Showing papers by "Philip S. Wang published in 2003"

The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R).

Abstract: ContextUncertainties exist about prevalence and correlates of major depressive disorder (MDD).ObjectiveTo present nationally representative data on prevalence and correlates of MDD by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, and on study patterns and correlates of treatment and treatment adequacy from the recently completed National Comorbidity Survey Replication (NCS-R).DesignFace-to-face household survey conducted from February 2001 to December 2002.SettingThe 48 contiguous United States.ParticipantsHousehold residents ages 18 years or older (N = 9090) who responded to the NCS-R survey.Main Outcome MeasuresPrevalence and correlates of MDD using the World Health Organization's (WHO) Composite International Diagnostic Interview (CIDI), 12-month severity with the Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR), the Sheehan Disability Scale (SDS), and the WHO disability assessment scale (WHO-DAS). Clinical reinterviews used the Structured Clinical Interview for DSM-IV.ResultsThe prevalence of CIDI MDD for lifetime was 16.2% (95% confidence interval [CI], 15.1-17.3) (32.6-35.1 million US adults) and for 12-month was 6.6% (95% CI, 5.9-7.3) (13.1-14.2 million US adults). Virtually all CIDI 12-month cases were independently classified as clinically significant using the QIDS-SR, with 10.4% mild, 38.6% moderate, 38.0% severe, and 12.9% very severe. Mean episode duration was 16 weeks (95% CI, 15.1-17.3). Role impairment as measured by SDS was substantial as indicated by 59.3% of 12-month cases with severe or very severe role impairment. Most lifetime (72.1%) and 12-month (78.5%) cases had comorbid CIDI/DSM-IV disorders, with MDD only rarely primary. Although 51.6% (95% CI, 46.1-57.2) of 12-month cases received health care treatment for MDD, treatment was adequate in only 41.9% (95% CI, 35.9-47.9) of these cases, resulting in 21.7% (95% CI, 18.1-25.2) of 12-month MDD being adequately treated. Sociodemographic correlates of treatment were far less numerous than those of prevalence.ConclusionsMajor depressive disorder is a common disorder, widely distributed in the population, and usually associated with substantial symptom severity and role impairment. While the recent increase in treatment is encouraging, inadequate treatment is a serious concern. Emphasis on screening and expansion of treatment needs to be accompanied by a parallel emphasis on treatment quality improvement.

Nonadherence to Adjuvant Tamoxifen Therapy in Women With Primary Breast Cancer

Abstract: Purpose: Although clinical trials have clearly demonstrated the benefits of tamoxifen in women with primary breast cancer, little is known about how this drug is actually used in the general population. We sought to estimate adherence and predictors of nonadherence in women starting tamoxifen as adjuvant breast cancer therapy. Patients and Methods: Subjects were age 18 years or older initiating tamoxifen for primary breast cancer and enrolled in New Jersey’s Medicaid or Pharmaceutical Assistance to the Aged and Disabled programs during the study period, from 1990 to 1996 (N = 2,378). Main outcome measures were number of days covered by filled prescriptions for tamoxifen in the first year of therapy with the 4 years after tamoxifen initiation for a subset; predictors of good versus poor adherence. Results: Twenty-three percent of patients missed taking tamoxifen on more than one fifth of days studied, although on average, patients filled prescriptions for tamoxifen for 87% of their first year of treatment....

The economic burden of depression and the cost-effectiveness of treatment

Abstract: Cost-of-illness research has shown that depression is associated with an enormous economic burden, in the order of tens of billions of dollars each year in the US alone. The largest component of this economic burden derives from lost work productivity due to depression. A large body of literature indicates that the causes of the economic burden of depression, including impaired work performance, would respond both to improvement in depressive symptomatology and to standard treatments for depression. Despite this, the economic burden of depression persists, partly because of the widespread underuse and poor quality use of otherwise efficacious and tolerable depression treatments. Recent effectiveness studies conducted in primary care have shown that a variety of models, which enhance care of depression through aggressive outreach and improved quality of treatments, are highly effective in clinical terms and in some cases on work performance outcomes as well. Economic analyses accompanying these effectiveness studies have also shown that these quality improvement interventions are cost efficient. Unfortunately, widespread uptake of these enhanced treatment programmes for depression has not occurred in primary care due to barriers at the level of primary care physicians, healthcare systems, and purchasers of healthcare. Further research is needed to overcome these barriers to providing high-quality care for depression and to ultimately reduce the enormous adverse economic impact of depression disorders.

Improved comorbidity adjustment for predicting mortality in Medicare populations.

Abstract: As with any observational research, epidemiologic studies using data from administrative datasets have been criticized for incomplete control for confounding. Poorly measured patient characteristics, including comorbidities, can affect clinical decisions and may therefore bias results from etiologic studies using observational data (Walker 1996). However, it is widely acknowledged that in many situations, claims data may be the best source to study the outcomes of therapeutic and other clinical strategies in routine medical care of the elderly (Wang, Solomon et al. 2000; Ray et al. 2002). Improving comorbidity adjustment is therefore an important goal to increase the validity of findings from epidemiologic studies of older patients (Schneeweiss and Maclure 2000). Comorbidity scores aggregate relevant comorbidities into a single variable. The attraction of such scores is that they are easy to apply and widely accepted tools. They can simplify data analysis, particularly when multiple hypotheses will be tested or when comorbidities are considered as time-varying confounders. In small studies or in subgroup analyses with limited sample size, the fact that comorbidity scores reduce the number of variables that need to be adjusted will improve statistical inference. However, in either of these circumstances scores must correctly model the underlying functional relation between comorbidity and outcome in a specific study population. In an ideal world, one would have enough data and well-measured variables to completely adjust statistically for differences in risk. Such adjustments would be tailored to the outcome measure (e.g., death, readmission) and the population under study. In the real world, however, one may not have a large enough dataset, or all the data one would like. A second best alternative, then, is to use a comorbidity score that has preassigned weights from a plausibly relevant population. Given the widespread use of scores such as the Charlson Index and Chronic Disease Score, this paper puts forward an alternative that is based on mortality in the Medicare population. The construct “comorbidity” reflects the aggregate effect of all clinical conditions a patient might have, excluding the disease of primary interest (Greenfield and Nelson 1992; Last 1995). Because there is no gold standard, researchers have validated measures of comorbidity by how well they predict mortality. The predictive performance of comorbidity scores depends on several factors, including (1) the clinical conditions included in a score and their relative weights, (2) the distribution of comorbid conditions in the source population, (3) the endpoint of a study, for example, one-year mortality, and (4) the accuracy and completeness of the administrative data (Iezzoni 1997). The predictive performance of two scores can be validly compared when factors 2 to 4 are held constant. Several studies have explored the predictive validity of comorbidity measures in claims data (Roos et al. 1989; Romano, Roos, and Jollis 1993a, 1993b; Von Korff, Wagner, and Saunders 1992; Clark et al. 1995; Deyo, Cherkin, and Ciol 1992; D'Hoore, Sicotte, and Tilquin 1993; D'Hoore, Bouckaert, and Tilquin 1996; Ghali et al. 1996; Melfi et al. 1995; Poses et al. 1995). However, only a few studies sought to improve the performance of these scores (Clark et al. 1995; Zhang, Iwashyna, and Christakis 1999; Wang, Walker et al. 2000; Schneeweiss et al. 2001) and often only for specific subpopulations, for example, patients undergoing bypass surgery (Ghali et al. 1996). From earlier studies it has become clear that specific weights must be applied to elderly populations to achieve acceptable comorbidity adjustment in epidemiologic research using claims data (Schneeweiss and Maclure 2000; Ghali et al. 1996). We sought to improve and validate the improved performance of an existing and frequently used ICD-9 diagnosis-based comorbidity score and a drug use-based score in predicting one-year mortality in U.S. Medicare patients aged 65 years or older.

Arthritis self-management education programs: a meta-analysis of the effect on pain and disability.

Abstract: Objective Some reports suggest that education programs help arthritis patients better manage their symptoms and improve function. This review of the published literature was undertaken to assess the effect of such programs on pain and disability. Methods Medline and HealthSTAR were searched for the period 1964–1998. The references of each article were then hand-searched for further publications. Studies were included in the meta-analysis if the intervention contained a self-management education component, a concurrent control group was included, and pain and/or disability were assessed as end points. Two authors reviewed each study. The methodologic attributes and efficacy of the interventions were assessed using a standardized abstraction tool, and the magnitude of the results was converted to a common measure, the effect size. Summary effect sizes were calculated separately for pain and disability. Results The search strategy yielded 35 studies, of which 17 met inclusion criteria. The mean age of study participants was 61 years, and 69% were female. On average, 19% of patients did not complete followup (range 0–53%). The summary effect size was 0.12 for pain (95% confidence interval [95% CI] 0.00, 0.24) and 0.07 for disability (95% CI 0.00, 0.15). Funnel plots indicated no significant evidence of bias toward the publication of studies with findings that showed reductions in pain or disability. Conclusion The summary effect sizes suggest that arthritis self-management education programs result in small reductions in pain and disability.

Patterns and correlates of contacting clergy for mental disorders in the United States.

Abstract: Despite the enormous burdens imposed by mental illnesses and the availability of effective treatments, unmet need for mental health care continues to be an enormous public health problem (Kessler, Olfson, and Berglund 1998; Olfson et al. 1998; Wang, Berglund, and Kessler 2000; Wang et al. 2002). To begin addressing this, it is crucial to shed light on the help-seeking processes of those with mental disorders, including to whom they go for help and what types of services they receive (Rogler and Cortes 1993; Gallo et al. 1995). Important unanswered questions remain concerning seeking help for mental disorders from the clergy. In one of the few earlier epidemiologic studies conducted among community samples, Gurin and colleagues (1960) observed in the middle of the last century that 42 percent of those seeking help for emotional problems sought it from a clergy member, a considerably larger proportion than those contacting physicians, mental health specialists, or any other professional. In a follow-up study 25 years later (Veroff, Kulka, and Douvan 1981), this proportion had fallen but was still high in absolute terms (34 percent). The Epidemiologic Catchment Area (ECA) study in the early 1980s found that only 20 percent of those who sought treatment for mental disorders contacted clergy and other human services professionals (Regier et al. 1993); however, seeking help from the clergy continued to be as common as seeking care from mental health professionals (Larson et al. 1988). Unfortunately, there is little empirical data shedding light on the more recent extent of seeking mental health care from clergy members. In addition, it is also unclear what types of patients now seek help from clergy and for what reasons; earlier investigations suggest that a variety of demographic (e.g., age, gender, race, region of the country, social class) and clinical characteristics (e.g., type and seriousness of mental disorders) may all be important factors (Larson et al. 1988; Ray, Raciti, and MacLean 1992; Sorgaard et al. 1996; Mitchell and Baker 2000). It is also critically important to understand what services the clergy provide to those with mental disorders, especially given the growing literature (Katon et al. 1995; 1996; Lehman and Steinwachs 1998a; Wells et al. 2000) suggesting that mental health treatments must conform with evidence-based guidelines (Agency for Health Care Policy and Research 1993; American Psychiatric Association 1994; 1997; 1998; 2000; Lehman and Steinwachs 1998b) regarding modality, intensity, and duration of treatment in order to be effective. Earlier surveys of clergy members have revealed that many are insufficiently trained in recognizing the presence and severity of psychopathology as well as in providing pastoral counseling (Wylie 1984; Rupert and Rogers 1985; Domino 1990; Weaver 1995). Perhaps for these reasons as well as having competing demands on their time, clergy members have been found to spend less than 10 percent of their time providing pastoral counseling (McCann 1962; Virkler 1979; Mollica et al. 1986). Earlier studies have also found that clergy refer fewer than 10 percent of those with emotional problems to other mental health care providers (McCann 1962; Piedmont 1968; Hong and Wiehe 1974; Virkler 1979; Mollica et al. 1986). More recent efforts to improve the mental health services delivered by clergy have had a positive impact on the quality of pastoral care and cooperation with health care professionals remains unknown (O'Connor and Meakes 1998). The specific aims of the current study were two-fold. First, we sought to describe the recent extent and correlates of seeking mental health care from clergy in the National Comorbidity Survey (NCS), a large general population survey of the United States conducted in the early 1990s. Second, we sought to shed light on the functions that clergy play in the mental health care delivery system by identifying characteristics of individuals they see, their frequency of visits with potential counselees, and the extent to which they work alone versus in conjunction with other professionals.

Chronic Medical Conditions and Work Performance in the Health and Work Performance Questionnaire Calibration Surveys

Abstract: Associations between chronic conditions and work performance (absenteeism, presenteeism, and critical incidents) were studied in reservation agents, customer service representatives, executives, and railroad engineers. Conditions and work performance were assessed with the World Health Organization's Health and Work Performance Questionnaire. Analysis of covariance was used to estimate associations. More work performance was lost from presenteeism than absenteeism. However, chronic conditions more consistently had negative impacts on absenteeism than presenteeism. Conditions with significant effects included arthritis, asthma, chronic obstructive pulmonary disease-emphysema, depression, and chronic headaches. Arthritis had the largest aggregate effect on absenteeism-presenteeism. Only depression affected both absenteeism-presenteeism and critical incidents. Some chronic conditions have substantial workplace effects. Disease management programs for these conditions might have a positive return on investment (ROI). Health and productivity tracking surveys are needed to evaluate ROI and provide quality assurance.

Recent developments in psychopharmacoepidemiology

Abstract: Purpose of review Psychopharmacoepidemiology has grown from its origins investigating unanticipated hazards from psychiatric drugs and now includes a wide array of studies. This review covers recent developments in the field including the current sources of data being used, examples of studies published in the past year, and potential directions for the future. Recent findings Investigators now have several important sources of psychopharmacoepidemiological data at their disposal, each with its own unique strengths and limitations. With them, psychopharmacoepidemiologists have recently identified potential adverse metabolic, electrophysiological, and cancer outcomes associated with the use of antipsychotic medications. Underrecognized benefits have also been found, such as the protective effect of clozapine on suicidality, a finding recently confirmed in the InterSePT trial. Investigations have also documented the marked expansion over the past decade in the use of psychotropic medications for disorders such as depression and attention deficit hyperactivity disorder. However, sobering results have shown that in spite of these secular increases the quality of care is often poor. For this reason, psychopharmacoepidemiological studies continue to shed light on modifiable determinants of suboptimal prescribing and patient non-adherence. Interventions to enhance the use of psychiatric medications have recently been shown to be effective and cost-effective for an ever wider set of disorders, populations, and outcomes, giving new grounds for optimism. Summary Psychiatric medications are increasingly effective, costly, and widely consumed. Psychopharmacoepidemiological studies can be of central importance in ensuring that the use of these medications is safe, appropriate, and optimal.

Nonadherence t o A djuvant T amoxifen T herapy i n W omen W ith Primary B reast C ancer

Abstract: Purpose: Although clinical trials have clearly demonstrated the benefits of tamoxifen in women with primary breast cancer, little is known about how this drug is actually used in the general population. We sought to estimate adherence and predictors of nonadherence in women starting tamoxifen as adjuvant breast cancer therapy. Patients and Methods: Subjects were age 18 years or older initiating tamoxifen for primary breast cancer and enrolled in New Jersey’s Medicaid or Pharmaceutical Assistance to the Aged and Disabled programs during the study period, from 1990 to 1996 (N 2,378). Main outcome measures were number of days covered by filled prescriptions for tamoxifen in the first year of therapy with the 4 years after tamoxifen initiation for a subset; predictors of good versus poor adherence. Results: Twenty-three percent of patients missed taking tamoxifen on more than one fifth of days studied, although on average, patients filled prescriptions for tamoxifen for 87% of their first year of treatment. The youngest, oldest, nonwhite, and mastectomy patients had significantly lower rates of adherence; patients who had seen an oncologist before taking tamoxifen had significantly higher rates of adherence. Overall adherence decreased to 50% by year 4 of therapy. Conclusion: The mean level of adherence to tamoxifen is high compared with other chronic medications. However, nearly one fourth of patients may be at risk for inadequate clinical response because of poor adherence. Because of the efficacy of tamoxifen therapy in preventing recurrence and death in women with early-stage breast cancer, further efforts are necessary to identify and prevent suboptimal adherence. J Clin Oncol 21:602-606. © 2003 by American Society of Clinical Oncology.