EE The Quality of Care for Depressive and Anxiety Disorders in the United States Alexander S. You Backgrounds Depressive and anxiety disorders are preva lentand cause substantial morbidity. While effective treat- ments exist litle is known about the quality of care for these disorders nationally. We estimated the rate of ap- propriate treatment among the US population with these disorders, and the effect of insurance, provider type, and individual characteristics on receipt of appropriate care. Methods: Data are froma cross-sectional telephone sur- vey conducted during 1997 and 1998 with 4 national sample. Respondents consisted of 1636 adults with aprob- able 12-month depressive of anxiety disorder as deter mined by brief diagnostic interview. Appropriate treat- ment was defined as present ifthe respondent had used medication or counseling that was consistent with treat- ment guidelines Results: During a 1-year period, 83% of adults with a probable depressive or anxiety disorder saw a health care MD, MSHS; Ruth Klap, PhD; Cathy D. Sherbourne, PhD; Kenneth B. Wells, MD, MPH. provider (95% confidence interval [CI], 81%-85%) and 30% received some appropriate treatment (05% CL 28%6-33%). Most visited primary care providers only. Ap” propriate care was received by 10% in this group (05% Cl, 16%-23%) and by 90% of individuals visiting men- tal health specialists (05% Cl, 85%-04%). Appropriate treatment Was less likely for men and those who were black, less educated, or younger than 30 or older than 59 years (range, 19-97 years). Insurance and income had no elfect on receipt of appropriate care Conclusions: I is possible o evaluate mental health care quality on a national basis, Most adults with a probable depressive or anxiety disorder do not receive approp: ate care for their disorder. While this holds across di verse groups, appropriate care is less common in cer- tain demographic subgroups. Arch Gen Psychiatry. 2001;58:55-61 From the Department of Veterans Afairs VISN 22 ‘Mental ness Research, Education, and Clinical Center, West Lo Angels Veterans Healthcare Cente, Los Angeles, Calf (Dr Young) the Department of Psychiatry, University of California, Los Angeles (Drs Young and Wells); the Health Services Research Center, University ‘of California, Los Angeles (Dr klap) and RAND, Santa Monica, Calif (rs Young, Sherbourne and Well). (aepnanteD) TECH EPRESSIVE AND anxiety disorders are common and have a substantial im- pact on functioning and quality of life, National treatment guidelines for major depres- sion document that effective treatments in- clude antidepressant medications and cog- nitive-behavioral and interpersonal psychotherapies."? Research also sup- ports the ellicacy of these treatments for dysthymia, although the literature is less well developed.» In panic disorder, treat- ‘ment guidelines strongly support the ef- ficacy of cognitive-behavioral psychothers- ples, some antidepressant medications, and benzodiazepines." In generalized anxi ety disorder (GAD), effective treatments include antidepressant medications, bu- spirone, benzodiazepines, cognitive: behavioral psychotherapies, and prob- ably relaxation and unstructured therapy techniques." Although these treat- ‘ments are effective, patients frequently do not receive them." However, there have (©2001 American Med Downloaded From: http:/jamanetwork.com/ on 11/26/2016 been few national studies of the quality of ‘mental health care. Researchers have suc cessfully characterized national quality of care for a variety of medical disorders, and itis important to know whether simi- lar research in psychiatry can provide data, to inform policy nationally. While th {sting literature suggests that quality of care for common psychiatric disorders is mod- erate to poor across dilferent types of teal- ‘ment settings, national data are limited and not clinically detailed, and it is unclear which populations are at greatest risk for not receiving appropriate eate. The National Comorbidity Survey (NCS) surveyed a household probability sample of persons between ages 14 and 55 years, and found that 27.7% of those with ‘major depression and 26.0% of those with dysthymia reported receiving outpatient ‘mental health services," while 35.2% with panic disorder and 31.8% with GAD re- ported receiving such services, Although rates of use of antidepressant medication were low for persons with major depres- Association, All rights reserved.MATERIALS AND METHODS SAMPLE ‘The sample is from HealthCare for Communities (HCC), whichis pat ofthe Robert Wood Johnson Foundation Health Tracking Initiative Data ae from the HCC tele phone survey, which was conducted during 1997 and 1998 Thedesignof HCC described in detal ele where” Health: Gare for Communities respondents were strated prob- abil sample of participants n the Commun Trackin Siudy (C9. The CIs was nationally represenavestaly of the US civil, noninsttutionalized population during {o9e and 1997, witha response vate of @9%" The sae pling strategy in HCC was designed to improve our ablty {osttdy people with low income and people with peychi- dc ditorders, This was done by oversampling individu ae with the following characteristics aly tncome be- low $20000, high peychological distress (messured using items from the L2-item Shor- Fort Health Survey"), ot any mental health specialty vist during te prior year: Of the 14083 CT respondent selected or HCC, 9585 were Feinteriewed, fora response rate of 64% Informed con- zen was obtained verbally before the interview. In analy tes, we weighed the data o be representative ofthe pop Intion ofthe United State by using CTS data to adjust for probability of selection, unit nonfesponse, and nontcle- Phone households MEASURES, Dataare from the HCC survey, with the exception of some {insurance information and demographics from the CTS str vey. Major depression, dysthymia, and GAD during the past, Yyearand lifetime mania were assessed using short-form ver- Sions of the Composite International Diagnostic Inter view (CIDD,*andare based on DSM-UER criteria.” Kessler and colleagues" reported that the sensitivity and specilic- ity of CIDI short-lorm relative to fall CIDI diagnosis is excellem, with concordance ranging [rom 90% to 100% Probable pic dsorder was asesed sing screening ems from the CID” supplemented by addiional ems from thle ha ber mod forts sty To re dice polenta false-positive on this instrument fr panic ve required imitation in socal or role functioning tsing tem from the 12-tem Shor-Form Health Survey and 3 items from the Sickness Impact Profile" Substance abuse twas assessed using the Alcohol Use Disorders Identifies tion Test and items adaped from the CIDI, Chron psy chosls was asessed by asking respondents whether they had everbeen told they had schizophrenia or schizolfec- tive disorder, or been hosplalized becatse of psychotic symptoms. Twohundred fry espondenteme criteria for chronic psychosis or mana and were excluded from our smalyses Respondents were alo scked whether, during the pst year, they had a need for emotional or mental health Fetp and whether they had any of the following severe life dias: witnessing an assall, losing custody of chil dren, or being homeless, sexually asaulted, incarcerated, oron parole or probation Use of alt services during the prior 12 months vas identified by sel-repor. Primary care provider (CP) isis included vist, for any reason, to 4 primary care Physician, family physician, general internist, muse, py Filan assistant, of chitopractr. Mental heath speciale, vist included vss toa peychiarit, pycholog, social ‘worker, poychiatric nurse or counselor, for emotional or imental health problems Respondents provided dally dlosage and duration of use for medications taken at eat several times a week fora month or more’ and reported on the number of couceling sessions with specialist. Counseling from PCPs was identlfed by asking whether the alread test 3 vanes of coun scling regarding an “emotional, menial heath lea or drug problem ‘Appropriate care for depressive and anxiety disor- ders wat assessed for respondent witha probable disor der, and was defined as use of ether appropriate paycho- tropic mediaton or appropiate counseling during the prior sion, the survey did not obtain information on actual names ‘or dosages of medications, so treatment appropriateness ac- ‘cording to national practice guidelines is uncertain.” Pur- thermore, NCS respondents only reported general medi- ‘al visits that they thought included care for mental health problems, and this approach could lead to undercounting ‘of mental health services since many general medical pa- tients may not recognize that they have an emotional prob- lem. Otherwise, studies of quality of care for depressive ‘oranxiety disorders re limited to reports from specie prac lice settings. For example, a study of primary care prac- ices in the 1980s found that 25% to 30% of those with ma- jor depression received antidepressant medication during ‘26-month period, and studies ina variety of other health ‘care organizations have produced similar results*"* The rae of appropriate treatment for persons with ansiety dis- ‘order may also below, but there are few practice-based stud ies. Even in mental health specialty settings, effective treat- ments for anxiety disorders may be underutilized. Researchers have found lower rates of mental health, * and treatment utilization in men,” ethnic minorities, (aepranteD) TET (©2001 American Med Downloaded From: http:/jamanetwork.com/ on 11/26/2016 SN TVCHATINVOL, NT individuals with lower socioeconomic status." Also, black, youngadult, and elderly individuals have been found to be less likely to visit mental health specialists,” and this may affect which treatments are received.» With regard to insurance, the Epidemiologic Catchment Area Study found that access to care was better under Medicaid than for the uninsured or those with private insurance,”* and the Medical Outcomes Study found that some aspects of lweatment were worse in prepaid care.'® However, these results were based on coverage in the 1980s and few r cent studies have identified predictors of receiving ap- propriate care among persons at risk for common psy- chiatric disorders. This isa study of access to appropriate care among representative household sample of adultsin the United States who had a symptomatic depressive or anxiety dis order during a 1-year period in 1997 and 1998, The fo- ceusis on individuals with probable major depression, dys- thymia, panic disorder, and GAD. We examine whether these individuals visita health care provider, whether those visiting a provider receive appropriate treatment, Association, All rights reserved.year. Appropriate peychotrople medication was defined ea medication that wa effleacous forthe Individuals disorder and used ata dosage exceeding the minimum recommended dosage for an adequate duration, Speci Cally for major depressive and dysthymc disorder (with or without anxiety), we used the lower end ofthe thea peatie dosage range for each antidepressant medication Irom the agency for Health Care Policy and Research Guideline for Depression in Primary Cate, updated for newer medications’ and required 2 or more months of tse during the prior 12 months. Examples of ankimom dosages are 10 mg per day for uoxetine and 75 mg pet day for desipramine For pant disorder (with or without GAD), appropriateness ctiteria were based on proposed guidelines for general practitioners.” Medication was Sppropriate ii included at least 2 months of an ante press medication (other than bupropion) at poss bly adequate dosage, or a benzodiazepine. For GAD, iedication was considered appropriate inluded at Teast 2 months of an antidepressant medication at an adequate dosage, buspirone, ora benzodiazepine. For respondents with multiple disorders, appropriateness tear evalusted for their mos "siglficant clinical disor der, based on the following hierarchy (rom Ito 4, in order of consideration by PCP): major depression (1), dysthymia (2), pante ditorder G3), and GAD (4). To ilustrate the rationale behind this hierarchy, an ind ‘dua with comorbid major depression and panic disor der has appropriate rcaiment for both disorders if he or she has any appropriate treatment for depression (eg, antidepressant); however, certain treatments for panic disorder (eg, « benzodiazepine alone without counse- ing) would not be sullicent ‘Appropriate counseling was defined as t leas 4 vis- ‘ts witha mental halh specialist or # vise with a PCP that included counseling for mental heath problems. very simular counseling definition was sed inthe Medial Out Comes Study, which found that appropriate counseling or tmedication vee was associated with improved 2-year fune- tional outcomes in depression” STATISTICAL ANALYSES states were calculated using SUDAAN sofware" and take (account the complex survey desgn and survey cuser- ing. Dilfeences between percentages were evaluted using Wald sass converted to states” Mulplelogistiere: gression was used to examine the elfect of individual, bess and insurance characteristics on both use ofsevies nd receipt of appropriate care. The population forall the main tmodelsconsised ofindviduas wth probable depression, j= tiymia, panic or GAD. Dependent variables were dichot- ‘mous, and indeaed the presence of at east service or ap- propriate care. Independent variables were the same in cach Inodl, and include age sex, thn group, marital tus, Yeas of edcation income, numberof chronic medial die Orders, and presence ofa severe fe dificalyorslohol or other drug problem, Primary medical insurance was en- tered into the modes as one ofthe following private health thaintenance organization, other private insurance, Medi Care, Medicaid, uninsured, or olherfunknown, Physi and smental esl functioning scores from the 13-tem Short Form Health Survey were tncluded in the models to control for seventy of lines We calculated standardized predic tions for variables inthe models by computing the wverage predicied probablies of obtaining quality care, controling Torother covariates, within sxnple subgroup of interes. ‘Weexamined the senstvity o our approach to changes in the methods used vo denfy appropriate reatinent. To do this, we developed alternative regresion models that had thesame independent and dependent arabes, but ex- amined a somewhat different population, First, since our tnain method could have included respondent wih mild inesses, we restricted the population identified as having 4 disorder to individuals witha imation in soil or role functioning (as defined above). Second, since our main ‘method may have missed individuals who dd not meet re irements for less during the past year because of sc cessful treatment we expanded the population dented ts having sdiordcro clude ll ndvidvale taking a depressant medication. and, overall, the probability of receiving appropriate care. We also analyze the effect of demographic factors, in- surance type, and provider Visits on receipt of appropri- Es} There were 174 respondents with dysthymia alone, 831 ‘with major depression alone, and 317 with both disor ders, There were 139 respondents with panic disorder alone, 146 with GAD alone, and 29 with both anxiety dis- forders, In total, 1636 respondents met criteria for | oF more depressive or anxiety disorders, and Table ¥ pre- sents the characteristics of these individuals. Compared swith other persons, individuals with a depressive or ans cexy disorder were significantly more likely to be female, ‘unmarried, unemployed, and to have problems with drugs, or alcohol (P<.0001, for each comparison). They also had significantly fewer years of education, lower family income, more life difficulties and chronic medical dis- ‘orders, and were more likely to have no medical insur (aepranteD) TET (©2001 American Med Downloaded From: http:/jamanetwork.com/ on 11/26/2016 TTCHATIUVOL SR, NTT ance (P<.0001 for each comparison). While respon- dents provided information on medical insurance, they were often unaware of their specific mental health ben- efits, and hence this could not be assessed, VISITS TO PROVIDERS AND USE OF MENTAL HEALTH TREATMENTS. During 1-year period, 80.8% of individuals with a prob- able anxiety oF depressive disorder saw a PCP. While 10.4% had seena mental health specialist, only 1.0% saw 1 specialist without seeing a PCP. Primaty care provider contact was most common with the anxiety disorders, and specialist contact was most common when both anxi ety and depressive disorders were present (Table 2). Al- though provider visits were common, receipt of mental health treatment was not. Among individuals with a prob- able disorder, 25.6% received some antidepressant or anx- folytic medication, and 20.6% received appropriate medi- cation; 31.3% received some counseling, and 17.6% received appropriate counseling, In all, 30.4% received Association, All rights reserved.HO inate health maltenance organization: SF-12, Ye ‘Short Form Heath Survey {The population nthe 2 columns areaitent at P< 0008 09 al items, ‘except etne group wich vas ferent at at least | appropriate treatment for thelr disorder (05% Ci, 27-7%-33.1%). The highest rates of treatment were found in people with both an anxiety and a depressive disorder, FACTORS AFFECTING PROVIDER CONTACT AND TREATMENT QUALITY Within people with a depressive or anxiety disorder, pro- Vider contact was significantly more likely among indi- viduals with more years of education or a greater num- ber of medical disorders, and was less likely among individuals with no medical insurance (Table 3). On the other hand, receipt of appropriate care was strongly influenced by demographic factors and not by presence ‘or type of insurance. As shown in Table 3, receipt of ap- propriate care was affected by the same factors in people who had seen a provider as in the general population. Specifically, the odds of receiving appropriate care var- led significantly by sex, ethnicity, age, and years of edu- (aepnu\teD) ARCTGEN PNCHATRIOL, NTT (©2001 American Med Downloaded From: http:/jamanetwork.com/ on 11/26/2016 Table 1. Characterstes, During 1997 and 1998, Table2. Adults With a Probable Depressive or Annety of Peope Wit and People Without a Probab Disorder Who Visite a Health Cae Provider or Used Mental Depressive or Ansel Oisorderin the United States" Health Treatment During a -Year Period in 1957 and 1968, Peon Tate wi Aa Wha Wn a sve wine oprstve Depresive ‘an andty_ Depressveané a order or Any Dsetoer Tora Rabe Osean Aloe Any rst carat 20) Tr (HEE 2 (Nesta oe (= 9)" ‘oa y mean 3D adaibs Sa T7 leypmyon TSC us Fare oc.) Ha7(648)——55(510) etoner it thn pou, a. (3) Anyrminath 127128 23 we seq) sau6,727) ‘pecs vt Bik fasils) ——“asr(rt3) fjaitopeent = 2057 oo Hsp 107 (07) 16 (07) ‘entany owe 70(45) 470(63) meeton ie avast witha s0eisi2) a1) Apron 5s ma orton (3) reson "| Eden, Wo.) njcouvsingice 209203 so ip stools siss2) 36501472) eprops is 108 20 Same calle i953) 18 286) couaig et Ayotcalegeormoe ——347(175) 2132 242) Aeropia ws te 460 Unenpoyed No.) 153164), 314(38) ‘eter ust Fan nea, 4o3ios30%00 5000051100 ne §D “Forte dtnton oppor Damen pee see he "Wer and Pinay eto secon instars o() Piva sora 273) a4 a7) Pears sian een cation, but not by income or insurance. The standard- Nedare 2r3(t60) 1285200) ‘zed prediction of appropriate care was 33% for women, aces 10273) 215,25) 26i% for men, 34% for whites, 249% for Hispanics, and 17% No isurance woven s(t) for blacks. in terms of age, oldcrand younger people were te or unknown s730) 225 (29) both less likely to receive appropriate care. The stan- Ne, ote ies, eeoeoge —aaae 065 dardized prediction of appropriate care was 20% for ages oe er 18 to 29 years, 37% for ages 30 to 39 years, 32% for ages ‘order an + $0 40 to 49 years, 37% for ages 50 to 59 years, and 22% for ‘ool ober dg muy 517168) 60 years and older. prolom, No() Overall, poor quality care (defined as no care oF ine S12 man 480 appropriate care) was quite cornmon, Poor ual cate oc Gyalecesco 01476 472458 Cire in 80.5% of individual wth PCP vss only (05% 1, 77.3%-83.8%), 11.4% individuals with mental health specialist visits only (05% C1, 0.0%-24.7%), and 10.1% of individuals with both types of visits (05% CI, 5.1%-15.2%). Within patients seeing PCPs, those receiving poor-quality care were less likely to report that mental health problems were evaluated (35.6% vs 65.3%, P<.0001), psychiatric medications were recommended (11.4% vs 55.7%, P<0001), oF a referral to a mental health speci made (4.1% vs 23.5%, P<.0001). The overall population with poor-quality care was much less likely to perceive a need for mental health care (31.4% vs 70.0%, P*<.0001) —1KInm—_@y_§_§_ This project indicates that itis possible to nationally evalu ate and monitor treatment quality for psychiatric cond tions, just as quality has been evaluated in other medi cal disorders. When care is examined, the rate of access to appropriate treatment for depressive and anxiety di orders is quite low, under 35% for the US adult popula- tion witha disorder, although closer to 50% for those with both types of disorder. These findings reflect practice and, utilization patterns in 1997 and 1008, well within the era of newer antidepressant medications and widespread dis- semination of managed care in primary and specialty care The substantial problems with access to mental health Association, All rights reserved.‘Table 3. The Effect, In Adults With a Probable Depressive or Anxiety Disorder, of Indvidual Characteristics on Visiting a Health Care Provider and Receiving Appropriate Care” Dichotomous (0 or>0) Log wanstormed Primary atic inuranes 1.40 (008-2400) 110(091-131) Prat non-A Prat, HO ose ode-1.48) Medicare 1.14(047-275) Medea 050(02¢106), No iurance 045 (02508) (ther or unknown 043 0221.08) Le diets No. 142 (078-258) (hie mace! orders, i. ‘Aah or tar dug proba ‘tem SheForm Hanh Survey Psa scale scre Metal ese sore 131 (1461.59 071 (oae.118) 1.02 (090-105) 10 (098-104 Recetea Appropriate Cre OR (99% ct) fon With Prova Contat ‘atiora Poputton charctrtte (= 1309), (We 157), oak ‘Decades 1.64(090-2.09 3841.90.70) 3m2(209-718) Decades squared 095 0801.02) 35 (08000) 085 (081-09), Fama sox 127(087-187) 152(108-223) 1.60(1.1-231) Ethne group White ack 060036100) 044 026.073) 030 023.058) Hipaie 090 (046-176) oso (02211) 058 (022-100) ote 113(0423.0H 054,025.13) 057 (026-128) Marridving wth a parer 105 (072-12) 085 (05612) 88 (058-130) Eduction y 125(1161.37 1.07 (100-114 1.10(108-117) Famiy income, $5 019,001-635) 04 (004550) 1.05 (80-138) 1.05 (082-134) 1.060 60-16) 000 65-1.40) 113(088.219) 120(060-238) 1.00(057-200), 1.01 (085-136), 111 (087-218) 8s (048-152) 145 (052-405) 1.03 (045.238) 167 (095-205) 172(098.200, 109 (1.00-1.19 1.14 (108-120) 130(088-228) 1.24(080-192) 098,096-100) 1.08 (095-101) (098 (096-10) 0.08 (0.95-101) OR neat oda, confidence neva: AO, health maintenance organization and elses, the ome dummy varie {forthe denton of appropriate cre, please sete “Mater and Methods section. ‘ig nas entered in the ode a oth decades and decades squared ober detet a online etfect Slocome was entered as both dichotomous and lgtanstorme, since tear income arabe was not normaly astute. lreatment occur even among persons receiving health ear. Infact, 76% of individuals with poor-quality care had seen ‘health care professional during a 1-year petiod. Most had been seen in primary care settings, making these promising locations for identifying individuals who could benefit from treatment. While the chances of appropri- ate careare much higher for individuals who have men- tal health specialist contact, these are probably individu- als who are more accepting of psychiatric diagnosis and lueatment. We found that persons not receiving appro- priate care were much less likely to think they needed treatment for an emotional problem. Primary care pro- Viders carry the burden of recognizing cases among pa- tients not presenting for psychological treatment, a task that mental health specialists may not have to face The policy significance of our findings is enhanced by identification of individuals at highest risk for not re- ceiving appropriate care for a depressive or anxiety dis- order. A large amount of the literature suggests that the effect of insurance on quality is inconsistent." We found that insurance had a significant effect on whether an ill individual would see a provider, but no effect on whether appropriate care would be received. In part, this may have ‘occurred because most visits were in primary care, where the rate of appropriate treatment was low. We were wn- able to evaluate generosity of specific coverage for men- (aepnu\teD) IRCTGEN PNCHNTRIOL, NT (©2001 American Med Downloaded From: http:/jamanetwork.com/ on 11/26/2016 tal health services because people were too uncertain about this aspect of their insurance. This is a imporlant area for further study. tn any case, our findings suggest that quality problems exist across insurance types and the un- insured. This is consistent with previous studies sig- gesting that simply providing insurance ts unlikely to sub- stantially improve rates of appropriate care in people with rental health disorders,” Rather, quality improvement programs may need to be implemented within various types of insurance programs and in the public sector to enhance awareness and utilization of appropriate teal- rent options Unlike insurance, demographic factors had le ef fect on whether an individual would see provider, but a large elleet on whether appropriate care would be re- ceived. For instance, despite the fact that blacks are as likely as whites to see a provider, they are significantly less likely to receive appropriate cate. This etlnie di parity in quality of care is similar to findings for ava ely of other medical conditions. Overall, groups al very high risk include men, blacks, olderadults, young adults, and people with less than a high school education. Our findings ate consistent with numerous studies showing that women are much more likely than men to use ott- patient mental health services.” We also find that lower socioeconomic status is strongly associated with nol re- Association, All rights reserved.ceiving appropriate care. These risk factors hold in both, in the general population and in the population that sees ‘health care provider. Our findings emphasize the s3- lience of the surgeon general's current elforts to redress differences in quality of care for major disease condi- lions based on socioeconomic or ethnic status differ- ‘ences, and suggest that major psychiatric conditions should be considered for such an effort ‘An encouraging finding was that when an antide- pressant or anxiolytic medication is used, itis often used ‘ata dosage and duration that may be effective. This sug- ‘gests thatthe main problem is identilying those in need, offering them appropriate care, and helping them ac~ ‘cept this cate, This represents a change from the 1980s, and may be because of the widespread availability ofse- lective serotonin reuptake inhibitor medications that are relatively easy to use at an effective dosage. Indeed, we found that selective serotonin reuptake inhibitors now account for 56% ofall antidepressant medications used for depression and anxiety, and are usually prescribed tan adequate dosage. For counseling, there was a greater difference between using any counseling and receiving appropriate care, with less than half of those with any ‘counseling receiving at least 4 sessions, With benefits de- clining and behavioral managed care becoming more prevalent, it may be more difficult to obtain more than a few visits, or there may be other barriers such as pa- tients not perceiving @ need for ongoing counseling oF ‘experiencing financial barriers, such as copayments, ‘One limitation ofthis study is that we used a brief di- agnosticscreening instrument to dently people witha prob- able disorder. Indeed, brief measures are required when implementing quality assessment in large national samples. ‘A recent study compared a similar brief diagnostic assess- ment with a structured, clinical assessment, and found that the brief assessment was highly specific, though not very sensilive.” Therefore, one would expect that most of the people we identified had, in fact, a depressive or anxiety disorder. Also, to examine the sensitivity of our approach to variation in severity of illness, we reran the model pre- dicting appropriate care after confining the population to those with a functional limitation (n= 1201). Inthe popu- lation with a depressive of anxiety disorder plus a fune- tional limitation, the posite predictive value of our screen- cers should be even higher (and need for treatment quite certain). The only substantive difference between this model ‘and the main model was that that having a chronic medi ‘eal disorder was more strongly associated with receiving appropriate care. Finally, the Partners in Care Study® ex- amined persons who met screening criteria for probable depressive disorder but did not have current disorder based ‘on full diagnostic assessment, and found that their out- ‘comes improved with a quality improvement program, Thus, rates of treatment among a brosder at-risk sample ‘are meaningful to practice policy ‘Our use of a cross-sectional strategy to select indi- viduals with a disorder means that we cannot distin- gush chronic refractory illness from incident condi- lions, oF identify people who were successfully treated more than a year before the interview, and had no symp- toms for the past year becauise of continued treatment. To examine the effect that this may have had, we ran sen- (aepranteD) TET (©2001 American Med Downloaded From: http:/jamanetwork.com/ on 11/26/2016 NTSVCHATIUVOL SR, FN TT sitivity analyses in a population that in included people with a depressive or anxiety disorder plus people who hhad no disorder but were using antidepressant mediea- Udon. Using this alternative approach, the rate of appro- priate cate increased from 30.4% to 40.2%, but predic- {ors of appropriate care did not change. Its noteworthy that we found low rates of appro- priate cate, even though we used a generous definition of appropriate counseling, requiring only 4 professional Visits and only 5 minutes of discussion in a primary care Visit. We were unable to measure the content of coun- seling visits or to reliably identify specific forms of ef- fective treatments, Indeed, a criterion standard for de- fining effective counseling in the context of usual practice does not exist. Also, our reliance on self-report of ser- vice use could have led to underreporting or misreport- ing of medication usage or counseling. However, our model was robust to variation in our assumptions, and our major findings were determined mostly by the pres- ence of any potentially effective treatment. Also, the method we used to measure appropriateness is very simi- lar to that used in the Medical Outcomes Study," which demonstrated that this definition of treatment appropri- ateness affects outcomes, Another potential limitation ofthis study fs that the accuracy ofthe results may have been alfected by the re- sponse rate, which is compounded by the initial re- sponse rate in CTS, We adjusted our findings statisti- cally for response using detailed CTS information on nonrespondents, While we cannot know the extent to Which thisadjustment was successful, features of our find ings are consistent with prior research, Compared with NCS, we found similar prevalence estimates for disor- ders, similar rates of treatment wulization in anxiety, and modestly higher rates of reatment utilization in depres- sion, In primary care, we found rates of mental health Uweatment use that are similar to those reported by the Medical Outcomes Study using 1980s data. Many factors can contribute to why people who need care do not receive it." These inelude, for instance, pe ceived need, willingness to accept cate, insurance cover age, detection by providers, and knowledge and belies of providers regarding ellective treatment. Pindings from this Study support efforts to improve care through either pub- lic education or quality improvement interventions, Re- cent research suggests that while a majority of the public ‘dentfies major depression as a mental illness, psychiatric disorders continue to be strongly stigmatized, * We found that people not receiving appropriate care were muich less likely to have had their mental health problems evalu- ated, and much less likely to believe they needed mental health treatment, Public and patient education efforts are needed to increase the extent to which people value treal- ment for common psychiatric disorders and demand ap- propriate care. Quality improvement efforts should focus fon strategies that bring elfective treatments to people— whether through improving practice infrastructure, en- hhancing benefit design, or implementing outreach pro- grams. Clinical research has made substantial progress in establishing efficacious treatments, nd progress must now proceed on dissemination to the public, especially for vul- erable subpopulations. Association, All rights reserved.Accepted for publication July 20, 2000. This study was supported by a grant from the Robert Wood Johnson Foundation, Princeton, NJ (Dr Wells); and bby grant P50 MH 54625, from the National Insitute of Men ‘al Health, Rockville, Md, to the University of California at Los Angeles-RAND Research Center on Managed Care Jor Psychiatric Disorders, Los Angeles (Dr Wells). Infrastruc- ture support was provided hy the Department of Veterans Affairs VISN 22 Mental Illness Research, Education, and Clinical Center, Los Angeles, Cali Presented in part al the Association of Health Services Research Annual Meeting, Chicago, Ill, June 29, 1999; the Department of Veterans Affairs Health Services Research ‘and Development Annual Mecting, Washington, DC, March 25, 2000; and the American Psychiatrie Association An- hnual Meeting, Chicago, Il, May 16, 2000. We thank Lily Zhang, MS, for assistance with data analysis, ‘Reprints: Alexander S. Young, MD, MSHS, UCLA New- ropsychiatric Institute, Health Services Research Center, 10920 Wilshire Blvd, Suite 300, Los Angeles, CA 90024-6505 1. Depression Guinean. Depression Panay Creat of aj De ‘rssion Race MUS Dept Heth and Human Serves, abl oath ce, Apne fo: Heath Cre Posy and serch 100, -AnarcanPsyeiaie Acsodain Paice gales fo jr depressive ds sider alts, A Psyehy 1003 180aypol 51-526 prea Veterans tae. Cnc! Gadine for Mio Ospressie Dior er Washington DC: Vans Heath Aston 108. Scher HE Kn Sion Rush AL ei dpi ity eae prac’ an uplre t ihe Agng or ath Cue Pay ard ffuch Pace Guenes Arch Gen Pajhaty. 10685: 111 127 Som, asca Matsuo Cf the Amen Cals of Physicians Amann Sec of tral Mein. haraealage rennet ete ar (apesson nd dsty-ma nn kr Me 20015278 102 Maran Pyotr. eRe 4-1 WPA ys Wring Grup Dsthyma nina races. Py. as ee ‘Tha ME, Fava. sree U Kocsis Kran Dion Rosana Haran W ples one ndomzed cnc aleanoanng sarang {td impanin fort teamed. rb Gen Peery. 100835 inaeh ‘Val, ao O, Pir MF Boas MB Oe J. Conta far tly of uoete nota. BJ Poychay. TBT 1703680 Ropar Si MBs A faton WPhamacaterapy fpr ir a propse guile forthe aly physan. J Board um Pract 1286, take oa -Anerean Payee Assocation Prac ule othe eaten ofp ‘us th pave ard Am ayy. OBB. 3 RoySyneP. Wingtsan 0, Cove , Dap 8 Psjhaphamacalog sat merlin geretatued ancy urd, tds hobs Pht Ce oth ‘on oases. Fila K Downing, Scaciar, assmanH.Andopassns orth a. ‘eat ered ans disorder apace conledconsarson lm ae tazdone, ad danpum. Ach Gon Paya. TOHSSO ARE ABS, ‘Sehweae Rika KT longterm management of generalae any di foe sus and aime. Jn Pena 109657 sup 3-2 otow Or LenranGL Adres nthe peyehosoel vee ay dsr ere mone retaoleat cr fc Gen Pye, 1006387735, Wale Ke St Sharoure CO Mrdih LS Caring fr Dgreesin Ca tng Mase Harré Unversity Pres 106, 8 6 17. Soh Mf Mian EA Brock How goodie uty ost caren ‘he Une Sie ibe 09678517363 1. Kesler Zh Kats) Moue AU, Fr RG, End Lea Paster of aut srs prea pales te Mana Cameras Srey dev Peay. 190 5615128 1, Kate) fear BE Ln Wes Maton management of depen ‘he United Stes Ono, Jan rer hd 100818772, ‘20, Sevan Vorkor i, Pill Falenen Oma). Aneta sly atthe elon teen somate sympa and epesson Eg Jd 109 dengan 21. RegarDA tron WE. a0, Mandesched RW, Lack BZ Godin The ‘eto US mul ana doers sani systan Epil Catch. (aepnaN TED) TECH GEN PNCHATRTOT NN 2 Es En 6 a. 28 0 2. a 2 2 au 2. 28 a. Py 2. ©. 4 2 2 “4 6 6 a. 8 2 0 a 2 me Ae prospec ye prone rus of order and sees. Ach ‘Ser Psyenaty OBS 98 Katlon W.Va or We Ln, Waker, Simon GE Bus ,RatioonP Russo ‘ Colaort magento arhrexmen gadsoesipcton dpe Sion pear cate JO Tons.275 026-1031 Fos ng Fone) Sth 4 Coy Sith GR. asst poor ‘teams of nde mao depression primary ex. Gon Hosp Poh ‘ys togn20 220, Wels, Schoenbaum, Una J Lagomasino Rubenstein LQ of "aro preva pues wah epson naageceare. Ach a Med fsoonsze 536 Tylor 8, Kg 8, Marga rs A Tach M, Roh WT. Ags WS. Us ot ‘nian and ino rosie valuta pre dpa eench im Pycny T9 a8 1-18 SnrsonR, Cor Wee Useo media seven samen pic ‘Sore wih aguapota anor sol ob CAL 100214787833, Gsman AM Wrsau Pasan 5 Raper PCa. Hue ME, Tain ‘anes ML Ka &, Gln J EpstyeT Rah Kale MB Pa ‘ora. apne ordi apraphai aa ambi an ty err study J Me Met i100 182 72-70 ‘ear, hae Sera OL Prat LA, C0, man er MG, Lr PW Oseorpton of aga trapy na parce angel shat. Cin Psychopharmacol 18616228 22, Past DK War's es some recon fora psynaty 087722284 Pat, Pack C Burs 8, Selsngr WL. tic and he us of ou tere altos inratonalnue apustion, AJP eth ‘soe 272706, ae) Rel RC Frank RG, Let? Li Maral ety cae ea. mari, ad ececanane Sus nth Untied Sines ad Ura. Inguy. 15 3-2, oper Panekt, Geum Rt Ford UE. Caractere pte th mao eon who read caren gna made snd spay meal hea se tgs Cr Toads2524 Nsted LS Wal Bar Csi spc and wet ty ford essed oapatons wan tat mae crores Arh Fy ed 0 oss. Hoygust Wels Men ota ra, Sturm Geen Sartoun Miu Kip Bhat Fey Young AS, ura HA, es, The cg of Heath Camu "es-a sty eather dele fr aeabal, dg ase, nmol haath ondans ogy. 198 36201-23. Kener lumerttlO, agar Cunsngham Pa SM Grossman eb eat CES Per Strouse A GsbugP The denna hs Court Tacrg Stud alongs tly of hath stem change nd isathts on peop ng 108 5105-205, ae Rosa ae SD 12-em Sort Frm He Sure: con Suton of ses adele isto lay ard ality Meda 1086 ua eer RC, dren 6, Mecezak , Uso Withen HUT Wort ath ‘ngancton Campeste Iran Dagoste inersew Shr Form (OD ‘Gene, Swtran Wor Heats Orancaon 068, Ameran Paya Assoon, Sacred nea In fr DSU Washo: Amerean Pye Pres 100 ‘anpetaranarl Dagnoste nen (CD), Vson2 1. Gene Si ‘tan: Word eth Ogencin: 07 Burger The Staness Inpro (I) Wenger NK Matson ME. Fu berg CO. Eison J ds Asessrat of Guy of Li Cel Ta of Cr ‘Sovascbr herpes Nt Yor NV Le Jeg Pblting 105 ‘he dena Us Deer Keeton Test AUDI. Gases fo Usain Pe may Heth Care Geneva, Suzan Word Heh Oran: 082 Sturm Wels How can care for depres bcos mae costae? ‘ake agzresi-o ‘SUDAANE Prosi Sutwar fr Survey Data Anais, Version 7.5 Re aren Tange Par NC: Raceah Tange teu: 157 ach 6, Festa, ruan JL Stata nth utara anaes of ata from comple surveys I St Ra TOTS s30-76, Hl Lt HS. Does managed cae lad ater or worse quay of care? ath A (tive). 057161 25. Dre 86 oseseck RA Ment ares ad aces to mei nthe Unie Sas. Jyh. 0615-175 177 Freeman HE, Paya acl sen ath eae. Wp J Med, 200032: fs, "ry J Menon RA, Lar MY, obo AM.Laighon A Acpaion ot tagnasittevene or apressan nthe Serng County Sy eatge tor eye epdamilgy. Ach Gan Paychay.20057 20-238 Wal Shetoure€.Schsnbaun WM Duan Meret Vout J Me Tan Gane ME Rubens LV. npat of dissing uy impor Ie tora for dogs managed inary cara atdomed or Wold nl ah 200028212 220 Chass sheath cre rd Sic Sigma uly? bank 0. 100876: coat Unk. Phun JC, Sesahan M, Sue A, Pescesolde BA abl coneap- "ens of mealies as, cases, dangeroustess, adsl stance. A {Pate Heath ona 2.189 rh AJ Ono df hui. Ach Gen Pci, (©2001 American Medical Association, All sights reserved. Downloaded From: http:/jamanetwork.com/ on 11/26/2016