Mental Health

Contents

Background and Impact
How the NHQR Measures Mental Health Quality of Care
How the Nation Is Doing
What We Don't Know
What Can Be Done
List of Measures
References

Key Findings: Almost 80% of patients diagnosed with depression do not have optimal levels of contact with their health care provider. Only about 20% of patients prescribed a medication to treat diagnosed depression have at least 3 followup visits to monitor their medication within 12 weeks after diagnosis. Mortality due to suicide has been relatively stable over the years, averaging about 10 deaths per 100,000.

Background and Impact

Mental illness is a large burden on America's health, afflicting almost 20% of the population age 18 and over in a given year.^1,2 This section of the report addresses a particularly prevalent form of mental illness, depression.ⁱ

Depressive disorders are the second most prevalent form of all mental illness behind simple anxiety disorders.³ Depressive disorders affect the ability of 19 million Americans to work, parent, learn, and fully participate in society.² Depression is the second leading cause of disability in the United States.³

The New Freedom Commission on Mental Health appointed by President Bush in 2002 attempts to address these longstanding problems.⁴

Costs of Depression

The personal and societal costs of depression are significant. They include:

• Higher rates of death. Studies show that depression is associated with higher mortality rates in all age groups.⁵ Depression's impact is clear in the case of suicide. Suicide, a risk of untreated depression, is the 11th leading cause of death in this country, accounting for some 30,000 deaths each year.^6,7,8 Fifteen percent of depressed people take their own lives.⁹ The suicide rate is six times higher among men age 85 and over than it is for the general population.^10,11,12
• Serious complications for chronic disease patients. People with heart disease, diabetes, cancer, stroke, Parkinson's disease, and HIV/AIDS are at much greater risk for depression than the overall population. Annual prevalence estimates of depression for these groups range from 10 to 65%.^7,8,13Depression often negatively affects the course of these diseases. For example, depressed heart disease patients are much more likely to die after a heart attack than heart disease patients who are not depressed.¹⁴ Depression can interfere with the ability of patients to follow medication and dietary regimens and has recently been linked to increased bone loss in women.^{11,12,15,16,17}
• Workplace costs of over $43 billion per year.^9,18 People suffering from depression have high rates of absenteeism⁹ (in some cases, three times more sick days than nondepressed workers)¹⁹ and are less productive at work.²⁰
• Detrimental effects on all family members. For example, children of mothers who suffer from chronic depression are more likely to have behavioral problems at school.²¹
• Associated substance abuse problems. Rates of undetected depression among drug and alcohol users are estimated to be as high as 30%. In 2001, the National Health Interview Survey reported that adults who used illicit drugs were twice as likely to report suffering from serious mental illness as adults who did not use drugs.²²

Depressive disorders can affect anyone, including children as young as 10 years. Rates are higher among patients with chronic diseases, among women vs. men (12% vs. 7%), and among institutionalized elderly people (25%) and elderly people who live in the community (15%).^{23,24,25,26,27,28,29}

Issues in Diagnosis and Treatment

• Despite the seriousness of depression, it is not widely recognized, diagnosed, or treated.
• Only half of those who suffer from depression consider going to the doctor.³
• Depression and mental illness continue to carry a stigma.
• Half of those who seek care for depression approach their primary care provider first. However, primary care doctors sometimes miss a diagnosis of depression.^18,30 Data discussed in the following section highlight the increases in diagnosed cases of depression and prescriptions for depression.³¹ However, primary care doctors correctly diagnose depression in only about one-third to one-half of their patients.^18,32 This is due to a number of factors which, taken together, make proper diagnosis very difficult. Depression's most common symptoms are the same as those for many physical ailments that doctors generally investigate.³³ In 2002, the U.S. Preventive Services Task Force formally recommended that doctors screen for depression.^18,30,34
• Even when depression is diagnosed, it sometimes is not treated. There is evidence that doctors often do not treat depression after they diagnose it — even though there are effective treatments for more than 80% of depressive disorders.^7,30 Patients often reject a diagnosis of depression, further complicating treatment.³⁴

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ⁱ Mental illness is a category of diseases and problems that includes major and minor depression, schizophrenia, substance abuse, bipolar disorder, Alzheimer's disease, and other disorders of the brain or mind. Limitations of national data sources resulted in a focus on depression in this report. It is envisioned that future reports will present a broader picture of mental health quality.

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How the NHQR Measures Mental Health Quality of Care

As in other areas of health care quality, there is not yet broad agreement within the mental health field on a core set of national quality of care performance measures for mental health in general, and for depression in particular. There is agreement about which antidepressant medications and psychological therapies are effective in treating depression and how medications should be prescribed and used for maximum benefit.

This report tracks three measures of medication treatment quality and one mortality measure. The medication measures come from the National Committee on Quality Assurance's HEDIS® (Health Employer Data and Information Set) measures for managed care plans. One of the primary reasons these measures were selected for the report was that regularly collected national data were available despite the fact that they were limited to managed care plans. These measures are:

• Percentage of adults diagnosed with a new episode of depression who had optimal practitioner contacts for medication management during the acute treatment phase. ("Optimal contact" is defined in HEDIS® as at least three followup office visits with a primary care or mental health provider in the 12-week acute treatment phase after a diagnosis of depression and prescription of antidepressant medication).³⁵
• Percentage of adults diagnosed with a new episode of depression and started on an antidepressant drug who received a continuous trial of medication treatment during the acute treatment phase ("acute phase" is defined as treatment after a new episode of depression).³⁵
• Percentage of adults diagnosed with a new episode of depression and started on an antidepressant drug who remained on an antidepressant medication through the continuation phase of treatment ("continuation phase" is defined as the percentage of patients who remained on antidepressant medication continuously in the 6 months after the initial diagnosis and treatment).³⁵

As progress continues to be made in identifying appropriate measures for mental illnesses and as regularly collected national data become available, examination of quality of care in mental illness can be expanded beyond the managed care setting.

The outcome measure for this section of the report focuses on mortality due to suicide and comes from the CDC/NCHS National Vital Statistics System:

• Deaths due to suicide per 100,000 population.

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How the Nation Is Doingⁱⁱ

Quality of Medication Treatment

Limited progress is being made in quality of medication treatment. Almost 80% of patients diagnosed with depression do not have optimal levels of contact with their health care provider. About 60% of depressed patients do not receive the acute phase treatment they need, and about 40% do not receive the continuous phase treatment they should have. Moreover, these rates have not improved over the 3-year period for which these measures were tracked (1998, 1999, and 2001; data were not available in 2000).

In 1999, almost 59% of adults diagnosed with a new episode of depression received a continuous trial of antidepressants through the acute phase of treatment, but in 2001, that dipped to less than 57%. Finally, in 2001 there was a decrease of 2 points to 40% from 42% in 1999 for adults who remained on antidepressants through the continuation phase of treatment.

Research shows that half of the outpatients being treated for depression in primary care settings stop using their medicines within the first month.³⁶ Sometimes side effects discourage patients from sticking with their treatment course.³⁷ Other times, the drugs work so well that the patients mistakenly believe they have been cured and discontinue the medication. Thus, they do not remain on drugs long enough to reap the full benefits of the drugs. For most patients, there is a range of treatments, and pharmacotherapy may be one of a set of treatment options.³ That said, research on therapeutic trends in mental health have pointed to the greater use of psychotropic medications and less use of psychotherapy.³⁸

Suicide

The suicide rate for adults has been relatively stable over the years, averaging just over 10 deaths per 100,000 in the adult population. For young adults, the rate has leveled off for the age group 5 to 14 years and even declined between 1991 and 2000 for the age group 15 to 24 years.³⁹ However, men are four times more likely to commit suicide than women, and elderly men have the highest suicide rate of all groups.⁵

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ⁱⁱ Adjusting for known contributing factors, such as gender, age, and insurance status (multivariate analysis), would allow for more detailed exploration of the data, but this generally was not feasible for this report. Any adjustments that were done are noted in the detailed tables. The data presented in this report do not imply causation.

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What We Don't Know

National data on core quality measures for mental health are needed. Mental health is recognized as an important national priority.⁴⁰ The Substance Abuse and Mental Health Services Administration and the American Medical Association's Physician Consortium for Performance Improvement are addressing the need for core measures through scientific review and consensus development of potential mental health quality measures. Because national data on a core set of measures are not available, we have only limited information on who is treated for mental illness and how often and effectively these treatments are administered.⁴¹

The limited national level information on mental illness that is available concentrates on depression, not other important mental health disorders, such as schizo-phrenia,⁴² bipolar disorder, posttraumatic stress, generalized anxiety, Alzheimer's disease, and others. Because successful treatments have been developed for some of these diseases and knowledge about them continues to grow, they may be good candidates for tracking quality of care and improvement.

Measures in two areas are particularly needed: mental disorders other than depression and for vulnerable population subgroups. Data are insufficient to track the quality of mental health treatment provided to young adults or the elderly, both of whom have high rates of suicide closely related to depression.

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What Can Be Done

Progress is being made in a number of areas related to the treatment of mental illness. One potentially important new initiative involves creating a searchable database of quality measures for mental health. Developed by the Center for Quality Assessment and Improvement in Mental Health (CQAIMH), with funding from AHRQ, the National Institute of Mental Health, and SAMHSA, this database includes more than 300 process measures in 7 domains of quality, including access, assessment, treatment, continuity, coordination, patient safety, and prevention.⁴³ The measures were developed by government agencies, researchers, professional organizations, consumer coalitions, commercial organizations, and others. The database provides the clinical context for the measure, a summary and rating of supporting research evidence, measure specifications, data requirements, domain of quality, treatment modality, population, and developer information. In the future, the CQAIMH intends to expand its Web site to include a toolkit of quality management tools and a consumer's guide to quality in mental health care. This is an important start in terms of identifying possible measures. Efforts currently being carried out by SAMHSA and others will help focus quality measurement on a limited set of valid key measures of quality for mental health care.

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List of Measures

Mental Health

Measure Title	National	State
Treatment of depression:
Process: % of adults diagnosed with a new episode of depression who had optimal practitioner contacts for medication management during the acute treatment phase	Table 1.65	N/A
Process: % of adults diagnosed with a new episode of depression and initiated on an antidepressant drug who received a continuous trial of medication treatment during the acute treatment phase	Table 1.66	N/A
Process: % of adults diagnosed with a new episode of depression and initiated on an antidepressant drug who remained on an antidepressant medication through the continuation phase of treatment	Table 1.67	N/A
Outcome: Deaths due to suicide per 100,000 population	Table 1.68a (00)
	Table 1.68b (99)	Table 1.68c (00)

Note: See Tables Appendix for tables listed above.

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References

¹ Lewis C. The lowdown on depression. FDA Consumer Magazine, 2003 Jan/Feb. Available at: http://www.fda.gov/fdac/features/2003/103_dep.html. Accessed October 30, 2003.

² National Mental Health Association. Clinical depression: what you need to know [Fact Sheet]. 2003.

³ U.S. Department of Health and Human Services. Mental health: a report of the surgeon general. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health; 1999.

⁴ President's New Freedom Commission on Mental Health. Achieving the promise: transforming mental health care in America. 2003. Available at: http://www.mentalhealthcommission.gov/reports/FinalReport/downloads/downloads.html. Accessed January 15, 2004.

⁵ Goldsmith S, Pellmar T, Kleinman A, et al. Reducing suicide: a national imperative. Washington, DC: National Academies Press; 2002. Available at http://www.nap.edu/books/0309083214/html/. Accessed November 20, 2003.

⁶ National Institute of Mental Health. Suicide facts: suicide deaths, US, 2000. 2003.

⁷ Cassano P, Fava M. Depression and public health: an overview. J Psychosom Res 2002;53(4): 849-57.

⁸ Pollard TJ. The acute myocardial infarction. Prim Care 2000;27(3):631-49;vi.

⁹ National Mental Health Association. Depression in the workplace [Fact Sheet]. 2003.

¹⁰ National Institute of Mental Health. Older adults: depression and suicide facts [Fact Sheet]. 2003. Available at: http://www.nimh.nih.gov/publicat/elderlydepsuicide.cfm. Accessed November 20, 2003.

¹¹ DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med 2000;160(14):2101-7.

¹² Singh N, Squier C, Sivek C, et al. Determinants of compliance with antiretroviral therapy in patients with human immunodeficiency virus: prospective assessment with implications for enhancing compliance. AIDS Care 1996;8(3):261-9.

¹³ National Mental Health Association. Co-occurrence of depression with medical, psychiatric, and substance abuse disorders [Fact Sheet]. 2003.

¹⁴ Pratt LA, Ford DE, Crum RM, et al. Depression, psychotropic medication, and risk of myocardial infarction. Prospective data from the Baltimore ECA follow-up. Circulation 1996;94(12):3123-9.

¹⁵ Ciechanowski PS, Katon WJ, Russo JE. Depression and diabetes: impact of depressive symptoms on adherence, function, and costs. Arch Intern Med 2000;160(21):3278-85.

¹⁶ Wang PS, Bohn RL, Knight E, et al. Noncompliance with antihypertensive medications: the impact of depressive symptoms and psychosocial factors. J Gen Intern Med 2002;17(7):504-11.

¹⁷ National Institute of Mental Health. Depression linked to bone loss [Press Release]. 1996 Oct 19.

¹⁸ Pignone MP, Gaynes BN, Rushton JL, et al. Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;136(10):765-76.

¹⁹ Kessler RC, Barber C, Birnbaum HG, et al. Depression in the workplace: effects on short-term disability. Health Aff (Millwood) 1999;18(5):163-71.

²⁰ Remick RA. Diagnosis and management of depression in primary care: a clinical update and review. Canadian Medical Association Journal 2002;167(11):1253-60.

²¹ McKinney M. Mom's depression ups child's depression risk: study. Reuters Health, 2003 Mar 10.

²² Roeloffs CA, Fink A, Unutzer J, et al. Problematic substance use, depressive symptoms, and gender in primary care. Psychiatr Serv 2001;52(9):1251-3.

²³ National Institute of Mental Health. Depression and diabetes [Fact Sheet]. 2002. NIH Publication No. 02-5003.

²⁴ National Institute of Mental Health. Depression and heart disease [Fact Sheet]; 2002. NIH Publication No. 02-5004.

²⁵ National Institute of Mental Health. Depression and HIV/AIDS [Fact Sheet]. 2002. NIH Publication No. 02-5005.

²⁶ National Institute of Mental Health. Depression and Parkinson's disease [Fact Sheet]; 2002. NIH Publication No. 02-5007.

²⁷ National Institute of Mental Health. Depression and cancer [Fact Sheet]; 2002. NIH Publication No. 02-5002.

²⁸ Bertakis KD, Helms LJ, Callahan EJ, et al. Patient gender differences in the diagnosis of depression in primary care. J Womens Health Gend Based Med 2001;10(7):689-98.

²⁸ Serby M, Yu M. Overview: depression in the elderly. Mt Sinai J Med 2003;70(1):38-44.

³⁰ U.S. Preventive Services Task Force. Screening for depression: recommendations and rationale. 2002. AHRQ Publication No. 03-509A. Available at: http://www.ahrq.gov/clinic/3rduspstf/depression/depressrr.pdf. Accessed November 24, 2003.

³¹ Brown C, Schulberg HC. Diagnosis and treatment of depression in primary medical care practice: the application of research findings to clinical practice. J Clin Psychol 1998;54(3):303-14.

³² Agency for Healthcare Research and Quality. Improving quality of care for people with depression. Translating research into practice [Fact Sheet]. 2000. AHRQ Publication No. 00-P020. Available at: http://www.ahrq.gov/research/deprqoc.htm. Accessed November 24, 2003.

³³ Campbell TL, Franks P, Fiscella K, et al. Do physicians who diagnose more mental health disorders generate lower health care costs? J Fam Pract 2000;49(4):305-10.

³⁴ Katon W. The epidemiology of depression in medical care. Int J Psychiatry Med 1987;17(1): 93-112.

³⁵ National Committee for Quality Assurance. The state of health care quality: 2002. Washington, DC; 2002.

³⁶ National Institute of Mental Health. The unwanted co-traveler: depression's toll on other illnesses. A day for the public. The advocate's perspective. Remarks by Lydia Lewis, Executive Director of the National Depressive and Manic-Depressive Association. 2001 Mar. Available at: http://www.dbsalliance.org/site/PageServer?pagename=media_speeches_cotravelerl. Accessed July 15, 2010.

³⁷ National Institute of Mental Health. Depression [Fact Sheet]. 2002. NIH Publication No. 02-3561. Available at: http://www.nimh.nih.gov/publicat/depression.cfm. Accessed November 25, 2003.

³⁸ Olfson M, Marcus SC, Druss B, et al. National trends in the outpatient treatment of depression. JAMA 2002;287(2):203-9.

³⁹ National Center for Health Statistics. Health, United States, 2002, with chartbook on trends in the Health of Americans. Hyattsville, MD: Public Health Service; 2002.

⁴⁰ Institute of Medicine. Priority areas for national action: transforming health care quality. Washington, DC: National Academies Press; 2003. Available at: http://www.nap.edu/catalog/10593.html. Accessed November 26, 2003.

⁴¹ Hermann RC, Palmer RH. Common ground: a framework for selecting core quality measures for mental health and substance abuse care. Psychiatr Serv 2002;53(3):281-7.

⁴² Lehman AF, Steinwachs DM. Patterns of usual care for schizophrenia: initial results from the Schizophrenia Patient Outcomes Research Team (PORT) Client Survey. Schizophr Bull 1998;24(1):11-20; discussion 20-32.

⁴³ Center for Quality Assessment and Improvement in Mental Health (CQAIMH). CQAIMH Website. Available at: www.cqaimh.org/quality.html. Accessed on January 6, 2003.

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