PI: Liza Solomon, M.H.S., Ph.D., Johns Hopkins University
Grant No.: R03 HS06441
Grant Period: 2/1/90-1/31/92
Title: Utilization and Insurance Among HIV-Positive Drug Users
Description: This study sought to determine the health services utilization of 1,881 HIV-positive intravenous drug users (IVDUs) in Baltimore. The researchers examined the impact of HIV serostatus, clinical symptoms, CD4 cell counts, and health insurance on utilization of health services over a 6-month period by administering self-report questionnaires about use of health services, insurance coverage, and HIV-related symptoms.
Findings: In this population, 67 percent of the participants had health insurance (including Medicaid), 48 percent had at least one outpatient visit, and 12 percent had at least one inpatient visit within the past 6 months. The presence of two or more HIV-related symptoms contributed the most to utilization of both inpatient and outpatient health care services. HIV-positive individuals presenting no symptoms were just as likely as HIV-seronegative individuals to not use services. The presence of health insurance was marginally associated with inpatient admissions. Only 42 percent of individuals meeting the criteria for zidovudine use reported actually taking the medication. Heavy injection drug use was significantly associated with delayed initiation of zidovudine use among those individuals who reported taking the medication. Despite the initial presence and continuation of high levels of health insurance in this population, HIV-positive serostatus and symptoms were linked to more months of health insurance coverage. The researchers suggest that HIV-positive IVDUs are not getting the preventive care that they need, due to the lack of a routine health care provider, barriers associated with a lack of health insurance, and complications associated with heavy injection drug use.
PI: Sarah W. Tracy, University of Pennsylvania (Dissertation Grant)
Grant No.: R03 HS06985
Grant Period: 9/1/91-12/31/92
Title: The Medicalization of Alcoholism in America, 1870-1919
Description: The purpose of this study was to examine the factors—political, social, economic, and medical—that have influenced current beliefs and policies toward alcohol abuse and problem drinkers. The researcher utilized the methods of social history, starting with the establishment of the American Association for the Cure of Inebriety in 1870 and ending with Prohibition in 1919, to document the ways in which alcoholism became established in the medical arena, how that understanding generated new health care and social policy, and the degree to which new institutions and organizations dealing with alcoholism were effective.
Findings: No findings are available at this time.
PI: A. Eugene Washington, M.D., M.Sc., University of California, San Francisco (Cooperative Agreement)
Grant No.: U01 HS07373
Grant Period: 1/1/93-12/31/98
Title: Medical Effectiveness Treatment Program (MEDTEP) Research Center on Minority Populations
Description: The purpose of this project was to establish a Medical Effectiveness Research Center on Diverse Populations at the University of California, San Francisco. The Center focused on the effectiveness and outcomes of medical treatments aimed at blacks, Hispanics/Latinos, and Asian Americans. Areas of research included cancer, cardiovascular disease, diabetes, glaucoma, prenatal care, and reproductive health. Studies specific to mental health included a random survey of current smokers aged 18-65 years, including Latinos and non-Latino whites, derived from the 1990 San Francisco census, as well as a community survey of behavioral risk factors for poor health among Latinos and non-Latino whites living in San Francisco.
Findings: Latinos' smoking behavior and attitudes differ from those of non-Latino white smokers, and they need more effective smoking cessation programs. For instance, Latinos most often quit smoking because of criticism by family, concern about damaging their children's health, and a desire to set a good example for their children, whereas whites more often cited concerns about their own health and the desire to achieve a difficult goal (not smoking). Latinos were more likely than whites to believe that tobacco is not addictive, and whites were more inclined than Latinos to continue smoking to avoid weight gain. Differences in attitudes and beliefs about cigarette smoking were independent of the number of cigarettes smoked and level of education. Researchers suggested that physicians who want to boost Latino patients' motivation to quit smoking should focus on maintenance of the family's health and personal appearance, as opposed to maintenance of personal health or getting rid of an addiction. Latino men and women smoked fewer than half as many cigarettes per day as non-Latino white men and women; were less likely to have consumed an alcoholic beverage in the previous month; and consumed fewer drinks per week. Researchers suggested that health promotion programs designed for Latinos should emphasize the importance of regular physical activity, increased use of cancer screening tests, and limited consumption of alcohol and cigarettes.
PI: Ruth E. Zambrana, Ph.D., University of California, Los Angeles
Grant No.: R01 HS05518
Grant Period: 8/1/87-7/31/90
Title: Mediators of Birth Outcome Among Three Low-Income Ethnic Groups
Description: The objective of this study was to examine the effect of sociodemographic, health behavior, medical risk, and psychosocial risk factors on the timing of prenatal care among low-income black-American, Mexican-American, and recent Mexican immigrant women in Los Angeles. Researchers compared various factors and birth outcomes for the three groups using interview data and medical records data from a sample of 1,800 women visiting 22 prenatal care clinics in Los Angeles. Comparisons were made between Mexican-Americans and Mexican immigrants to measure the role of acculturation in birth outcomes. Substance use/abuse was given particular attention as a risk factor for birth outcomes.
Findings: About 7 percent of poor black and Hispanic women who received prenatal care at community clinics continued to use drugs during pregnancy, a rate comparable to national estimates. Black women are much more apt to use substances during pregnancy than Hispanic women, but stress and anxiety, not ethnicity, are highly associated with substance use during pregnancy. Black women reported more stressful life events, such as death or injury of someone close, problems with alcohol and drugs, problems at work, an arrest, or problems with government agencies; more distress from these events; and higher anxiety than Hispanic women. Black women were also the least likely to be employed full time or to live with the baby's father, and they were the most likely to receive public health insurance. Researchers interviewed women about their use of substances in the 3 months before they became pregnant and during pregnancy. They found that black women were more likely than Mexican-American or Mexican-immigrant women to be heavy users of alcohol, to have used drugs, and to have smoked cigarettes. Women who continued to use substances during pregnancy, regardless of ethnicity, experienced twice as many stressful life events as women who did not use substances. Mexican-immigrant women are more likely than Mexican-American women, who have been in the United States many years, to abstain from alcohol, drug, and cigarette use during pregnancy. A higher degree of integration into the United States is associated with increased prenatal stress, which in turn is associated with fewer social supports and more substance use. However, these behavioral risk factors do not appear to directly affect preterm births or birth weight.
PI: Katharine C. Cook, University of Virginia, Charlottesville (Dissertation Grant)
Grant No.: R03 HS10762
Grant Period: 7/1/00-8/31/01
Title: Making Care Decisions for Cognitively Impaired Parents
Description: This study described the decisionmaking processes experienced by adult offspring seeking and choosing care for their cognitively impaired parents. The study drew information from the experiences of adult offspring who decided to utilize respite care, supportive living, assisted care, and long-term care services over the course of 1 year. The research strategy used sensitized the researchers to the preferences of the decisionmakers in their attempt to improve family outcomes.
Findings: No findings are available at this time.
PI: Christopher Frueh, Ph.D., Medical University of South Carolina
Grant No.: R01 HS11642
Grant Period: 7/5/02-6/30/05
Title: Telepsychiatry Service Delivery to Trauma Victims
Description: To test the hypothesis that a novel mode of mental health service delivery using telepsychiatry is as effective as traditional modes of treatment, this study will compare videoconferencing technology (telepsychiatry) to "same-room" (traditional) treatment. Veterans who are trauma victims with post-traumatic stress disorder (PTSD) at a Veterans Affairs outpatient PTSD clinic will be randomized to either intervention and followed for 6 months. Two categories of outcome variables will be assessed: (1) clinical outcomes, such as symptom severity and social functioning; and (2) process outcomes, such as patient satisfaction/acceptance, treatment credibility, session attendance, treatment adherence, and treatment dropout.
Findings: No findings are available at this time.
PI: Douglas F. Zatzick, M.D., University of Washington
Grant No.: R03 HS11372, Previous No. R01 HS11372
Grant Period: 5/1/01-10/31/02
Title: Collaborative Intervention for Post-Traumatic Stress Disorder Trauma Survivors
Description: This investigation examined the effectiveness of a collaborative mental health intervention pilot for physically injured trauma survivors suffering from post-traumatic stress disorder (PTSD), developed methods for assessment of the cost-effectiveness of the intervention, and documented the processes of collaborative care delivery. The study followed 160 trauma survivors for 12 months, from hospital admission through outpatient care and community rehabilitation.
Findings: No findings are available at this time.
PI: Joan R. Asarnow, Ph.D., University of California, Los Angeles
Grant No.: R01 HS09908
Grant Period: 8/1/98-7/31/03
Title: Youth Partners in Care: Depression and Quality Improvement
Description: This project is evaluating the impact of a quality-improvement intervention designed to enhance the outcomes of mental health care for children in managed care practices and reduce their families' stress by educating them and their primary care physicians about depression treatment. The intervention will also assist in providing the primary care practices with the clinical resources to implement the necessary medication management and/or cognitive-behavior therapy. The study will measure outcomes such as satisfaction with care, clinical symptoms, daily functioning, service use and costs, indirect costs, and parental psychological distress.
Findings: Thus far, brief screening surveys for depression have been created. They can be completed in primary care waiting rooms and are feasible for use within primary care settings.
PI: Jonathan B. Brown, M.P.P., Ph.D., Kaiser Foundation Research Institute (Cooperative Agreement)
Grant No.: U01 HS07649
Grant Period: 9/30/92-9/30/96
Title: Implementations of Guidelines in a Large Group-Model Health Maintenance Organization
Description: The objective of this study was to evaluate strategies used by a large group-model health maintenance organization (HMO) to implement national clinical guidelines for the detection and treatment of hypertension and depression. The implementation of the Guideline for the Detection and Treatment of Depression in Primary Care from the Agency for Health Care Policy and Research (now AHRQ) was studied.
Findings: Quality improvement teams alone were insufficient to improve depressive symptoms among primary care patients with chronic depression in managed care organizations. Tailoring clinical guidelines to suit local conditions may greatly increase the likelihood that physicians will implement them. The continuous quality improvement implementation strategy did not effect adherence to guideline care for depression, while the academic detailing (AD) strategy induced increased antidepressant drug use by clinicians. In the AD group, worse depressive symptoms and functional status among patients with chronic recurring depressive illness seemed to be responsible for causing increased treatment of depression. The Kaiser Permanente Northwest Region Guideline for the Management of Depression in Primary Care, 1993, contains more specific material on depression screening, offers practical details about referral to the HMO's mental health department, and describes self-help options and local community resources not mentioned in the AHRQ document because of its national orientation. Although the Kaiser Permanente guideline is now out of print, it is described in detail in "The Paradox of Guideline Implementation: How AHCPR's Depression Guideline Was Adapted at Kaiser Permanente Northwest Region," by Jonathan Brown, Diana Shye, and Bentson McFarland, in the January 1995 Journal of Quality Improvement 21(1), pp. 5-20.
PI: Edward J. Callahan, Ph.D., University of California, Davis
Grant No.: R03 HS08029
Grant Period: 12/1/93-5/31/95
Title: Impact of Depressive Symptoms on Process of Primary Care
Description: This study was designed to examine and evaluate data based on three hypotheses surrounding physicians and their depressed patients. First, concerning the physician-patient interaction, the study examined whether or not the physician recognizes the patient's depressive symptoms. Second, concerning the differences in process and cost of care, the study examined whether or not the physician appropriately recognizes the patient's depressive symptoms. Finally, concerning the outcome of care, the study examined when the patient's depressive symptoms are appropriately recognized.
Findings: When physicians did recognize depression, they treated patients differently. Missed depression diagnoses can lead to unnecessary and costly tests to uncover the cause of vague physical complaints such as headache and fatigue, which frequently mask depression. Improving physicians' recognition of depression could improve quality of care for these patients and save health care costs. Primary care physicians often fail to recognize depression when it is present in their patients, yet they are less likely to miss it in women and more educated patients than in men and less educated patients.
PI: Gregory N. Clarke, Ph.D., Kaiser Foundation Research Institute
Grant No.: R01 HS10535
Grant Period: 6/1/99-5/31/03
Title: Health Maintenance Organization Collaborative Care Treatment for Depressed Youth
Description: This study examines the effectiveness, in terms of both patient outcomes and overall costs, of a cognitive behavioral therapy used as an adjunct to antidepressant medication therapy to treat adolescents ages 12-18 who are experiencing depression for the first time. The randomized clinical trial will be conducted in four large managed care practices in the Northwest that provide primary care, and it will involve the teaming of pediatricians and trained mental health therapists.
Findings: No findings are available at this time.
PI: Harold I. Goldberg, M.D., University of Washington (Cooperative Agreement)
Grant No.: U01 HS07652
Grant Period: 12/1/92-11/30/96
Title: Evaluation of Guidelines in Large Group Practices
Description: In this study the researchers conducted a randomized controlled trial to determine the effectiveness of academic detailing (AD) techniques and continuous quality improvement (CQI) teams in increasing compliance with a national guideline for the primary care of hypertension and depression.
Findings: Both the AD techniques and CQI teams failed to improve guideline compliance or clinical outcomes for depression. No intervention effects were found in depression recognition, improved prescribing, or reduced symptomatology, with the exception of a small decrease (4.7 percent) in first-generation tricyclic use associated with the AD technique compared to usual care. This change was consistent with the guideline recommendation to avoid antidepressants that frequently cause side effects.
PI: David E. Grembowski, Ph.D., University of Washington
Grant No.: R01 HS06833
Grant Period: 5/1/95-11/30/99
Title: Managed Care, Physician Referral and Medical Outcomes
Description: The purpose of this study was to assess the role played by managed care in physician referral behavior among pain or depression patients in primary care and to determine the health outcomes of referred and nonreferred patients as a result of managed care.
Findings: Plans that are "more managed" were less likely to refer patients to a psychiatrist. Low-income patients were less likely to be referred to a mental health specialist if there was physician financial withhold for referral. A physician productivity bonus was associated with greater access to specialists, and patients in more managed plans had lower ratings of care from their primary physicians.
Patients in managed care organizations with the primary care physician as gatekeeper are less likely to see specialists than other patients because patients typically face higher out-of-pocket costs when they self-refer. Evidence suggests that minimal benefits with high out-of-pocket costs for a category of health services, such as mental health, decrease the probability that a patient will be referred for those services.
PI: Ronald D. Hays, Ph.D., RAND
Grant No.: R01 HS06171
Grant Period: 6/1/90-5/31/92
Title: Patient Adherence Among Chronic Disease Patients
Description: This study investigated the factors that predict patient adherence to prescribed medical therapy and the resulting patient health outcomes. The researchers analyzed data collected from the Medical Outcomes Study (MOS), a 6-year study of patients with specific chronic diseases, including depression. The MOS includes data from both solo and group practices and from both prepaid and fee-for-service arrangements in Boston, Chicago, and Los Angeles.
Findings: Patients are more likely to follow their doctors' advice if their doctors have busy practices, are happy in their work, and take time to answer questions and conduct patient followup via phone or office visits. A physician's personal characteristics such as age, sex, and ethnic group had no significant effect on patient adherence.
PI: Rachel Manber, Ph.D., Stanford University
Grant No.: R01 HS09988
Grant Period: 9/30/98-9/29/01
Title: Acupuncture Treatment of Depression During Pregnancy
Description: This study tested the efficacy of acupuncture therapy used to treat pregnant women who have been diagnosed with major depression. The study specifically tested the effectiveness of acupuncture therapy in treating depression in comparison to (1) other forms of acupuncture treatment used to address valid symptoms separate from the depressive symptoms and (2) prenatal massage. The study analyzed the effects of the acupuncture treatment, as compared with the controls, on depression during pregnancy, depression post partum, and infant outcomes.
Findings: No findings are available at this time.
PI: Geoffry W. McEnany, Ph.D., University of California, San Francisco (Fellowship Grant)
Grant No.: F32 HS00093
Grant Period: 3/1/95-2/28/97
Title: Nursing Strategies for Major Depression in Women
Description: This clinical trial study utilized an experimental design, collecting data over a 1-month period regarding fatigue, mood, and sleep pattern rhythms before and after nonpharmacologic treatment for a major nonseasonal, non-bipolar depressive episode. The study focused on pre- and post-menopausal women, examining the potential gender-bound effects of treatment. This study aimed to assess the impacts of intervention in order to demonstrate treatment efficacy, specifically the use of phototherapy as a treatment for nonseasonal, non-bipolar depression.
Findings: No findings are available at this time.
PI: Gregory A. Nichols, M.B.A., Kaiser Foundation Research Institute (Dissertation Grant)
Grant No.: R03 HS07991
Grant Period: 8/1/93-7/31/95
Title: The Detection and Treatment of Depression in a Large Health Maintenance Organization
Description: The goal of this study was to compare the skill of family practice and internal medicine primary care physicians in communicating the detection of depression to their patients, the subsequent treatment of depressive disorders, and the patients' use of health care resources. First, a depression screening questionnaire scale was distributed to randomly selected members of the Kaiser Permanente Northwest health maintenance organization. Members with ongoing or recurring depression or dysthymia who identified either a family practice or internal medicine physician as their primary care provider were identified and studied further to assess any differences between family practice and internal medicine physicians. The study also compared the utilization of health care resources between members being treated and members not being treated for depression.
Findings: Family practice physicians may be more attentive to depressive disorders than internal medicine physicians. Chronically or recurrently depressed patients of family practice physicians were more likely to report that their physician asked them about depressive symptoms than were patients of internal medicine physicians (34.0 percent vs. 27.3 percent). Family practice patients had more visits and were more likely to use antidepressant medications.
PI: Jacqueline A. Pugh, M.D., University of Texas (Cooperative Agreement)
Grant No.: U01 HS07397
Grant Period: 9/9/92-2/28/98
Title: Mexican American Effectiveness Research Center
Description: The objective of this study was to establish a Mexican American Effectiveness Research Center (MERECE) to examine the effectiveness of treatments for chronic disabling conditions in Mexican Americans, including type II diabetes, mental health issues such as depression, and problems with functional status. Through the establishment of a research core, a training core, a technical assistance core, and a dissemination core, this study intended to assess outcomes of measures and treatments regarding the conditions in Mexican Americans, to train investigators for outcomes research within the Mexican-American population, to provide technical assistance to MERECE-related projects, and to disseminate research information.
Findings: Subsyndromal depression is more prevalent than major depression in primary care settings with a majority of Mexican-American patients. Both subsyndromal and minor depression are associated with significant functional impairment. Symptom relief and potential recovery from depression rely on the availability of informal social supports and the development of religious faith. Of nursing home residents, 26 percent have major depression. Depressed nursing home residents are more functionally impaired, use more health care resources, and may be at increased risk of death compared to their nondepressed counterparts. The Geriatric Depression Scale (GDS) and Brief Carrol Depression Rating Scale (BCDRS) met criteria for moderate to substantial agreement with the standard for depression, whereas the Short Geriatric Depression Scale (SGDS) and Center for Epidemiologic Studies Depression Scale (CES-D) achieved only fair agreement. Researchers suggest that the GDS is a preferred measure and that brief interviewer-administered tools may improve detection of depression in the nursing home. The GDS also was culturally adapted for use with Spanish-speaking individuals, with performance equivalent to that of the English version. Mexican-American nursing home residents are more impaired, both cognitively and functionally, than non-Hispanic white residents as measured by the Mini-Mental State Examination. It is not clear whether patients' medical conditions, nursing home selection and referral patterns, or cultural factors play a role in functional differences between ethnicities.
PI: Rebecca L. Schein, Ph.D., Duke University Medical Center (Fellowship Grant)
Grant No.: F32 HS00108
Grant Period: 9/1/95-6/30/96
Title: Depression Treatment in Elderly Medical Outpatients
Description: The purpose of this research was to investigate the effectiveness of short-term problem-solving therapy (PST) in treating depression in elderly medical outpatients. The study examined 24 elderly outpatients fulfilling the criteria for major depression and having at least one chronic medical illness. Participants were then referred for PST by physicians treating geriatric outpatients at the Duke Medical Center. Patients were evaluated in measures of depression, multidimensional functional status, self-rated health, and social problem-solving abilities to determine if the PST had a significant impact in these areas, as compared with a wait-list control group.
Findings: Application of the Center for Epidemiological Studies-Depression Scale (CES-D) to elderly medical patients may compromise the validity of the scale in terms of sensitivity and specificity for the elderly medical population, as the study found that some of the CES-D items failed to differentiate between major, minor, and nondepressed patients.
PI: Karen Swanson, B.A., S.C.M., University of California, Los Angeles
Grant No.: R03 HS11407
Grant Period: 7/1/01-6/30/02
Title: Patient Satisfaction for Depressed Patients in Primary Care
Description: Patient satisfaction is usually conceptualized by assessing either technical competency (appropriate care) or interpersonal aspects of care (patient-provider relationship). The main objective of this study is to test whether patient satisfaction is determined by both types of quality of care for people who are diagnosed with major depression and if there are any gender differences in this relationship. Another objective is to determine if provider switching is a consequence of patient dissatisfaction with care. It is hoped that findings from this study will assist health plans in understanding what predicts satisfaction with care so they can target and restructure care.
Findings: No findings are available at this time.
PI: Kenneth B. Wells, M.D., M.P.H., RAND
Grant No.: R01 HS06802
Grant Period: 4/1/91-3/31/94
Title: Variations in the Process/Outcomes of Care—Depression
Description: This study used data from two large quasi-experimental studies, the Medical Outcomes Study and the Prospective Payment Quality of Care Study, to examine variations in quality and outcomes of care for depression for different groups of depressed patients (age groups, men vs. women, poor vs. nonpoor, ethnic minority vs. white) and for different types of treatment locations (rural vs. urban, for-profit vs. nonprofit organizations, public vs. private). Further, it determined how variations in outcomes correspond to variations in the process of care for depressed patients.
Findings: Patients with dysthymia may have poorer outcomes than patients with a severe episode of depression and no chronic depression. Patients with subthreshold depressive symptoms but no current disorder had the best outcomes, although 25 percent of this group had a major depressive episode within 2 years. Patients who were not white were more likely than whites to have a remission during the 2-year followup but other demographic factors were not related to remission. Classifying patients according to depression severity and functional status rather than a specific depressive disorder may be particularly useful in primary care practice for two reasons: (1) many clinicians resist existing psychiatric diagnostic classifications; (2) depressed primary care patients may be more likely to present with complaints about their functioning rather than their mood.
It was also found that 60 percent of depressed outpatients had at least one chronic medical condition. Depression was worse in patients with a history of heart attacks than those with hypertension and insulin-dependent diabetes. In a related analysis, it was found that medically healthy depressed patients can be more limited physically and socially than individuals with chronic conditions such as diabetes and arthritis. Depressed persons were found to be less able to perform their social roles as parents or workers, experience more physical pain, and generally perceive their health as worse than persons with chronic medical conditions.
Differences were found in outcomes for depressed patients depending on their payment type. Prepaid patients who received outpatient treatment for depression from psychiatrists became more limited in role and physical functioning over time than patients who received traditional fee-for-service care. These same prepaid patients also sharply reduced their use of antidepressants after 2 years even though evidence strongly supports the value of maintenance therapy in patients with chronic and recurrent depression.
Depressed patients being treated by a specialist usually receive psychotherapy and/or antidepressants. General medical providers are more apt to use less intensive and more advice-oriented depression counseling as treatment. A depressed patient is less likely to receive counseling in a prepaid plan than under fee-for-service (FFS) care. Additionally, the most severely depressed patients are treated by psychiatrists, less depressed patients by psychologists or nonphysician therapists, and the least depressed by primary care providers in both prepaid and FFS systems.
Approximately 11 percent of depressed outpatients switch from FFS to prepaid plans and vice versa, a rate that is higher than that for patients with other disorders. Patient satisfaction and outcomes are not significantly affected by a switch in either direction. However, patients switching from prepaid to FFS plans may be at risk for poorer functional outcomes, although not necessarily poorer mental health, probably due to a break in continuity of care. Patients tended to decrease the number of their visits while switching.
The trend away from mental health specialty care and toward general medical provider care for depression reduces costs, but it also worsens outcomes and does not increase the value of health care in terms of functional improvement per dollar spent. Depressed patients treated for any reason in the general medical care sector had fewer functional limitations than individuals receiving no care. Patients treated by psychiatrists fared the best. Additional improvements in care for depressed patients were indicated for all treatment types. Patients who were sicker and those with more education were less likely to use a subtherapeutic dose. Minority patients used antidepressants at one-third the rate of white patients and were more than twice as likely to use a dose below the minimum therapeutic level.
In evaluating the impact of Medicare's Prospective Payment System, it was found that after implementation of the system, a higher percentage of hospitalized depressed elderly patients had clinically appropriate acute-care admissions; the initial assessment of psychological status by the treating provider was more complete; the quality of psychotropic medication management improved; and the rates of inpatient medical or psychiatric complications, discharge to another hospital or nursing home, and inpatient readmission declined.