Showing papers by "Philip S. Wang published in 2008"

The descriptive epidemiology of commonly occurring mental disorders in the United States.

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 tr...

Individual and societal effects of mental disorders on earnings in the United States: results from the national comorbidity survey replication.

Abstract: Objective: 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). Method: 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. Results: A DSM-IV serious mental illness in the preceding 12 months significantly...

Elderly Patients with Dementia-Related Symptoms of Severe Agitation and Aggression: Consensus Statement on Treatment Options, Clinical Trials Methodology, and Policy

Abstract: Atypical antipsychotic drugs have been used off-label in clinical practice for treatment of serious dementia-associated agitation and aggression. Following reports of cerebrovascular adverse events associated with the use of atypical antipsychotic in elderly patients with dementia, the FDA issued black box warnings for several atypical antipsychotics, titled “Cerebrovascular Adverse Events, including Stroke, in Elderly Patients with Dementia.” Subsequently, the FDA initiated a meta-analysis of safety data from 17 registration trials across six antipsychotic drugs (five atypical antipsychotics and haloperidol). In 2005, the Agency issued a black box warning regarding increased risk of mortality associated with the use of atypical antipsychotic drugs in this patient population. Geriatric mental health experts participating in a 2006 consensus conference reviewed evidence on the safety and efficacy of antipsychotics, as well as nonpharmacologic approaches, in treating dementia-related symptoms of agitation and aggression. They concluded that, while problems in clinical trials design may have been one of the contributors to the failure to find a signal of drug efficacy, the findings related to drug safety should be taken seriously by clinicians in assessing the potential risks and benefits of treatment in a frail population, and in advising families about treatment. Information provided to patients and family members should be documented in the patient’s chart. Drugs should be used only when non-pharmacologic approaches have failed to adequately control behavioral disruption. Participants also agreed that that there is a need for an FDA-approved medication for the treatment of severe, persistent or recurrent dementia-related symptoms of agitation and aggression (even in the absence of psychosis), that are unresponsive to nonpharmacologic intervention. The authors have outlined methodological enhancements to better evaluate treatment approaches in future registration trials, and they provided an algorithm for improving the treatment of these patients in nursing home and non-nursing home settings.

The prevalence of psychological distress in employees and associated occupational risk factors.

Abstract: Objective: 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. Method: 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 >= 13 was chosen to indicate high psychological distress. Results: 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. Conclusion: 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.

The prevalence and correlates of workplace depression in the national comorbidity survey replication.

Abstract: Although surveys designed to estimate the prevalence and correlates of mental disorders in the workplace as well as in larger community samples have been carried out in the United States since the end of World War II,1–3 it was not until the early 1980s that the development of fully structured diagnostic interviews made it possible to assess specific mental disorders with accuracy in such assessments.4,5 Several large-scale surveys using fully structured psychiatric diagnostic interviews have been carried out since that time. However, changes in the criteria for major depression in successive editions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) have hampered efforts to replicate results. The most recent nationally representative population data on the prevalence and correlates of depression come from the National Comorbidity Survey Replication (NCS-R).6 The NCS-R data also provide useful information about the workplace consequence of depression.7 The current report presents an overview of NCS-R results on the prevalence and correlates of depression and relates these results to those in previous studies.

Potential Causes of Higher Mortality in Elderly Users of Conventional and Atypical Antipsychotic Medications

Abstract: OBJECTIVES: 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. DESIGN: Cohort study. SETTING: Community. PARTICIPANTS: All British Columbia residents aged 65 and older who initiated a conventional or atypical APM between 1996 and 2004. MEASUREMENTS: 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. RESULTS: 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. CONCLUSION: 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.

Disruption of existing mental health treatments and failure to initiate new treatment after Hurricane Katrina.

Abstract: Objective: 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. Methods: 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. Results: 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 ...

Making the business case for enhanced depression care: the National Institute of Mental Health-harvard Work Outcomes Research and Cost-effectiveness Study

Abstract: Objective:Explore the business case for enhanced depression care and establish a return on investment rationale for increased organizational involvement by employer-purchasers.Method:Literature review, focused on the National Institute of Mental Health-sponsored Work Outcomes Research and Co

The impact of cost sharing on antidepressant use among older adults in British Columbia.

Abstract: Depression burdens nearly one in six persons over age 65 with substantial morbidity, mortality, and costs (1–3). Although treatment consists almost entirely of antidepressants (4,5), pharmacotherapy for depression among older populations can be problematic (6,7). Perhaps partly a result of high costs, many elderly persons with depression never begin appropriate antidepressant regimens, and of those who do, less than half fill prescriptions for 30 days or more (8–13). Although the Medicare Modernization Act (MMA) in the United States improves seniors’ access to antidepressants through Medicare Part D coverage, it may also lead to large expenditures for these medications (14). There are particular pressures to control such psychotropic costs, because the proportion of spending on prescription drugs is twice as high in mental health care as in general health care (15). Costs of psychotropic medications have increased 17% annually, far outpacing other mental health expenditures and spending increases on medications overall (15,16). Newer agents with potentially greater tolerability are widely available (16–18), making anti-depressants among the most widely prescribed classes of medications in most health care systems (19,20). Prescription benefit plans operating under Medicare Part D use many strategies to contain costs, including via copayments, coinsurance, income-based deductibles, and combinations of these (21). Copayments require a fixed amount to be paid for each prescription. Copayments also can be tiered, with the lowest tier for generics, requiring small copays, and higher tiers for brand names, requiring larger copays. Coinsurance requires payment of a proportion of the medication price. Coinsurance policies have been criticized as being unfair to sicker patients who require more medications (22). Therefore, most coinsurance policies have annual out-of-pocket ceilings; costs up to the ceiling are paid out of pocket, whereas costs above the ceiling are reimbursed. Ceiling amount also can be linked to income in the prior year, under the presumption that patients with higher incomes can afford to pay more for medications. Such forms of cost sharing might reduce payers’ expenditures by increasing patients’ out-of-pocket contributions, thereby ensuring the fiscal viability of medication assistance programs for seniors. However, some analysts argue that coverage restrictions will adversely affect the elderly population’s use of essential medications (23,24). For these reasons, it is critical to understand how medication cost sharing affects older patients, especially those who use antidepressants. Aims of this study were to evaluate the impact of two sequential large-scale “natural experiments” in cost sharing on antidepressant use among seniors in British Columbia, Canada. In January 2002 the province-funded prescription benefit program introduced a copayment (“copay”) policy requiring a $25 Canadian copay ($10 Canadian for low-income seniors). In May 2003 this copay policy was replaced by a second policy, which featured an income-based deductible, 25% coinsurance once a beneficiary’s deductible was met, and full coverage once an out-of-pocket ceiling was met. The transition from one new policy to the next emulates the experience of many U.S. seniors who transitioned from private insurance programs requiring copays to Medicare’s medication coverage system requiring deductibles and coinsurance. This natural experiment among all elderly British Columbia residents provided a unique opportunity to evaluate the impact of these two sequential cost-sharing interventions on antidepressant utilization, initiation, and discontinuation.