Background Dramatic changes have occurred in mental health treatments during the past decade. Data on recent treatment patterns are needed to estimate the unmet need for services. Objective To provide data on patterns and predictors of 12-month mental health treatment in the United States from the recently completed National Comorbidity Survey Replication. Design and Setting Nationally representative face-to-face household survey using a fully structured diagnostic interview, the World Health Organization’s World Mental Health Survey Initiative version of the Composite International Diagnostic Interview, carried out between February 5, 2001, and April 7, 2003. Participants A total of 9282 English-speaking respondents 18 years and older. Main Outcome Measures Proportions of respondents with 12-monthDSM-IVanxiety, mood, impulse control, and substance disorders who received treatment in the 12 months before the interview in any of 4 service sectors (specialty mental health, general medical, human services, and complementary and alternative medicine). Number of visits and proportion of patients who received minimally adequate treatment were also assessed. Results Of 12-month cases, 41.1% received some treatment in the past 12 months, including 12.3% treated by a psychiatrist, 16.0% treated by a nonpsychiatrist mental health specialist, 22.8% treated by a general medical provider, 8.1% treated by a human services provider, and 6.8% treated by a complementary and alternative medical provider (treatment could be received by >1 source). Overall, cases treated in the mental health specialty sector received more visits (median, 7.4) than those treated in the general medical sector (median, 1.7). More patients in specialty than general medical treatment also received treatment that exceeded a minimal threshold of adequacy (48.3% vs 12.7%). Unmet need for treatment is greatest in traditionally underserved groups, including elderly persons, racial-ethnic minorities, those with low incomes, those without insurance, and residents of rural areas. Conclusions Most people with mental disorders in the United States remain either untreated or poorly treated. Interventions are needed to enhance treatment initiation and quality.

https://jamanetwork.com/journals/jamapsychiatry/articlepdf/208673/yoa40304.pdf

Twelve-Month Use of Mental Health Services in the United States Results From the National Comorbidity Survey Replication

ContextFew depressed older adults receive effective treatment in primary care
settings.ObjectiveTo determine the effectiveness of the Improving Mood–Promoting
Access to Collaborative Treatment (IMPACT) collaborative care management program
for late-life depression.DesignRandomized controlled trial with recruitment from July 1999 to August
2001.SettingEighteen primary care clinics from 8 health care organizations in 5
states.ParticipantsA total of 1801 patients aged 60 years or older with major depression
(17%), dysthymic disorder (30%), or both (53%).InterventionPatients were randomly assigned to the IMPACT intervention (n = 906)
or to usual care (n = 895). Intervention patients had access for up to 12
months to a depression care manager who was supervised by a psychiatrist and
a primary care expert and who offered education, care management, and support
of antidepressant management by the patient's primary care physician or a
brief psychotherapy for depresssion, Problem Solving Treatment in Primary
Care.Main Outcome MeasuresAssessments at baseline and at 3, 6, and 12 months for depression, depression
treatments, satisfaction with care, functional impairment, and quality of
life.ResultsAt 12 months, 45% of intervention patients had a 50% or greater reduction
in depressive symptoms from baseline compared with 19% of usual care participants
(odds ratio [OR], 3.45; 95% confidence interval [CI], 2.71-4.38; P<.001). Intervention patients also experienced greater rates of
depression treatment (OR, 2.98; 95% CI, 2.34-3.79; P<.001),
more satisfaction with depression care (OR, 3.38; 95% CI, 2.66-4.30; P<.001), lower depression severity (range, 0-4; between-group
difference, −0.4; 95% CI, −0.46 to −0.33; P<.001), less functional impairment (range, 0-10; between-group
difference, −0.91; 95% CI, −1.19 to −0.64; P<.001), and greater quality of life (range, 0-10; between-group
difference, 0.56; 95% CI, 0.32-0.79; P<.001) than
participants assigned to the usual care group.ConclusionThe IMPACT collaborative care model appears to be feasible and significantly
more effective than usual care for depression in a wide range of primary care
practices.

https://jamanetwork.com/journals/jama/articlepdf/195599/JOC21093.pdf

Collaborative Care Management of Late-Life Depression in the Primary Care Setting: A Randomized Controlled Trial

Background There is a significant gap between the demand for psychological therapy services and the available supply. One proposal to overcome this problem is to increase efficiency of provision through the adoption of briefer ‘minimal interventions’ within stepped care models.

Aims To examine the theoretical underpinnings of stepped care, together with the practicalities of the adoption of this system of care.

Method Narrative literature review.

Results The potential clinical and economic benefits of stepped care are dependent upon underlying assumptions of equivalence in terms of clinical outcomes, efficiency in terms of resource use and costs, and acceptability of ‘ minimal interventions’ to patients and therapists. Illustrative studies of these issues are considered.

Conclusions Although psychological services might benefit from the adoption of the stepped care model, a substantial research agenda needs to be fulfilled before a judgement can be made as to whether stepped care might be an efficient method of delivering psychological services.

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/16CE065666C896FAAC8A39B80AE470E7/S0007125000230298a.pdf/div-class-title-stepped-care-in-psychological-therapies-access-effectiveness-and-efficiency-div.pdf

Stepped care in psychological therapies: Access, effectiveness and efficiency. Narrative literature review.

For people at risk of depressive relapse, mindfulness-based cognitive therapy (MBCT) has an additive benefit to usual care (H. F. Coelho, P. H. Canter, & E. Ernst, 2007). This study asked if, among patients with recurrent depression who are treated with antidepressant medication (ADM), MBCT is comparable to treatment with maintenance ADM (m-ADM) in (a) depressive relapse prevention, (b) key secondary outcomes, and (c) cost effectiveness. The study design was a parallel 2-group randomized controlled trial comparing those on m-ADM (N = 62) with those receiving MBCT plus support to taper/discontinue antidepressants (N = 61). Relapse/recurrence rates over 15-month follow-ups in MBCT were 47%, compared with 60% in the m-ADM group (hazard ratio = 0.63; 95% confidence interval: 0.39 to 1.04). MBCT was more effective than m-ADM in reducing residual depressive symptoms and psychiatric comorbidity and in improving quality of life in the physical and psychological domains. There was no difference in average annual cost between the 2 groups. Rates of ADM usage in the MBCT group was significantly reduced, and 46 patients (75%) completely discontinued their ADM. For patients treated with ADM, MBCT may provide an alternative approach for relapse prevention.

/pdf/mindfulness-based-cognitive-therapy-to-prevent-relapse-in-3k1wxep54a.pdf

Mindfulness-based cognitive therapy to prevent relapse in recurrent depression.

This review is published as a Cochrane Review in the Cochrane Database of Systematic Reviews 2012, Issue 10. Cochrane Reviews are regularly updated as new evidence emerges and in response to comments and criticisms, and the Cochrane Database of Systematic Reviews should be consulted for the most recent version of the Review.

/pdf/collaborative-care-for-depression-and-anxiety-problems-1zevl94j7q.pdf

Collaborative care for depression and anxiety problems

OBJECTIVE\nThe authors evaluated the incremental cost-effectiveness of stepped collaborative care for patients with persistent depressive symptoms after usual primary care management.\n\n\nMETHOD\nPrimary care patients initiating antidepressant treatment completed a standardized telephone assessment 6-8 weeks after the initial prescription. Those with persistent major depression or significant subthreshold depressive symptoms were randomly assigned to continued usual care or collaborative care. The collaborative care included systematic patient education, an initial visit with a consulting psychiatrist, 2-4 months of shared care by the psychiatrist and primary care physician, and monitoring of follow-up visits and adherence to medication regimen. Clinical outcomes were assessed through blinded telephone assessments at 1, 3, and 6 months. Health services utilization and costs were assessed through health plan claims and accounting data.\n\n\nRESULTS\nPatients receiving collaborative care experienced a mean of 16.7 additional depression-free days over 6 months. The mean incremental cost of depression treatment in this program was $357. The additional cost was attributable to greater expenditures for antidepressant prescriptions and outpatient visits. No offsetting decrease in use of other health services was observed. The incremental cost-effectiveness was $21.44 per depression-free day.\n\n\nCONCLUSIONS\nA stepped collaborative care program for depressed primary care patients led to substantial increases in treatment effectiveness and moderate increases in costs. These findings are consistent with those of other randomized trials. Improving outcomes of depression treatment in primary care requires investment of additional resources, but the return on this investment is comparable to that of many other widely accepted medical interventions.

M. Vonkorff

Papers

Cost-effectiveness of a collaborative care program for primary care patients with persistent depression