[Show abstract][Hide abstract]ABSTRACT: Supplemental Figure 2. Three-way sensitivity analysis of prevalence of positive test for SSRI response, relative risk of remission in test+ versus test- subjects, and utility of depressed state.
[Show abstract][Hide abstract]ABSTRACT: Supplemental Figure 1. Schematic Diagram of the State-transition Model
Supplemental Figure 1 presents a schematic diagram of the state-transition model used in this analysis. All subjects begin in the “depressed, on antidepressant” state. Probabilities of transitions between states are adjusted based upon treatment selection and test results.
[Show abstract][Hide abstract]ABSTRACT: The paper reviews recent findings from the WHO World Mental Health (WMH) surveys on the global burden of mental disorders.
The WMH surveys are representative community surveys in 28 countries throughout the world aimed at providing information to mental health policy makers about the prevalence, distribution, burden, and unmet need for treatment of common mental disorders.
The first 17 WMH surveys show that mental disorders are commonly occurring in all participating countries. The inter-quartile range (IQR: 25th-75th percentiles) of lifetime DSM-IV disorder prevalence estimates (combining anxiety, mood, externalizing, and substance use disorders) is 18.1-36.1%. The IQR of 12-month prevalence estimates is 9.8-19.1%. Prevalence estimates of 12-month Serious Mental Illness (SMI) are 4-6.8% in half the countries, 2.3-3.6% in one-fourth, and 0.8-1.9% in one-fourth. Many mental disorders begin in childhood-adolescence and have significant adverse effects on subsequent role transitions in the WMH data. Adult mental disorders are found to be associated with such high role impairment in the WMH data that available clinical interventions could have positive cost-effectiveness ratios.
Mental disorders are commonly occurring and often seriously impairing in many countries throughout the world. Expansion of treatment could be cost-effective from both employer and societal perspectives.
Full-text · Article · Mar 2009 · Epidemiologia e psichiatria sociale
[Show abstract][Hide abstract]ABSTRACT: Nonrandomised studies on the causal effects of psychotropic medications may be biased by patient characteristics that are not fully adjusted.
Studies using linked claims databases found that typical antipsychotic medications were associated with increased short-term mortality compared with atypical antipsychotics. It has been suggested that such results may be due to residual confounding by factors that cannot be measured in claims databases. Using detailed survey data we identified the direction and magnitude of such residual confounding.
Cross-sectional survey data.
17 776 participants aged > or =65 years from the Medicare Current Beneficiary Survey (MCBS).
To determine the association between typical antipsychotic use and potential confounding factors we assessed five factors not measured in Medicare claims data but in the MCBS, i.e. body mass index, smoking, activities of daily living (ADL) score, cognitive impairment and Rosow-Breslau physical impairment scale. We estimated adjusted associations between these factors and antipsychotic use. Combined with literature estimates of the independent effect of confounders on death, we computed the extent of residual confounding caused by a failure to adjust for these factors.
Comparing typical antipsychotic users with atypical antipsychotic users, we found that not adjusting for impairments in the ADL score led to an underestimation of the association with death (-13%), as did a failure to adjust for cognitive impairment (-7%). The combination of all five unmeasured confounders resulted in a net confounding of -5% (range -19% to +2%). After correction, the reported association between typical antipsychotic use and death compared with atypical antipsychotic use was slightly increased from a relative risk (RR) of 1.37 to 1.44 (95% CI 1.33, 1.56). Comparing any antipsychotic use with non-users would result in overestimations of >50% if cognitive impairment remained unadjusted.
Claims data studies tend to underestimate the association of typical antipsychotics with death compared with atypical antipsychotics because of residual confounding by measures of frailty. Studies comparing antipsychotic use with non-users may substantially overestimate harmful effects of antipsychotics.
[Show abstract][Hide abstract]ABSTRACT: Mental disorders impose considerable socioeconomic costs due to their episodic/chronic nature, their relatively early ages at onset, and the highly disabling nature of inadequately treated mental illness. Despite substantial increases in the volume of mental health treatment for disorders in the past two decades, particularly pharmacotherapies, the level of morbidity and mortality from these disorders does not appear to have changed substantially over this period. Improving outcomes will require the development and use of more efficacious treatments for mental disorders. Likewise, implementation of cost-effective strategies to improve the quality of existing care for these disabling conditions is required.
[Show abstract][Hide abstract]ABSTRACT: Translational research is urgently needed to turn basic scientific discoveries into widespread health gains and nowhere are these needs greater than in conditions such as schizophrenia and other psychotic disorders. In this article, we discuss one type of translational research--called T1--which is needed to take advantage of developments in the basic neurosciences and translate them into more efficacious diagnostic, preventive, and therapeutic interventions. However, ensuring that interventions from T1 research actually benefit patients will require a second form of translational research--called T2--to turn innovations into everyday clinical practice and health decision-making. Recent examples of T1 and T2 research in schizophrenia and other psychotic disorders as well as strategies for better linking T1 and T2 research agendas are covered.
Full-text · Article · Nov 2008 · Neuropsychopharmacology: official publication of the American College of Neuropsychopharmacology
[Show abstract][Hide abstract]ABSTRACT: To investigate the potential mechanisms through which conventional antipsychotic medication (APM) might act, the specific causes of death in elderly patients newly started on conventional APM were compared with those of patients taking atypical APM.
All British Columbia residents aged 65 and older who initiated a conventional or atypical APM between 1996 and 2004.
Cox proportional hazards models were used to compare risks of developing a specific cause of death within 180 days of APM initiation. Potential confounders were adjusted for using traditional multivariable, propensity-score, and instrumental-variable adjustments.
The study cohort included 12,882 initiators of conventional APM and 24,359 initiators of atypical APM. Of 3,821 total deaths within the first 180 day of use, cardiovascular (CV) deaths accounted for 49% of deaths. Initiators of conventional APM had a significantly higher adjusted risk of all CV death (hazard ratio (HR)=1.23, 95% confidence interval (CI)=1.10-1.36) and out-of-hospital CV death (HR=1.36, 95% CI=1.19-1.56) than initiators of atypical APM. Initiators of conventional APM also had a higher risk of death due to respiratory diseases, nervous system diseases, and other causes.
These data suggest that greater risk of CV deaths might explain approximately half of the excess mortality in initiators of conventional APM. The risk of death due to respiratory causes was also significantly higher in conventional APM use.
No preview · Article · Sep 2008 · Journal of the American Geriatrics Society
[Show abstract][Hide abstract]ABSTRACT: There is limited occupational health industry data pertaining to 1) the prevalence of psychological distress in various employee subtypes and 2) risk factors for employee psychological distress.
The employees of 58 large public and private sector employers were invited to complete the Kessler 6 (K6) as part of the Health and Performance at Work Questionnaire. A K6 score of > or =13 was chosen to indicate high psychological distress.
Data on 60,556 full-time employees indicate that 4.5% of employees have high psychological distress of which only 22% were in current treatment. Occupational risk factors identified include long working hours, sales staff and non-traditional gender roles.
High psychological distress is pervasive across all employee subtypes and remains largely untreated. Risk factors identified will guide the targeting of mental health promotion, prevention and screening programs.
No preview · Article · Jul 2008 · Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine
[Show abstract][Hide abstract]ABSTRACT: The purpose of this report was to update previous estimates of the association between mental disorders and earnings. Current estimates for 2002 are based on data from the National Comorbidity Survey Replication (NCS-R).
The NCS-R is a nationally representative survey of the U.S. household population that was administered from 2001 to 2003. Following the same basic approach as prior studies, with some modifications to improve model fitting, the authors predicted personal earnings in the 12 months before interview from information about 12-month and lifetime DSM-IV mental disorders among respondents ages 18-64, controlling for sociodemographic variables and substance use disorders. The authors used conventional demographic rate standardization methods to distinguish predictive effects of mental disorders on amount earned by persons with earnings from predictive effects on probability of having any earnings.
A DSM-IV serious mental illness in the preceding 12 months significantly predicted reduced earnings. Other 12-month and lifetime DSM-IV/CIDI mental disorders did not. Respondents with serious mental illness had 12-month earnings averaging $16,306 less than other respondents with the same values for control variables ($26,435 among men, $9,302 among women), for a societal-level total of $193.2 billion. Of this total, 75.4% was due to reduced earnings among mentally ill persons with any earnings (79.6% men, 69.6% women). The remaining 24.6% was due to reduced probability of having any earnings.
These results add to a growing body of evidence that mental disorders are associated with substantial societal-level impairments that should be taken into consideration when making decisions about the allocation of treatment and research resources.
Full-text · Article · Jul 2008 · American Journal of Psychiatry
[Show abstract][Hide abstract]ABSTRACT: To review evidence on the workplace prevalence and correlates of major depressive episodes, with a particular focus on the National Comorbidity Survey Replication, the most recent national survey to focus on these issues.
Nationally representative survey of Diagnostic and Statistical Manual, 4th Revision Mental Disorders.
A total of 6.4% of employed National Comorbidity Survey Replication respondents had 12-month major depressive disorder. An additional 1.1% had major depressive episodes due to bipolar disorder or mania-hypomania. Only about half of depressed workers received treatment. Fewer than half of treated workers received care consistent with published treatment guidelines.
Depression disease management programs can have a positive return-on-investment from the employer perspective, but only when they are based on best practices. Given the generally low depression treatment quality documented here, treatment quality guarantees are needed before expanding workplace depression screening, outreach, and treatment programs.
Preview · Article · May 2008 · Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine
[Show abstract][Hide abstract]ABSTRACT: Antidepressant therapies are underused among older adults and could be further curtailed by patient cost-sharing requirements. The authors studied the effects of two sequential cost-sharing policies in a large, stable population of all British Columbia seniors: change from full prescription coverage to 10-25 dollars copayments (copay) in January 2002 and replacement with income-based deductibles and 25% coinsurance in May 2003.
PharmaNet data were used to calculate monthly dispensing of antidepressants (in imipramine-equivalent milligrams) among all British Columbia residents age 65 and older beginning January 1997 through December 2005. Monthly rates of starting and stopping antidepressants were calculated. Population-level patterns over time were plotted, and the effects of implementing cost-sharing policies on antidepressant use, initiation, and stopping were examined in segmented linear regression models.
Implementation of the copay policy was not associated with significant changes in level of antidepressant dispensing or the rate of dispensing growth. Subsequent implementation of the income-based deductible policy also did not lead to a significant change in dispensing level but led to a significant (p=.02) decrease in the rate of growth of antidepressant dispensing. The copay policy was associated with a significant (p=.01) drop in the frequency of antidepressant initiation among persons with depression. Income-based deductibles reduced the rate of increase in antidepressant initiation over time. Implementation of the copay and income-based deductible policies did not have significant effects on stopping rates.
Introducing new forms of medication cost sharing appears to have the potential to reduce some use and initiation of antidepressant therapy by seniors. The clinical consequences of such reduced use need to be clarified.
Preview · Article · May 2008 · Psychiatric Services
[Show abstract][Hide abstract]ABSTRACT: Explore the business case for enhanced depression care and establish a return on investment rationale for increased organizational involvement by employer-purchasers.
Literature review, focused on the National Institute of Mental Health-sponsored Work Outcomes Research and Cost-effectiveness Study.
This randomized controlled trial compared telephone outreach, care management, and optional psychotherapy to usual care among depressed workers in large national corporations. By 12 months, the intervention significantly improved depression outcomes, work retention, and hours worked among the employed.
Results of the Work Outcomes Research and Cost-effectiveness Study trial and other studies suggest that enhanced depression care programs represent a human capital investment opportunity for employers.
No preview · Article · May 2008 · Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine
[Show abstract][Hide abstract]ABSTRACT: The authors examined the disruption of ongoing treatments among individuals with preexisting mental disorders and the failure to initiate treatment among individuals with new-onset mental disorders in the aftermath of Hurricane Katrina.
English-speaking adult Katrina survivors (N=1,043) responded to a telephone survey administered between January and March of 2006. The survey assessed posthurricane treatment of emotional problems and barriers to treatment among respondents with preexisting mental disorders as well as those with new-onset disorders posthurricane.
Among respondents with preexisting mental disorders who reported using mental health services in the year before the hurricane, 22.9% experienced reduction in or termination of treatment after Katrina. Among those respondents without preexisting mental disorders who developed new-onset disorders after the hurricane, 18.5% received some form of treatment for emotional problems. Reasons for failing to continue treatment among preexisting cases primarily involved structural barriers to treatment, while reasons for failing to seek treatment among new-onset cases primarily involved low perceived need for treatment. The majority (64.5%) of respondents receiving treatment post-Katrina were treated by general medical providers and received medication but no psychotherapy. Treatment of new-onset cases was positively related to age and income, while continued treatment of preexisting cases was positively related to race/ethnicity (non-Hispanic whites) and having health insurance.
Many Hurricane Katrina survivors with mental disorders experienced unmet treatment needs, including frequent disruptions of existing care and widespread failure to initiate treatment for new-onset disorders. Future disaster management plans should anticipate both types of treatment needs.
Full-text · Article · Feb 2008 · American Journal of Psychiatry
[Show abstract][Hide abstract]ABSTRACT: Data are reviewed on the descriptive epidemiology of commonly occurring DSM-IV mental disorders in the United States. These disorders are highly prevalent: Roughly half the population meets criteria for one or more such disorders in their lifetimes, and roughly one fourth of the population meets criteria in any given year. Most people with a history of mental disorder had first onsets in childhood or adolescence. Later onsets typically involve comorbid disorders. Some anxiety disorders (phobias, separation anxiety disorder) and impulse-control disorders have the earliest age of onset distributions. Other anxiety disorders (panic disorder, generalized anxiety disorder, post-traumatic stress disorder), mood disorders, and substance disorders typically have later ages of onset. Given that most seriously impairing and persistent adult mental disorders are associated with child-adolescent onsets and high comorbidity, increased efforts are needed to study the public health implications of early detection and treatment of initially mild and currently largely untreated child-adolescent disorders.
Preview · Article · Feb 2008 · Annual Review of Public Health
[Show abstract][Hide abstract]ABSTRACT: This study examined use of mental health services among adult survivors of Hurricane Katrina in order to improve understanding of the impact of disasters on persons with mental disorders.
A geographically representative telephone survey was conducted between January 19 and March 31, 2006, with 1,043 displaced and nondisplaced English-speaking Katrina survivors aged 18 and older. Survivors who reported serious and mild-moderate mood and anxiety disorders in the past 30 days and those with no such disorders were identified by using the K6 scale of nonspecific psychological distress. Use of services, system sectors, and treatments and reasons for not seeking treatment or dropping out were recorded. Correlates of using services and dropping out were examined.
An estimated 31% of respondents (N=319) had evidence of a mood or anxiety disorder at the time of the interview. Among these only 32% had used any mental health services since the disaster, including 46% of those with serious disorders. Of those who used services, 60% had stopped using them. The general medical sector and pharmacotherapy were most commonly used, although the mental health specialty sector and psychotherapy played important roles, especially for respondents with serious disorders. Many treatments were of low intensity and frequency. Undertreatment was greatest among respondents who were younger, older, never married, members of racial or ethnic minority groups, uninsured, and of moderate means. Structural, financial, and attitudinal barriers were frequent reasons for not obtaining care.
Few Katrina survivors with mental disorders received adequate care; future disaster responses will require timely provision of services to address the barriers faced by survivors.
Full-text · Article · Dec 2007 · Psychiatric Services
[Show abstract][Hide abstract]ABSTRACT: Epidemiologic surveys have consistently found that approximately half of respondents who obtained treatment for mental or substance use disorders in the year before interview did not meet the criteria for any of the disorders assessed in the survey. Concerns have been raised that this pattern might represent evidence of misallocation of treatment resources.
To examine patterns and correlates of 12-month treatment of mental health or substance use problems among people who do not have a 12-month DSM-IV disorder.
Data are from the National Comorbidity Survey Replication, a nationally representative face-to-face US household survey performed between February 5, 2001, and April 7, 2003, that assessed DSM-IV disorders using a fully structured diagnostic interview, the World Health Organization Composite International Diagnostic Interview (CIDI).
A total of 5692 English-speaking respondents 18 years and older.
Patterns of 12-month service use among respondents without any 12-month DSM-IV CIDI disorders.
Of respondents who used 12-month services, 61.2% had a 12-month DSM-IV CIDI diagnosis, 21.1% had a lifetime but not a 12-month diagnosis, and 9.7% had some other indicator of possible need for treatment (subthreshold 12-month disorder, serious 12-month stressor, or lifetime hospitalization). The remaining 8.0% of service users accounted for only 5.6% of all services and even lower proportions of specialty (1.9%-2.4%) and general medical (3.7%) visits compared with higher proportions of human services (18.9%) and complementary and alternative medicine (7.6%) visits. Only 26.5% of the services provided to the 8.0% of presumably low-need patients were delivered in the mental health specialty or general medical sectors.
Most services provided for emotional or substance use problems in the United States go to people with a 12-month diagnosis or other indicators of need. Patients who lack these indicators of need receive care largely outside the formal health care system.
Full-text · Article · Nov 2007 · Archives of General Psychiatry
[Show abstract][Hide abstract]ABSTRACT: Postmarketing studies of prescription drugs are challenging because prognostic variables that determine treatment choices are often unmeasured. In this setting, instrumental variable (IV) methods that exploit differences in prescribing patterns between physicians may be used to estimate treatment effects; however, IV methods require strong assumptions to yield consistent estimates. We sought to explore the validity of physician-level IV in a comparative study of short-term mortality risk among elderly users of conventional versus atypical antipsychotic medications (APM).
We studied a cohort of patients initiating APMs in Pennsylvania who were eligible for Medicare and a state-funded pharmaceutical benefit plan. The IV was defined as the type of the APM prescription written by each physician before the index prescription. To evaluate whether the IV was related to other therapeutic decisions that could affect mortality, we explored the association between the instrument and 2 types of potentially hazardous coprescriptions: a tricyclic antidepressant (TCA) not recommended for use in the elderly or a long-acting benzodiazepine. To insure that the IV analysis was not biased by case-mix differences between physicians, we examined the associations between the observed patient characteristics and the IV.
The cohort consisted of 15,389 new users of APMs. Our multivariable model indicated that physicians who had most recently prescribed a conventional APM were not significantly more or less likely to coprescribe a potentially hazardous TCA [odds ratio (OR), 0.78; 95% confidence interval (CI), 0.58-1.02] but were less likely to prescribe a long-acting benzodiazepine (OR, 0.57; 95% CI, 0.45-0.72) with their current APM prescription. The association between long-acting benzodiazepine prescribing and APM preference was no longer significant when the analysis was restricted to primary care physicians (OR, 0.84; 95% CI, 0.62-1.15). Multivariable regression indicated that important medical comorbidities (eg, cancer, hypertension, stroke) were unrelated to the IV.
The previous APM prescription written by the physician was unassociated with major medical comorbidities in the current patient, suggesting that the IV estimates were not biased by case-mix differences between physicians. However, we did find that the IV was associated with the use of long-acting benzodiazepines. This association disappeared when the study was restricted to the patients treated by primary care physicians. Our study illustrates how internal validation approaches may be used to improve the design of quasi-experimental studies.