Skip Navigation Archive: U.S. Department of Health and Human Services U.S. Department of Health and Human Services
Archive: Agency for Healthcare Research Quality www.ahrq.gov
Archival print banner

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://info.ahrq.gov. Let us know the nature of the problem, the Web address of what you want, and your contact information.

Please go to www.ahrq.gov for current information.

National Healthcare Disparities Report, 2013

Chapter 2. Effectiveness of Care for Common Clinical Conditions (continued)

Mental Health and Substance Abuse

Importance

Mortality
Number of deaths due to suicide (2010 prelim.) 38,285 (Hoyert & Xu, 2012)
Rank among causes of death in the United States—suicide (2011 prelim.) 10th (Hoyert & Xu, 2012)
Rank of suicide among people ages 12-17 (2010) 2nd (CDC, 2011d)
Alcohol-impaired driving fatalities (2010) 10,322 (NHTSA, 2013)
Overdose of prescription painkillers (2011) 15,000 (NCIPC, 2011)
Prevalence
People age 12 and over with alcohol and/or illicit drug dependence or abuse in the past year (2011) 20.6 million (8.0%) (CBHSQ, 2012b)
Children ages 6-17 who had depression or anxiety in their lifetime (2007-2008 est.based on parent report) 3.8 million (7.8%) (Ghandour, et al., 2012)
Youths ages 12-17 with a major depressive episode during the past year (2011) 2.0 million (8.2%) (CBHSQ, 2012a)
Adults age 18 and over with a major depressive episode during the past year (2011) 15.2 million (6. 6%) (CBHSQ, 2012a)
Adults with at least one major depressive episode in their lifetime (2006) 30.4 million (13.9%) (CBHSQ, 2007)
Cost
National expenditures for treatment of mental health and substance abuse disorders (2014 est.) $239 billion (CBHSQ, 2008)
Cost-effectiveness of screening and brief counseling for problem drinking $0-$14,000/QALY (Maciosek, et al., 2006)

Measures

The NHQR and NHDR track measures of the quality of treatment for major depression and substance abuse. Mental health treatment includes counseling, inpatient care, outpatient care, and prescription medications. This section highlights four measures of mental health and substance abuse treatment:

  • Treatment for depression.
  • Suicide deaths.
  • Treatment for illicit drug use or alcohol problem.
  • Completion of substance abuse treatment.

Findings

Treatment for Depression

Treatment for depression can be very effective in reducing symptoms and associated illnesses and returning individuals to a productive lifestyle. The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, funded by the National Institute of Mental Health, was the largest clinical trial ever conducted to help determine the most effective treatment strategies for major depressive disorder. It involved both primary care and specialty care settings. Participants included people with complex health conditions, such as multiple concurrent medical and psychiatric conditions.

This study found that between 28% and 33% of participants achieved a symptom-free state after the first round of medication, and nearly 70% achieved remission after 12 months (Insel & Wang, 2009). Strategies for treating depression in primary care settings, such as the collaborative care model, have also been shown to generate positive net social benefits in cost-benefit analyses compared with usual care (Glied, et al., 2010).

Barriers to high-quality mental health care include cost of care, lack of sufficient insurance for mental health services, discrimination and negative attitudes toward mental health problems, fragmented organization of services, and mistrust of providers. In rural and remote areas, limited availability of skilled care providers is also a major problem. For racial and ethnic populations, these problems are compounded by the lack of culturally and linguistically competent providers.

Barriers can exist for patients across the lifespan. The National Survey of Children's Health (HRSA, 2010) showed that among children with emotional, developmental, or behavioral conditions, 45.6% were receiving needed mental health services, and about half were taking medications. Recent data indicate, however, that service use for mental health is increasing among children (Pfuntner, et al., 2013).

Figure 2.31. Adults with a major depressive episode in the past year who received treatment for depression in the past year, by race/ethnicity, 2008-2011

Text description is below image

[D] Select for Text Description.

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2008-2011.
Denominator: Adults age 18 and over with a major depressive episode in the past year.
Note: Major depressive episode is defined as a period of at least 2 weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities and had a majority of the symptoms of depression described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. Treatment for depression is defined as seeing or talking to a medical doctor or other professional or using prescription medication in the past year for depression. White and Black are non-Hispanic; Hispanic includes all races.

  • In 2011, only 68% of adults with a major depressive episode received treatment for depression (Figure 2.31).
  • In all years, Black adults were less likely to receive treatment for depression than White adults.  

Also, in the NHQR:

  • In all years, adult males were less likely than adult females to receive treatment for depression.  

Figure 2.32. Adolescents with a major depressive episode in the past year who received treatment for depression in the past year, by race/ethnicity, 2008-2011

Text description is below image

[D] Select for Text Description.

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2008-2011.
Denominator: Adolescents ages 12-17 with a major depressive episode in the past year.
Note: Major depressive episode is defined as a period of at least 2 weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities and had a majority of the symptoms of depression described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. Treatment for depression is defined as seeing or talking to a medical doctor or other professional or using prescription medication in the past year for depression. White and Black are non-Hispanic; Hispanic includes all races.

  • In 2011, only 38% of adolescents with a major depressive episode received treatment for depression (Figure 2.32).
  • Until 2011, Black adolescents were less likely to receive treatment for depression than White adolescents.

Also, in the NHQR:

  • In 2009 and 2010, adolescent males were less likely than adolescent females to receive treatment for depression; in 2008 and 2011, this difference was not statistically significant.

Outcome: Suicide Deaths

Most individuals who die by suicide have mental illnesses, such as depression or schizophrenia, or have substance abuse problems (Moscicki, 2001). Suicide may be prevented when its warning signs are detected and treated. Identification of suicidal ideas and plans among individuals being treated for depression is expected to increase with the growing use of standardized screening instruments and electronic medical records. A National Institute of Mental Health (NIMH)-supported study recently reported that positive response to the final item ("thoughts that you would be better off dead, or of hurting yourself in some way") on the widely used Patient Health Questionnaire for depression (PHQ-9) was found to be a strong predictor of suicide attempts and completed suicides over the following year (Simon, et al., 2013).

The increasing use of technology to enhance the quality of mental health care is growing by delivering treatment services via the Internet to supplement routine face-to-face care and occasionally to replace it. Ongoing NIMH-supported research is showing promising results for Internet-based cognitive-behavioral therapy and psychoeducation in the treatment of individuals dealing with conditions such as mood, eating, and sleep disorders (Thorndike, et al., 2013). As such "mobile health" interventions become more sophisticated, they can be adapted to be culturally specific and sensitive (Burns, et al., 2013).

Suicide prevention is multifaceted and other methods include educating physicians and keeping lethal weapons away from suicidal people (Mann, et al., 2005), as well as:

  • Cognitive-behavioral therapy (Tarrier, et al., 2008).
  • Universal strategies that target entire populations (e.g., public education and awareness programs), selective strategies that address at-risk populations (e.g., peer "natural helpers" and accessible crisis services), and indicated strategies that address specific high-risk individuals (e.g., case management and parent-supported programs) (Nordentoft, 2011).

Figure 2.33. Suicide deaths per 100,000 population age 12 and over, by race and ethnicity, 2008-2010
Text description is below image

Text description is below image

[D] Select for Text Description.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System—Mortality, 2008-2010.
Note: For this measure, lower rates are better. Estimates are age adjusted to the 2000 U.S. standard population.

  • In 2010, the overall suicide death rate was 14.6 per 100,000 population age 12 and over (Figure 2.33).
  • In all years, Blacks, APIs, and AI/ANs had lower suicide death rates than Whites, and Hispanics had lower suicide death rates than non-Hispanic Whites.xxv
  • The 2008 top 5 State achievable benchmark was 9 suicide deaths per 100,000 population.xxvi Data are insufficient to assess progress toward the benchmark.

Also, in the NHQR:

  • In all years, adolescents ages 12-17 had lower suicide death rates than adults ages 18-44. However, suicide is the second leading cause of death for youth ages 12-17 (CDC, 2011d). Adults ages 45-64 had higher suicide death rates than adults ages 18-44.
  • In all years, residents of medium and small metropolitan areas, micropolitan areas, and noncore areas (the most rural) had higher suicide death rates than residents of large fringe metropolitan areas (suburbs).

Treatment for Illicit Drug Use or Alcohol Problem

Use of illicit drugsxxvii can lead to addiction and other medical problems that can have a direct toxic effect on a number of bodily organs and exacerbate numerous physical and mental health conditions. Alcohol problems also can lead to serious health risks. Heavy drinking can increase the risk of certain cancers and cause damage to the liver, brain, and other organs. In addition, alcohol can cause birth defects, including fetal alcohol spectrum disorders. Alcoholism and illicit drug use increase the risk of death from car crashes and other injuries (Ringold, et al., 2006).

The Drug Abuse Warning Network (DAWN) estimates that in 2011, 2.5 million emergency department (ED) visits resulted from medical emergencies involving drug misuse or abuse (1.25 million involved illicit drugs, 1.24 million involved nonmedical use of pharmaceuticals, and 0.61 million involved drugs combined with alcohol [SAMHSA, 2013]). Illicit drug use and alcohol problems can be effectively treated at specialty facilities (e.g., hospitals [inpatient], drug or alcohol rehabilitation [inpatient or outpatient facilities], or mental health centers).

Figure 2.34. People age 12 and over who needed treatment for illicit drug use or an alcohol problem and who received such treatment at a specialty facility in the last 12 months, by race/ethnicity and sex, 2002-2011

Text description is below image

Text description is below image

[D] Select for Text Description.

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2002-2011.
Denominator: Civilian noninstitutionalized population age 12 and over who needed treatment for illicit drug use or an alcohol problem.
Note: Treatment refers to treatment at a specialty facility, such as a drug and alcohol inpatient and/or outpatient rehabilitation facility, inpatient hospital setting, or mental health center. White and Black are non-Hispanic; Hispanic includes all races.

  • In 2011, only 11% of people age 12 and over who needed treatment for illicit drug use or an alcohol problem received such treatment at a specialty facility in the last 12 months (Figure 2.34).
  • From 2002 to 2007, Blacks were more likely to receive needed treatment for illicit drug use or an alcohol problem than Whites. There were no statistically significant differences between Blacks and Whites from 2008 to 2011.
  • From 2007 to 2010, Hispanics were less likely to receive treatment than Whites.
  • The 2011 top 5 State achievable benchmark was 15%.xxviii The overall population of people ages 12 and over as well as people of both sexes would need 30 years to achieve this benchmark. Whites could achieve the benchmark in 18 years while rates among Blacks are moving away from the benchmark.

Also, in the NHQR:

  • In all years, people with any college education were less likely to receive needed treatment for illicit drug use or an alcohol problem than people with less than a high school education.
  • In 3 of 4 years, adolescents ages 12-17 were less likely to receive treatment than adults ages 45-64.

Treatment: Completion of Substance Abuse Treatment

Completion of substance abuse treatment is strongly associated with improved outcomes, such as long-term abstinence from substance use. Dropout from treatment often leads to relapse and return to substance use.

Figure 2.35. People age 12 and over treated for substance abuse who completed treatment course, by race/ethnicity and education, 2005-2010
Text description is below image

Text description is below image

[D] Select for Text Description.

Source: Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set, Discharge Data Set, 2005-2010.
Denominator: Discharges age 12 and over from publicly funded substance abuse treatment facilities.
Note: White and Black are non-Hispanic; Hispanic includes all races.

  • In 2010, only 44% of people age 12 and over treated for substance abuse completed their treatment course (Figure 2.35).
  • Except in 2009, Blacks who were treated for substance abuse were significantly less likely than Whites to complete treatment.
  • In all years, people with less than a high school education who were treated for substance abuse were less likely than people with any college education to complete treatment.
  • The 2008 top 5 State achievable benchmark was 74%.xxix No group showed progress toward the benchmark.

Also, in the NHQR:

  • In all years, people ages 12-19 and 20-39 were less likely than those age 40 and over to complete substance abuse treatment. Females were less likely than males to complete substance abuse treatment.

Return to Contents

Musculoskeletal Diseases

Importance

Prevalence
People who have arthritis, gout, lupus, or fibromyalgia (2010-2012) 52.5 million (22.7% of U.S. adults) (MMWR, 2013)
Number of people with low bone density 52 million (Crandall, et al., 2012)
Morbidity
Activity limitations attributable to arthritis, gout, lupus, or fibromyalgia (2010-2012) 22.7 million adults (MMWR, 2013)
Lifetime osteoporosis-related fractures among women over age 50 approx. 50% (NOF)
Lifetime osteoporosis-related fractures among men over age 50 approx. 25% (NOF)
Cost
Total cost of arthritis and other rheumatic conditions (2003) $128 billion (MMWR, 2007)
Direct medical cost of arthritis and other rheumatic conditions (2003) $81 billion (MMWR, 2007)
Indirect costs of arthritis and other rheumatic conditions (2003) $47 billion (MMWR, 2007)
Total cost of osteoporosis-related fractures (2005) $19 billion (NOF)

Measures 

This section tracks several quality measures for prevention and management of musculoskeletal diseases. The arthritis measures are part of the Arthritis Foundation's Quality Indicator Set for Osteoarthritis. A multidisciplinary panel of experts on arthritis and pain reviewed scientific evidence to help develop the Quality Indicator Set (Pencharz & MacLean, 2004). The measures were tracked as part of Healthy People 2010 and continue to be tracked in Healthy People 2020. Osteoporosis measures are usually tracked in this section, but no new data are available for this year's reports.

This section highlights three measures related to quality of care for arthritis:

  • Arthritis education for adults with arthritis.
  • Counseling about physical activity for adults with arthritis.
  • Counseling about weight reduction for overweight and obese adults with arthritis.

Findings

Management: Arthritis Education for Adults With Arthritis

Osteoarthritis is the most common form of arthritis, affecting about 12% of the general population. Patients with symptomatic osteoarthritis who receive education about the natural history, treatment, and self-management of the disease have better knowledge and self-efficacy and experience less pain and functional impairment (Pencharz & MacLean, 2004).

Figure 2.36. Adults with doctor-diagnosed arthritis who reported they had effective, evidence-based arthritis education as an integral part of the management of their condition, by race/ethnicity and sex, 2009

Text description is below image

[D] Select for Text Description.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2009.
Denominator: Civilian noninstitutionalized adults with doctor-diagnosed arthritis.
Note: Estimates are age adjusted to the 2000 U.S. standard population. People were considered to have doctor-diagnosed arthritis if they answered yes to "Have you ever been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?" White and Black are non-Hispanic. Hispanic includes all races.

  • Rates for all groups regardless of ethnicity and sex are low; only about 7% to 13% of adults diagnosed with arthritis said they had arthritis education as part of the management of their condition (Figure 2.36).
  • Male adults were less likely to receive education than female adults. However, there were no statistically significant differences between Black males and Black females.
  • The percentage of adults who received education was higher for White females and Black females than for Hispanic females. There were no statistically significant differences between White females and Black females.

Also, in the NHQR:

  • Adults with any college education were more likely to receive effective, evidence-based arthritis education than high school graduates and adults with less than a high school education.

Management: Counseling About Physical Activity for Adults With Arthritis

Patients with symptomatic osteoarthritis should also receive counseling about muscle strengthening and aerobic exercise programs. Such programs can reduce pain and improve functional ability (Pencharz & MacLean, 2004).

Figure 2.37. Adults with doctor-diagnosed arthritis who reported they received health care provider counseling about physical activity or exercise, ethnicity/race and age, 2009

Text description is below image

[D] Select for Text Description.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2009.
Denominator: Civilian noninstitutionalized adults with doctor-diagnosed arthritis.
Note: Estimates are age adjusted to the 2000 U.S. standard population. White and Black are non-Hispanic. Hispanic includes all races. People were considered to have doctor-diagnosed arthritis if they answered yes to "Have you ever been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?"

  • More than 50% of all adults with doctor-diagnosed arthritis reported they received health care provider counseling, regardless of ethnicity and age (Figure 2.37).
  • Among adults ages 45-64, Hispanics were more likely than Whites to receive exercise counseling. Overall, adults 45-64 were more likely to receive counseling about physical activity or exercise than those ages 18-44 and 65 and over.
  • Adults 65 and over were less likely to receive exercise counseling than adults in the 45-64 age range.
  • Hispanic and Black adults in all age categories with doctor-diagnosed arthritis were more likely to receive counseling than White adults.

Also, in the NHQR:

  • Poor, low-income, and middle-income adults were less likely than high-income adults to receive health care provider counseling about physical activity or exercise.

Management: Counseling About Weight Reduction for Overweight And Obese Adults With Arthritis

Weight is a risk factor for osteoarthritis, and weight reduction can be used to prevent the development of osteoarthritis among overweight and obese people. Moreover, overweight and obese people with osteoarthritis who lose weight experience less joint pain and have improved function (Pencharz & MacLean, 2004).

Figure 2.38. Overweight and obese adults with doctor-diagnosed arthritis who reported they received health care provider counseling about weight reduction, by income and race/ethnicity, 2009

Text description is below image

[D] Select for Text Description.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2009.
Denominator: Civilian noninstitutionalized overweight and obese adults with doctor-diagnosed arthritis.
Note: Estimates are age adjusted to the 2000 U.S. standard population. White and Black are non-Hispanic. Hispanic includes all races. People were considered to have doctor-diagnosed arthritis if they answered yes to "Have you ever been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?" For both men and women, overweight is BMI ≥25 to <30; obese is BMI ≥30.

  • Overweight and obese Hispanics and Blacks were more likely to receive weight reduction counseling than Whites (Figure 2.38).
  • Overweight and obese Black adults were more than likely to receive counseling than overweight and obese White adults regardless of income level.
  • Poor overweight and obese adults were more likely than high-income overweight and obese adults to report they received health care provider counseling about weight reduction (46.2% compared with 44.4%).

Also, in the NHQR:

  • Overweight and obese adults with basic or complex activity limitations were more likely to receive weight reduction counseling than overweight and obese adults with neither limitation.

xxv. Racial/ethnic data on death certificates are underreported, especially for Hispanics, AI/ANs, and APIs. For more information, see Arias E, Schauman WS, Eschbach K, et al. The validity of race and Hispanic origin reporting on death certificates in the United States. Vital Health Stat 2008; 2(148).
xxvi. The top 5 States that contributed to the achievable benchmark are Connecticut, District of Columbia, Massachusetts, New Jersey, and New York.
xxvii. Illicit drugs included in this measure are marijuana/hashish, cocaine (including crack), inhalants (e.g., inhalation of various substances other than for intended use, such as toluene), hallucinogens, heroin, and prescription-type psychotherapeutic drugs (nonmedical use).
xxviii. The top 5 States that contributed to the achievable benchmark are Alabama, Delaware, Maryland, Oregon, and Utah.
xxix. The top 5 States that contributed to the achievable benchmark are Colorado, Connecticut, District of Columbia, Mississippi, and Texas.


Return to Contents

Page last reviewed May 2014
Page originally created May 2014

 

The information on this page is archived and provided for reference purposes only.

 

AHRQ Advancing Excellence in Health Care