Benjamin G. Druss

This study examined the rates and correlates of mental health care performance measures in the Health Employer Data and Information Set (HEDIS). For all 384 health maintenance organizations (HMOs) participating in the HEDIS program of the National Committee for Quality Assurance during 1999, analyses examined the rates of compliance with five mental health care performance measures and their association with general medical care quality, public reporting, and HMO finances. The mean rate of mental health care performance was 48.0%, compared with 69.2% for non-mental-health care domains. In multivariate models adjusted for plan characteristics, scores for worse quality of non-mental-health domains, failure to report data publicly, and low medical-loss ratio (proportion of revenues spent on clinical care) all predicted poor mental health care performance. Better general medical care, transparency of reporting, and commitment of fiscal resources to clinical care predicted better mental health care performance for U.S. HMOs.

This study compares quality of preventive services between persons with and without mental/substance use disorders for a national sample of medical outpatients. Cross-sectional study. A total of 113,505 veterans with chronic conditions and at least three general medical visits to Veterans Health Administration medical providers during 1998 to 1999. Chart-derived rates of eight preventive services: two measures of immunization, four measures of cancer screening, and two of tobacco screening and counseling. Multivariable-generalized estimating equations compared rates of each preventive service among veterans with psychiatric disorders, substance use disorders, both, and neither, adjusting for demographic, health status, and facility-level characteristics. On average, persons in the sample obtained 64% of the eight preventive procedures for which they were eligible. Overall rates of currency with preventive services were 58% for patients with combined psychiatric/substance use disorders, 60% and 65% for those with psychiatric and substance use disorders alone, and 66% for those with neither psychiatric nor substance use disorders. Each difference remained statistically significant in multivariable models. In this sample of patients in active medical treatment, rates of preventive services were higher than rates reported for population-based, private-sector samples. Despite these high-baseline rates, persons with psychiatric disorders, particularly with comorbid substance use, were at risk for lower rate of receipt of preventive services.

Research from JAMA Psychiatry — Integrated Medical Care for Patients With Serious Psychiatric Illness — A Randomized Trial

MUCH LITERATURE has demonstrated that patients with mental disorders are at risk for elevated rates of cardiovascular mortality.%^1-8 Authors have postulated that arrhythmogenic, neuroendocrine, or other direct physiological mechanisms mediate this excess mortality,%^9,10 and thus previous studies of mortality in mental disorders have generally not examined the quality of these patients' medical care. However, patterns of cardiac procedures after acute myocardial infarction (AMI) have been found to differ substantially for patients with and without mental disorders,%¹¹ raising the question as to whether there may also be a gap in quality of medical care. If quality of care does vary, such differences might play a role in mediating excess cardiovascular mortality in patients with mental disorders.

The relationship of depressive symptoms, satisfaction with health care, and 2-year work outcomes was examined in a national cohort of employees. A total of 6,239 employees of three corporations completed surveys on health and satisfaction with health care in 1993 and 1995. This study used bivariate and multivariate analyses to examine the relationships of depressive symptoms (a score below 43 on the Medical Outcomes Study Short-Form Health Survey mental component summary), satisfaction with a variety of dimensions of health care in 1993, and work outcomes (sick days and decreased effectiveness in the workplace) in 1995. The odds of missed work due to health problems in 1995 were twice as high for employees with depressive symptoms in both 1993 and 1995 as for those without depressive symptoms in either year. The odds of decreased effectiveness at work in 1995 was seven times as high. Among individuals with depressive symptoms in 1993, a report of one or more problems with clinical care in 1993 predicted a 34% increase in the odds of persistent depressive symptoms and a 66% increased odds of decreased effectiveness at work in 1995. There was a weaker association between problems with plan administration and outcomes. Depressive disorders in the workplace persist over time and have a major effect on work performance, most notably on "presenteeism," or reduced effectiveness in the workplace. The study's findings suggest a potentially important link between consumers' perceptions of clinical care and work outcomes in this population.

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.

Employers are playing an increasingly influential role in determining the scope and character of health coverage in the United States. This study compares the health and disability costs of depressive illness with those of four other chronic conditions among employees of a large U.S. corporation. Data from the health and employee files of 15,153 employees of a major U.S. corporation who filed health claims in 1995 were examined. Analyses compared the mental health costs, medical costs, sick days, and total health and disability costs associated with depression and four other conditions: heart disease, diabetes, hypertension, and back problems. Regression models were used to control for demographic differences and job characteristics. Employees treated for depression incurred annual per capita health and disability costs of $5,415, significantly more than the cost for hypertension and comparable to the cost for the three other medical conditions. Employees with depressive illness plus any of the other conditions cost 1.7 times more than those with the comparison medical conditions alone. Depressive illness was associated with a mean of 9.86 annual sick days, significantly more than any of the other conditions. Depressed employees under the age of 40 years took 3.5 more annual sick days than those 40 years old or older. The cost of depression to employers, particularly the cost in lost work days, is as great or greater than the cost of many other common medical illnesses, and the combination of depressive and other common illnesses is particularly costly. The strong association between depressive illness and sick days in younger workers suggests that the impact of depression may increase as these workers age.

To our knowledge, this study provides the first national estimates for use of practitioner-based complementary treatments by US residents reporting mental conditions. A total of 16038 respondents to the 1996 Medical Expenditure Panel Survey were asked about visits for 12 complementary medical services (eg, chiropractic services and herbal remedies). Bivariate and multiple regression models examined use of these therapies in individuals reporting a mental condition (n= 1803), fair or poor mental health status (n=992), and 1 of 4 chronic medical conditions (n = 3262) and in the remainder of the sample (n= 10 793). A total of 9.8% of those reporting a mental condition made a complementary visit, and about half of these (4.5%) made a visit to treat the mental condition. Persons reporting transient stress or adjustment disorders were most likely (odds ratio, 9.1%; 95% confidence interval, 5.5%-12.7%), and those with psychotic (odds ratio, 1.5%; 95% confidence interval, 0.0%-4.2%) and affective (odds ratio, 2.6%; 95% confidence interval, 1.5%-3.8%) conditions least likely, to use complementary therapies to treat their mental condition. In multivariate models controlling for medical comorbidity, fair or poor mental health status, and demographic factors, report of a mental condition predicted a 1.27-fold increase in the odds of a complementary visit (95% confidence interval, 1.04-1.54). Self-reported mental conditions were associated with increased use of complementary treatments, although use of these treatments was concentrated in respondents with transient distress rather than chronic and serious conditions. More research using structured diagnostic interviews is needed to examine the prevalence, patterns, and clinical implications of use of these treatments by individuals with mental conditions in "real world" community settings.

Epidemiological surveys suggest that half of mental disorders in the community are treated in general medical settings. This paper examines delivery of mental health services in psychiatric, primary care, and specialty medical clinics in the Department of Veterans Affairs (VA), the largest integrated public-sector health care system in the United States. The study examined all outpatient visits to VA clinics between October 1996 and March 1998, a time during which VA policy promoted a shift to a primary care model. For veterans with a primary diagnosis of a mental or substance use disorder who made any visit to a VA psychiatric, primary care, or specialty medical clinic, we compared the locus of care and case mix as well as changes in treatment patterns during the study period. Of 437,035 veterans treated for a mental disorder during the final six months of the study period, only 7 percent were seen for their mental disorders exclusively in primary care and specialty medical clinics. Compared with veterans with mental disorders treated in specialty mental health clinics, those treated in medical clinics had less serious psychiatric diagnoses and made fewer visits. While there was a substantial shift of care from specialty to primary care during the study period, no comparable change in the distribution of care between medical and mental health settings was found. Treatment patterns in VA clinics differ markedly from those in the private sector. Research is needed to determine whether and how staffing models developed in HMOs and community samples should be extended to these public-sector settings.