The aim was to examine barriers to initiation and continuation of treatment among individuals with common mental disorders in the US general population.
Respondents in the National Comorbidity Survey ...Replication with common 12-month DSM-IV mood, anxiety, substance, impulse control and childhood disorders were asked about perceived need for treatment, structural barriers and attitudinal/evaluative barriers to initiation and continuation of treatment.
Low perceived need was reported by 44.8% of respondents with a disorder who did not seek treatment. Desire to handle the problem on one's own was the most common reason among respondents with perceived need both for not seeking treatment (72.6%) and for dropping out of treatment (42.2%). Attitudinal/evaluative factors were much more important than structural barriers both to initiating (97.4% v. 22.2%) and to continuing (81.9% v. 31.8%) of treatment. Reasons for not seeking treatment varied with illness severity. Low perceived need was a more common reason for not seeking treatment among individuals with mild (57.0%) than moderate (39.3%) or severe (25.9%) disorders, whereas structural and attitudinal/evaluative barriers were more common among respondents with more severe conditions.
Low perceived need and attitudinal/evaluative barriers are the major barriers to treatment seeking and staying in treatment among individuals with common mental disorders. Efforts to increase treatment seeking and reduce treatment drop-out need to take these barriers into consideration as well as to recognize that barriers differ as a function of sociodemographic and clinical characteristics.
Hospital-based medical records are abstracted to create International Classification of Disease (ICD) coded discharge health data in many countries. The 'main condition' is not defined in a ...consistent manner internationally. Some countries employ a 'reason for admission' rule as the basis for the main condition, while other countries employ a 'resource use' rule. A few countries have recently transitioned from one of these approaches to the other. The definition of 'main condition' in such ICD data matters when it is used to define a disease cohort to assign diagnosis-related groups and to perform risk adjustment. We propose a method of harmonizing the international definition to enable researchers and international organizations using ICD-coded health data to aggregate or compare hospital care and outcomes across countries in a consistent manner. Inter-observer reliability of alternative harmonization approaches should be evaluated before finalizing the definition and adopting it worldwide.
Major depression is a widespread, often chronic disorder affecting the individual, his or her family, and society as a whole. It incurs tremendous social and financial costs in the form of impaired ...relationships, lost productivity, and lost wages. Although chronic major depression is eminently treatable, it continues to be undertreated and underrecognized. This is particularly true in primary care settings, where physicians are usually the first to encounter chronic depression but are seldom trained to distinguish depression from other medical illnesses with similar symptoms. In addition, because of the stigma attached to depression, patients often characterize their symptoms as part of a physical illness or fail to report them to a clinician at all. This article discusses the epidemiology of depression, its impact and burden on society, and its special character (including diagnosis and treatment) as a chronic illness.
To develop a consensus opinion regarding capturing diagnosis-timing in coded hospital data.
As part of the World Health Organization International Classification of Diseases-11th Revision initiative, ...the Quality and Safety Topic Advisory Group is charged with enhancing the capture of quality and patient safety information in morbidity data sets. One such feature is a diagnosis-timing flag. The Group has undertaken a narrative literature review, scanned national experiences focusing on countries currently using timing flags, and held a series of meetings to derive formal recommendations regarding diagnosis-timing reporting.
The completeness of diagnosis-timing reporting continues to improve with experience and use; studies indicate that it enhances risk-adjustment and may have a substantial impact on hospital performance estimates, especially for conditions/procedures that involve acutely ill patients. However, studies suggest that its reliability varies, is better for surgical than medical patients (kappa in hip fracture patients of 0.7-1.0 versus kappa in pneumonia of 0.2-0.6) and is dependent on coder training and setting. It may allow simpler and more precise specification of quality indicators.
As the evidence indicates that a diagnosis-timing flag improves the ability of routinely collected, coded hospital data to support outcomes research and the development of quality and safety indicators, the Group recommends that a classification of 'arising after admission' (yes/no), with permitted designations of 'unknown or clinically undetermined', will facilitate coding while providing flexibility when there is uncertainty. Clear coding standards and guidelines with ongoing coder education will be necessary to ensure reliability of the diagnosis-timing flag.
Using a nationally representative sample of 23,230 U.S. residents, we examine patterns of economic burden across five chronic conditions: mood disorders, diabetes, heart disease, asthma, and ...hypertension. Almost half of U.S. health care costs in 1996 were borne by persons with one or more of these five conditions; of that spending amount, only about one-quarter was spent on treating the conditions themselves and the remainder on coexistent illnesses. Each condition demonstrated substantial economic burden but also unique characteristics and patterns of service use driving those costs. The findings highlight the differing challenges involved in understanding needs and improving care across particular chronic conditions.
This study examined recent changes in the prescribing patterns for medications to treat bipolar disorder in office-based psychiatric practice.
The authors analyzed physician-reported data from the ...National Ambulatory Medical Care Survey for 1992-1995 and 1996-1999, focusing on physicians specializing in psychiatry. Demographic, clinical, and medication prescription characteristics of patients' visits were compared to identify changes between the periods. Logistic regression models were used to identify predictors of medication prescription, with adjustment for the presence of other covariates.
In both survey periods, over one-third of the total psychiatrist visits by patients with bipolar disorder did not include prescription of a mood stabilizer. There was a decrease in the use of lithium over time, accompanied by an increase in the use of valproic acid. Antipsychotic medication was prescribed more frequently for the bipolar manic and mixed subtypes, and there was a secular increase in the use of the newer antipsychotics. During each time period, prescription of antidepressants was common, often in the absence of a mood stabilizer.
Despite important advances in the range of mood stabilizers available, the pharmacological treatment of bipolar disorder continues to be an area with substantial opportunity for quality improvement.
This article reports recent trends in the use of outpatient psychotherapy in the United States.
Data from the household sections of the 1987 National Medical Expenditure Survey and the 1997 Medical ...Expenditure Panel Survey were analyzed. Trends in the rate of psychotherapy use from these nationally representative samples are presented by age, sex, race/ethnicity, marital status, education, employment status, and income. Psychotherapy users are compared over time by provider specialty, concomitant psychotropic medication use, number of annual visits, and costs. In addition, trends in payment source and primary diagnosis are assessed for psychotherapy visits.
Between 1987 and 1997, there was no statistically significant change in the overall rate of psychotherapy use (3.2 per 100 persons in 1987 and 3.6 per 100 in 1997). However, significant increases were observed in psychotherapy use by adults aged 55-64 years and by unemployed adults. Among psychotherapy patients, there was a marked increase in the use of antidepressant medications (14.4% to 48.6%), mood stabilizers (5.3% to 14.5%), stimulants (1.9% to 6.4%), and psychotherapy provided by physicians (48.1% to 64.7%). A smaller proportion of patients made more than 20 psychotherapy visits in 1997 (10.3%) than in 1987 (15.7%). Over this period, psychotherapy visits for mood disorders became more common. In 1997, 9.7 million Americans spent $5.7 billion on outpatient psychotherapy.
From 1987 to 1997, access to psychotherapy in the United States remained constant overall but was characterized by increased use by some socioeconomically disadvantaged groups. However, the number of visits per user markedly decreased during this period. Psychotherapy was increasingly administered by physicians and provided in conjunction with psychotropic medications. These changes occurred during a period of expansion in the number of available psychotropic medications and growth in managed behavioral health care.
This study characterized the prevalence, characteristics, and impact of mental and general medical disabilities in the United States.
The 1994-1995 National Health Interview Survey of Disability was ...the largest disability survey ever conducted in the United States. A national sample was screened for disability, defined as limitation or inability to participate in a major life activity. Analyses compared cohorts who attributed their disability to physical, mental, or combined conditions.
Of 106,573 adults, 1.1% reported functional disability from mental conditions, 4.8% from general medical conditions, and 1.2% from combined mental and general medical conditions. Disabilities attributed to a mental condition were predominantly associated with social and cognitive difficulties, those attributed to general medical conditions with physical limitations, and combined disabilities with deficits spanning multiple domains. In multivariate models, comorbid medical and mental conditions were associated with a twofold increase in odds of unemployment and a two-thirds increase in odds of support on disability payments compared to respondents with a single form of disability. More than half the nonworking disabled reported that economic, social, and job-based barriers contributed to their inability to work. One-fourth of working disabled people reported discrimination on the basis of their disability during the past 5 years.
An estimated three million Americans (one-third of disabled people) reported that a mental condition contributes to their disability. Mental, general medical, and combined conditions are associated with unique patterns of functional impairment. Social and economic factors and job discrimination may exacerbate the functional impairments resulting from clinical syndromes.
Psychotropic medications are widely prescribed, but how new classes of psychotropic medications have affected prescribing patterns has not been well documented.
To examine changes between 1985 and ...1994 (data from 1993 and 1994 were combined) in the prescribing patterns of psychotropic medications by office-based primary care physicians, psychiatrists, and other medical specialists.
National estimates for the number of visits during which a physician prescribed a psychotropic medication based on the National Ambulatory Medical Care Surveys conducted in 1985, 1993, and 1994.
Office-based physician practices in the United States.
A systematically sampled group of office-based physicians.
National estimates of visits that included a psychotropic medication.
The number of visits during which a psychotropic medication was prescribed increased from 32.73 million to 45.64 million; the proportion of such visits, as a proportion of all visits, increased from 5.1% to 6.5% (P< or =.01). Antianxiety or hypnotic drug visits, previously the largest category, decreased as a proportion of psychotropic drug visits (P< or =.01) and are now surpassed by antidepressant visits. Visits for depression increased from 10.99 million in 1988 to 20.43 million in 1993 and 1994 (P< or =.01). Stimulant drug visits increased from 0.57 million to 2.86 million (P< or =.01). Although visits for depression doubled for both primary care physicians and psychiatrists, the proportion of visits for depression during which an antidepressant was prescribed increased for psychiatrists but not for primary care physicians.
The patterns of psychotropic medication use in outpatient medical practice changed dramatically during the study period, especially in psychiatric practice.
Purpose National initiatives, such as the UK Improving Access to Psychological Therapies program (IAPT), demonstrate the feasibility of conducting empirical mental health assessments on a large ...scale, and similar initiatives exist in other countries. However, there is a lack of international consensus on which outcome domains are most salient to monitor treatment progress and how they should be measured. The aim of this project was to propose (1) an essential set of outcome domains relevant across countries and cultures, (2) a set of easily accessible patientreported instruments, and (3) a psychometric approach to make scores from different instruments comparable. Methods Twenty-four experts, including ten health outcomes researchers, ten clinical experts from all continents, two patient advocates, and two ICHOM coordinators worked for seven months in a consensus building exercise to develop recommendations based on existing evidence using a structured consensus-driven modified Delphi technique. Results The group proposes to combine an assessment of potential outcome predictors at baseline (47 items: demographics, functional, clinical status, etc.), with repeated assessments of disease-specific symptoms during the treatment process (19 items: symptoms, side effects, etc.), and a comprehensive annual assessment of broader treatment outcomes (45 items: remission, absenteeism, etc.). Further, it is suggested reporting disease-specific symptoms for depression and anxiety on a standardized metric to increase comparability with other legacy instruments. All recommended instruments are provided online (www.ichom.org). Conclusion An international standard of health outcomes assessment has the potential to improve clinical decision making, enhance health care for the benefit of patients, and facilitate scientific knowledge.
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