaningful effects on functional recovery.

Trajectories of Work-Related Functional Impairment prior to Suicide

Background

Work-related functional impairment in terms of sickness absence and disability pension (SA/DP) has been reported to be associated with subsequent suicide. However, there is only limited knowledge on SA/DP patterns prior to suicide. The aim was to identify trajectories of work-related functional impairment prior to suicide and to describe associations of socio-demographic and medical factors with such trajectories.

Methods

This is a population-based retrospective cohort study of the 4 209 individuals aged 22–65 years who committed suicide during 2007–2010 in Sweden. Work-related functional impairment was measured as mean annual number of months of SA/DP. We analyzed trajectories of SA/DP during five years prior to suicide (i.e., 2002–2009) by a group-based trajectory method. Associations between socio-demographic and medical factors with different groups of trajectories were estimated by chi²-test and multinomial logistic regression.

Results

Five different functional impairment trajectory groups were identified prior to suicide. One group had constant low levels of SA/DP (46%), while 30% had constant high levels of SA/DP. Two groups (16%) showed increasing number of SA/DP months. The remaining 7% showed decreasing number of SA/DP months before the suicide. Sex, age, educational level, family situation, and diagnosis-specific healthcare were significantly associated with different trajectory groups (Likelihood ratio X² tests <0.05). A larger proportion of higher educated and younger men with a lower proportion of previous suicide attempts were found in the group with constant low levels. Opposite characteristics were displayed in the group with constant high levels.

Conclusions

This study identified five different groups of work-related functional impairment trajectories before suicide. These differences might be partly explained by the variations in socio-demographic profiles and health care consumptions five years before suicide.

Gender differences in general and specialty outpatient mental health service use for depression

BACKGROUND

This study ascertained gender-specific determinants of outpatient mental health (MH) service use for depression to highlight any gender disparities in barriers to care and explain how depressed men and women in need of care might differ in their help-seeking behaviour.

METHODS

Data used in this study came from the Canadian Community Health Survey on Mental Health and Well Being, cycle 1.2 (CCHS 1.2) conducted by Statistics Canada in 2002 (N = 36,984). The sample was limited to respondents filling criteria for a probable major depression in the 12 months prior to the interview (n = 1743). Gender-specific multivariate logistic regression analyses were carried out.

RESULTS

The results showed that 54.3% of respondents meeting criteria for major depression had consulted for mental health reasons in the year prior to interview. When looking at type of outpatient mental health service use, males were more likely to consult a general practitioner and a mental health specialist in the past year as opposed to females. However, females were more likely to consult a general practitioner only as opposed to no service use than males. Gender specific differences in determinants associated with outpatient service use included for males, lower adjusted household income, and for females, a younger age, the presence of social support, self-reported availability barriers, the presence of self-reported suicidal thoughts or attempt and a poorer self- perceived mental health.

CONCLUSIONS

Continued efforts to promote access to mental health care are needed for men and women affected by depression, and this, to target specific vulnerable populations and increase utilization rates.

Community-partnered evaluation of depression services for clients of community-based agencies in under-resourced communities in Los Angeles

BACKGROUND

As medical homes are developing under health reform, little is known regarding depression services need and use by diverse safety-net populations in under-resourced communities. For chronic conditions like depression, primary care services may face new opportunities to partner with diverse community service providers, such as those in social service and substance abuse centers, to support a collaborative care model of treating depression.

OBJECTIVE

To understand the distribution of need and current burden of services for depression in under-resourced, diverse communities in Los Angeles.

DESIGN

Baseline phase of a participatory trial to improve depression services with data from client screening and follow-up surveys.

PARTICIPANTS

Of 4,440 clients screened from 93 programs (primary care, mental health, substance abuse, homeless, social and other community services) in 50 agencies, 1,322 were depressed according to an eight-item Patient Health Questionnaire (PHQ-8) and gave contact information; 1,246 enrolled and 981 completed surveys. Ninety-three programs, including 17 primary care/public health, 18 mental health, 20 substance abuse, ten homeless services, and 28 social/other community services, participated.

MAIN MEASURES

Comparisons by setting in 6-month retrospective recall of depression services use.

KEY RESULTS

Depression prevalence ranged from 51.9 % in mental health to 17.2 % in social-community programs. Depressed clients used two settings on average to receive depression services; 82 % used any setting. More clients preferred counseling over medication for depression treatment.

CONCLUSIONS

Need for depression care was high, and a broad range of agencies provide depression care. Although most participants had contact with primary care, most depression services occurred outside of primary care settings, emphasizing the need to coordinate and support the quality of community-based services across diverse community settings.

Help-seeking for emotional problems in major depression : findings of the 2006 Estonian health survey

To study help-seeking among the general population and people with major depression. 12-month help-seeking for emotional problems was assessed in a cross-sectional 2006 Estonian Health Survey. Non-institutionalized individuals aged 18-84 years (n = 6,105) were interviewed. A major depressive episode was assessed using the Mini-International Neuropsychiatric Interview. The factors associated with help-seeking, received help, and health service use were analyzed. The prevalence of 12-month help-seeking for emotional symptoms was 4.8%. The rate of 12-month help-seeking in the depressed sample was 34.1%. Depressed people used non-mental health services 1.5-3 times more than non-depressed persons even when adjusted for the chronic somatic disorder. Only one third of depressed persons sought help, which was most of all associated with severity of depression. Underdiagnosis and undertreatment of depression leads to an increased use of expensive but non-specific health services by depressed persons.

Meeting the mental health needs of low-income immigrants in primary care: a community adaptation of an evidence-based model

Low-income, uninsured immigrants are burdened by poverty and a high prevalence of trauma exposure and thus are vulnerable to mental health problems. Disparities in access to mental health services highlight the importance of adapting evidence-based interventions in primary care settings that serve this population. In 2005, the Montgomery Cares Behavioral Health Program began adapting and implementing a collaborative care model for the treatment of depression and anxiety disorders in a network of primary care clinics that serve low-income, uninsured residents of Montgomery County, Maryland, the majority of whom are immigrants. In its 6th year now, the program has generated much needed knowledge about the adaptation of this evidence-based model. The current article describes the adaptations to the traditional collaborative care model that were necessitated by patient characteristics and the clinic environment.

Predictors of overnight hospital admission in older African American and Caucasian Medicare beneficiaries

BACKGROUND

Potential disparities in health care utilization were examined using overnight hospitalization data from the University of Alabama at Birmingham Study of Aging, a longitudinal investigation of a stratified sample of Medicare beneficiaries.

METHODS

Racial differences in self-reported surgical and nonsurgical overnight hospital admissions were examined using Cox proportional hazards models. Andersen's Behavioral Model provided the conceptual framework to identify other potential predictors of admission.

RESULTS

Nine hundred and forty-two participants, 50.1% African American, provided data at baseline and at least one follow-up assessment (mean age = 75.3 years, range: 65-106). African Americans were less likely to utilize surgical admissions compared with Caucasians in a bivariate model (hazard ratio = 0.63, 95% confidence interval = 0.41-0.98). This effect was not significant after controlling for demographics and self-reported physical health. Additional bivariate predictors of surgical admission were intact mental status, having private insurance, and higher education. African Americans were less likely to utilize nonsurgical admissions in both bivariate (hazard ratio = 0.74, 95% confidence interval = 0.59-0.93) and covariate-adjusted models (hazard ratio = 0.64, 95% confidence interval = 0.50-0.84). This effect was significantly stronger for men than for women, with African American men only 0.50 times as likely as Caucasian men to report a nonsurgical admission. Other bivariate predictors of nonsurgical admission were increased age, poor physical health, negative psychological characteristics, higher levels of social support, and low perceived discrimination.

CONCLUSION

Underutilization of services has been linked to increased mortality in African Americans. Modifications in mutable domains associated with service utilization such as perceived discrimination, social support, and having private insurance may be beneficial.

A pilot for improving depression care on college campuses: results of the College Breakthrough Series-Depression (CBS-D) project

OBJECTIVE

To implement a pilot quality improvement project for depression identification and treatment in college health.

PARTICIPANTS

Eight college health center teams composed primarily of primary care and counseling service directors and clinicians.

METHODS

Chronic (Collaborative) Care Model (CCM) used with standardized screening to identify, treat, and track depressed students for 12 weeks to monitor predetermined process and clinical outcomes.

RESULTS

Of all students receiving primary medical care services between January 2007 and May 2008, 69% (n = 71,908) were screened for depression. A total of 801 depressed students were treated and tracked; most predetermined treatment process and clinical outcome targets were achieved.

CONCLUSION

The CCM for depression shows promise for improving depression identification and care for college students.

Undetected depression in primary healthcare: occurrence, severity and co-morbidity in a two-stage procedure of opportunistic screening

BACKGROUND

Depression often remains undetected in primary healthcare, and a two-stage screening procedure has been recommended for future research on the recognition, management and outcome of these patients. The aim of this study was to analyse the occurrence and the severity of depression, as well as gender, age and psychiatric co-morbidity in patients with previously undetected depression using a screening questionnaire followed by a diagnostic interview for detecting depression among patients visiting primary healthcare.

METHODS

All patients visiting a primary healthcare centre during a period of 10 days were asked to fill in the self-rating version of the Montgomery-Åsberg Depression Rating Scale. Patients with a score of 12 or more were invited to participate in a structured diagnostic interview based on the Primary Care Evaluation of Mental Disorders.

RESULTS

Out of 221 (=N) participants, 45 (20.4%) patients showed signs of depression (scores of 12 or more). Of these 45 patients, 31 consented to the structured interview, and of those, 28 (12.7%) fulfilled the criteria for depression, 17 (7.7%) had a major depression and 11 (5.0%) had a mixed depression-anxiety condition.

CONCLUSIONS

The rate of undetected depression in primary healthcare was considerable. The majority of these patients had a major depression. Psychiatric co-morbidity among depressed patients was almost universal. The two-stage procedure of opportunistic screening with the Montgomery-Åsberg Depression Rating Scale and the Primary Care Evaluation of Mental Disorders seems to be a feasible method for detecting these patients in primary healthcare.

Conditions that influence a primary care clinician's decision to refer patients for depression care

The objective of this study was to identify conditions that influence primary care clinicians' referral decisions related to depression care. Forty primary care clinicians (15 general internists, 10 nurse practitioners, and 15 family practice physicians) were included in this study. The clinicians participated in semistructured interviews and completed two quantitative instruments (with 33 items on depression treatment decision making and 32 items on provider attitudes toward psychosocial care). Data analysis revealed that several conditions influence a clinician's decision to refer a depressed patient to a mental health specialist: the patient's resources, the clinician's comfort in prescribing antidepressants and counseling patients with depression, and familiarity with a mental health specialist and practice environment. The decision to refer a patient with depression to a mental health specialist is a complex process involving the clinician, patient, and practice-related issues. Understanding these relationships may provide strategies to improve depression care management and lead to the design of depression care quality-improvement interventions that accommodate primary care practice context. The findings from this study suggest a need to increase mental health training opportunities for primary care clinicians to strengthen their skills and comfort level in managing depressed patients and encourage the development of relationships between primary care clinicians and mental health specialists to facilitate timely and accessible mental health care for patients.

Perceived need for mental health care among community-dwelling older adults

Only half of older adults with a mental disorder use mental health services, and little is known about the causes of perceived need for mental health care (MHC). We used logistic regression to examine relationships among depression, anxiety, chronic physical illness, alcohol abuse and/or dependence, sociodemographics, and perceived need among a national sample of community-dwelling individuals 65 years of age and older (the Collaborative Psychiatric Epidemiology Surveys data set). Less than half of respondents with depression or anxiety perceived a need for care. Perceived need was greater for respondents with more symptoms of depression regardless of whether they met diagnostic criteria for a mental illness. History of chronic physical conditions, history of depression or anxiety, and more severe mental illness were associated with greater perceived need for MHC. Future studies of perceived need should account for individual perceptions of mental illness and treatment and the influence of social networks.

How quality improvement interventions can address disparities in depression

The quality of depression care, especially care received by minorities, needs improvement. Several interventions have been developed for the purpose of improving the quality of depression management in primary care, including quality improvement strategies employing disease management approaches, the chronic care model, and the Breakthrough Collaborative Series developed by the Institute for Healthcare Improvement. This article reviews these interventions and examines their potential to contribute to the improvement of depression care.

The impact of patient participation on adherence and clinical outcome in primary care of depression

OBJECTIVE

Patient participation in shared treatment decision-making is hypothesized to improve depression treatment adherence and clinical outcomes in depressed patients. The study aim was to evaluate the impact of patient participation on these factors and to determine the variance of clinical outcome as the primary outcome variable.

METHODS

A survey was administered to 30 general practitioners and 207 depressed patients, at initial consultation and 6-8 weeks later. General practitioners documented their clinical practice and patients completed questionnaires including Brief-PHQ for depression and clinical outcome, patient participation scale, and visual analogue scales for treatment adherence. Assessment of correlations was followed by the development of a structural equation model (as a latent variable analysis) to define a model to explain the entire set of the variables' relationships.

RESULTS

Sixty percent of the variance in clinical outcome was attributable to patient adherence (beta=0.41) and baseline depression severity (beta=0.65). Depression severity predicted clinical outcome but not patient participation. Participation predicted adherence (beta=0.39) but did not directly affect clinical outcome. Adherence was explainable by physician- (beta=0.57) and patient-reported treatment adherence (beta=0.66).

CONCLUSION

In a specific pathway via adherence, patient participation in decision-making influences clinical outcome in primary care of depression.

PRACTICE IMPLICATIONS

The research findings reveal the significance of patient participation as a key factor to address for improving treatment adherence and clinical outcome. Quality improvement strategies for depression treatment should emphasize patient participation.

Barriers to psychotherapy among depressed and nondepressed primary care patients

BACKGROUND

Most primary care patients who experience depression state that they would prefer psychotherapy over antidepressant medications. However, when referrals for psychotherapy are made, only 20% ever follow up, and of these, half drop out of treatment. This suggests that there are substantial barriers to accessing psychotherapy.

PURPOSE

The aim of this study was to investigate perceived barriers to psychotherapy in a sample of primary care patients and to test the hypothesis that these barriers would be more common among patients with depression.

METHODS

Patients were sampled from a large primary care service and mailed a survey. The survey included evaluation of barriers using items identified in previous published research, which we refer to as Perceived Barriers to Psychotherapy (PBP). Depression was measured using the Perceived Health Questionnaire-9 (PHQ-9).

RESULTS

Of the 904 surveys sent, 290 (32.1%) were returned. The PBP produced two factors-practical barriers and emotional barriers-explaining 58.2% of the variance with an internal reliability of alpha = .79. Among all patients, 59.5% reported at least one barrier that would make it very difficult or impossible to participate in psychotherapy. Depression was associated with increased frequency of perceived barriers, with 74.0% of depressed patients reporting one or more barriers, versus 51.4% of nondepressed patients (p = .008). One or more perceived practical barriers were reported by 56.6% of the sample, whereas only 11.1% reported perceived emotional barriers. Depression was consistently associated with increased emotional barriers. Practical barriers were not consistently associated with depression but were influenced by history of psychotherapy.

CONCLUSIONS

The majority of primary care patients surveyed reported one or more perceived barriers that would interfere with or prevent initiation or regular attendance of psychotherapy. Perceived barriers were more common among depressed than nondepressed patients making depression both an indicator for psychotherapy and a barrier to receiving it.

Knowledge and attitude towards suicide among medical students in Japan: preliminary study

Japan has one of the highest suicide rates in the world. Suicides numbered 32,863 in 1998 and have exceeded 30,000 in every subsequent year. Education of those involved in general and psychosocial patient care can contribute greatly to suicide prevention. The authors administered a brief knowledge and attitude assessment questionnaire concerning suicide to students in their first, third, and fifth years at a Japanese medical school. Participants numbered 160 (94 men with a mean age of 21.8 years, SD = 3.01, and 66 women with a mean age of 21.2 years, SD = 2.64); 59 first year, 52 third year, and 49 in their fifth year. The questionnaire consists of eight multiple-choice questions asking knowledge of suicide and one open-ended question asking attitude. In the knowledge part, only about half of the items were answered correctly (mean score was 4.21, SD = 1.28). A significant difference was observed in prevalence of attitudes as categorical variables between student years (P = 0.001). Sympathetic comments increased along with student years, while critical comments decreased. Given the frequent and interventional opportunities of primary-care medical contacts, poor understanding of suicide from the medical viewpoint was of concern. Moreover, judgmental attitudes were common, especially in earlier school years. Better informed, more understanding physicians and other health professionals could contribute greatly to prevention.

Depression diagnosis and antidepressant treatment among depressed VA primary care patients

This study examined the extent to which 3559 VA primary care patients with depression symptomatology received depression diagnoses and/or antidepressant prescriptions. Symptomatology was classified as mild (13%), moderate (42%) or severe (45%) based on SCL-20 scores. Diagnosis and treatment was related to depression severity and other patient characteristics. Overall, 44% were neither diagnosed nor treated. Only 22% of those neither diagnosed nor treated for depression received treatment for other psychopathology. Depression treatment performance measures dependent on diagnoses and antidepressant prescriptions from administrative databases exclude undiagnosed patients with significant, treatable, symptomatology.

Recent treatment history vs clinical characteristics in the prediction of use of outpatient psychiatric services

BACKGROUND

The use of outpatient psychiatric services has been shown to be a complex function of sociodemographic, clinical, and pathway variables. The relative contribution of each variable or groups of variables in explaining the variability in the use of outpatient psychiatric services, however, remains poorly documented.

METHODS

The subjects (N=382) were all patients admitted to an outpatient psychiatric clinic serving mostly a minority and low-income population. The charts of the patients were reviewed for sociodemographic, clinical, and pathway variables and the number of outpatient visits. The pathway variables studied were source of referral and most recent psychiatric treatment service used. Both bivariate and multivariate statistics were used to analyze the data.

RESULTS

Pathway variables were better predictors of the number of outpatient visits than clinical variables after controlling for sociodemographic variables.

CONCLUSION

Patients recently hospitalized may be sicker or have fewer social supports and therefore require more outpatient visits. Recent treatment history stands out as an important variable in the prediction of the number of outpatient mental health visits. More research is needed to examine the influence of pathway variables on treatment decisions.

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.

Depressive symptoms among women with an abnormal mammogram

An abnormal mammography finding constitutes a stressful event that may increase vulnerability by developing or intensifying pre-existing psychological morbidity. We evaluated depressive symptoms using the Composite International Diagnostic Interview among women of four ethnic groups who had an abnormal mammography result controlling for the effect of demographic, psychosocial and medical factors on recent onset of depressive symptoms. Telephone surveys were conducted among women aged 40-80 years recruited from four clinical sites in the San Francisco Bay Area after receiving a screening mammography result that was classified as abnormal but probably benign, suspicious or highly suspicious, or indeterminate using standard criteria. Among the 910 women who completed the interview, mean age was 56 (S.D.=10), 42% were White, 19% Latina, 25% African American, and 14% Asian. Prevalence of lifetime depressive symptoms was 44%, and 11% of women had symptoms in the previous month. Multivariate logistic regression models showed that Asian ethnicity, annual income >$10 000 and weekly attendance at religious services were significantly associated with decreased depressive symptoms. Having an indeterminate result on mammography and being on disability were significantly associated with more depressive symptoms. Reporting a first episode of depression more than a year before the interview was associated with significant increase in depressive symptoms in the month prior to the interview regardless of mammography result. Women with an indeterminate interpretation on mammography were at greater risk of depressive episode in the month prior to the interview compared to women with probably benign results (odds ratio=2.41; 95% CI=1.09-5.31) or with a suspicious finding. Clinicians need to consider depression as a possible consequence after an abnormal mammography result.

Use of health services for major depressive episode in Finland

BACKGROUND

A universal finding in psychiatric epidemiology is that only a minority of currently depressed people seek or receive treatment.

AIMS

To investigate the predictors of use of health care services for depression.

METHODS

A representative random sample of 5993 non-institutionalised Finnish individuals aged 15-75 years was interviewed in 1996. Major depressive episode during the last 12 months was assessed using the Short Form of the University of Michigan version of the Composite International Diagnostic Interview (the UM-CIDI Short Form). Characteristics and health service use of the 557 depressed individuals were assessed.

RESULTS

The proportion of people classified as having a major depressive episode who used any health services for their depression during the past 12 months was only 31% for men and 25% for women. Use of services was not predicted by sociodemographic factors. Longer duration, and greater severity and perceived disability predicted overall health service use for depression, but not significantly whether treatment was sought from primary or psychiatric care.

CONCLUSIONS

The probability of use of health services for major depression increases with duration, severity and perceived disability related to depression. Only 59% of those suffering from even the most severe major depressive episodes use health services for depression. Use appears to be unrelated to sociodemographic factors in Finland.

Integrating mental health screening and abnormal cancer screening follow-up: an intervention to reach low-income women

The results of implementing mental health screening within cancer screening and diagnostic programs serving low-income ethnic minority women are reported. Multi-phased screening for anxiety and depression was provided as part of structured health education and intensive case management services to improve abnormal mammogram or Pap test follow-up. Seven hundred fifty-three women were enrolled in the Screening Adherence Follow-up Program. Ten percent (n = 74) met criteria for depressive or anxiety disorder. Women with depressive or anxiety disorders were more likely to have cancer, significant psychosocial stress, fair or poor health status, a comorbid medical problem, and limitation in functional status. Forty-seven women with disorders were receiving no depression care.

Race, gender, and health care service utilization and costs among Medicare elderly with psychiatric diagnoses

OBJECTIVE

To investigate race and gender differences in health care service utilization and costs among the Medicare elderly with psychiatric diagnoses.

METHODS

The authors employ a 5% sample of Medicare beneficiaries from Tennessee (N = 33,680), and among those with a psychiatric diagnosis (n = 5,339), they examine health care service utilization and costs by race and gender.

RESULTS

African Americans had significantly higher rates of diagnosis for dementia, organic psychosis, and schizophrenia, whereas Whites had significantly higher rates for mood and anxiety disorders. White and African American men have higher rates of utilization of emergency and inpatient services and lower rates of outpatient utilization compared to White women and African American women. African American men have significantly higher health care costs.

DISCUSSION

The findings suggest that race and gender interact to influence service utilization and preventive care, thereby driving up costs of care, for elderly persons with psychiatric diagnoses.