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Biomedical subjects

Harold Alan Pincus

Publications and source records attributed to Harold Alan Pincus.

At least 19 recordsLinked to original sources
PubMed2007

Reducing the societal burden of depression: a review of economic costs, quality of care and effects of treatment.

Depression is a highly prevalent condition that results in substantial functional impairment. Advocates have attempted in recent years to make the 'business case' for investing in quality improvement efforts in depression care, particularly in primary care settings. The business case suggests that the costs of depression treatment may be offset by gains in worker productivity and/or reductions in other healthcare spending. In this paper, we review the evidence in support of this argument for improving the quality of depression treatment. We examined the impact of depression on two of the primary drivers of the societal burden of depression: healthcare utilisation and worker productivity. Depression leads to higher healthcare utilisation and spending, most of which is not the result of depression treatment costs. Depression is also a leading cause of absenteeism and reduced productivity at work. It is clear that the economic burden of depression is substantial; however, critical gaps in the literature remain and need to be addressed. For instance, we do not know the economic burden of untreated and/or inappropriately treated versus appropriately treated depression. There remain considerable problems with access to and quality of depression treatment. Progress has been made in terms of access to care, but quality of care is seldom consistent with national treatment guidelines. A wide range of effective treatments and care programmes for depression are available, yet rigorously tested clinical models to improve depression care have not been widely adopted by healthcare systems. Barriers to improving depression care exist at the patient, healthcare provider, practice, plan and purchaser levels, and may be both economic and non-economic. Studies evaluating interventions to improve the quality of depression treatment have found that the cost per QALY associated with improved depression care ranges from a low of 2519 US dollars to a high of 49,500 US dollars. We conclude from our review of the literature that effective treatment of depression is cost effective, but that evidence of a medical or productivity cost offset for depression treatment remains equivocal, and this points to the need for further research in this area.

Cost-Benefit Analysis↗
PubMed2006

Depression in primary care: learning lessons in a national quality improvement program.

In this introduction, we describe the overall context and rationale for the Depression in Primary Care program and the design and implementation of its key components, especially emphasizing its unique combined clinical and economic/systems framework. We also discuss some of the new challenges and opportunities that may impact the program's evolution and the state of behavioral health care more generally. We conclude with some thoughts on potential future scenarios and strategies for improving the quality of behavioral health care, including the treatment of depression in primary care.

Depression↗
PubMed2006

Management of mental disorders in VA primary care practices.

The association between facility-level organizational features and management of mental health services was assessed based on a survey of directors from 219 VA primary care facilities. Overall, 26.4% of VA primary care facilities referred patients with depression, while 72.6% and 46.1% referred patients with serious mental illness and substance use disorders, respectively Staffing mix (i.e., physician extenders such as nurse practitioners) was associated with a lesser likelihood of mental health referral. Managed care (preauthorization requirement) was associated with a greater likelihood of referral for depression. VA primary care programs, while tending to refer for more serious mental illnesses, may also be using mental health specialists and physician extenders to provide mental health care within general medical settings.

Cross-Sectional Studies↗
PubMed2006

Quality of care for substance use disorders in patients with serious mental illness.

We assessed the quality of care for substance use disorders (SUDs) among 8,083 patients diagnosed with serious mental illness from the VA mid-Atlantic region. Using data from the National Patient Care Database (2001-2002), we assessed the percentage of patients receiving a diagnosis of SUD, percentage beginning SUD treatment 14 days or earlier after diagnosis, and percentage receiving continued SUD care 30 days or less. Overall, 1,559 (19.3%) were diagnosed with an SUD. Of the 1,559, 966 (62.0%) initiated treatment and 847 (54.3%) received continued care. Although patients diagnosed with bipolar disorder were more likely to receive a diagnosis of SUD than those diagnosed with schizophrenia or schizoaffective disorder (22.7%, 18.9%, and 17.7%, respectively; chi(2) = 26.02, df = 2, p < .001), they were less likely to initiate (49.1%, 70.7%, and 68.6%, respectively; chi(2) = 59.29, df = 2, p < .001) or continue treatment (39.9%, 63.2%, and 62.2%, respectively; chi(2) = 72.25, df = 2, p <. 001). Greater efforts are needed to diagnose and treat SUDs in patients with serious mental illness, particularly for those with bipolar disorder.

Adult↗
PubMed2006

Models of integrated care.

This article describes the range of options for integrating medicine and psychiatry, with a focus on the advantages and limitations of each model. The models were developed in different countries with specific health care cultures. This article illustrates the range of in- and outpatient options as currently practiced, with case reports from practitioners when possible, and describes qualifications for practicing in each model, the settings, the patient populations, the relevant financial issues, and the advantages and disadvantages of practicing in each model. It closes with comments on the next steps for advancing integrated care and the barriers to be overcome.

Communication↗
PubMed2006

General medical and psychiatric perspectives on somatoform disorders: separated by an uncommon language.

PURPOSE OF REVIEW: While Diagnostic and Statistical Manual of Mental Disorders-IV provided updated definitions and diagnostic criteria for the diagnoses subsumed under the category of somatoform disorders, various nosological questions are still unresolved. We assessed current research activity on important key concepts related to nosology, validity, and reliability of the Diagnostic and Statistical Manual of Mental Disorders-IV somatoform diagnoses. RECENT FINDINGS: The initial Medline search for articles from 2000 through 2005 yielded a total of 912 articles. After checking for redundancy and excluding publications using other than Diagnostic and Statistical Manual of Mental Disorders-IV diagnostic criteria, a total of 101 articles was further reviewed. Heterogeneity of papers precluded statistical approaches; thus, a descriptive and narrative review was pursued. SUMMARY: It appears that applying the specific categories and criteria as proposed by Diagnostic and Statistical Manual of Mental Disorders-IV only captures a small proportion of the phenomena of interest at the interface of medicine and psychiatry. A paradigm shift towards 'general medical/psychiatry interface disorders' in exchange for the current dichotomy of 'mind' vs. 'body' disorders, may reduce stigma associated with current diagnostic labeling, improve user acceptability, and stimulate research in this important but still fragmented clinical area that still lacks agreed-upon diagnostic definitions.

Diagnostic and Statistical Manual of Mental Disord↗
PubMed2006

Patterns of psychotropic medication use by race among veterans with bipolar disorder.

OBJECTIVE: This study investigated whether race was associated with patterns of psychotropic medication use among veterans with bipolar disorder. METHODS: Data were examined for veterans from the mid-Atlantic region with a diagnosis of bipolar disorder in fiscal year 2001. Prescription data determined whether differences existed between black and nonblack patients in the receipt of lithium, other mood stabilizers, all mood stabilizers, first-generation antipsychotics, second-generation antipsychotics, all antipsychotics, selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, all antidepressants, and benzodiaze-pines. RESULTS: Data for 2,958 patients were sampled: 347 blacks and 2,611 nonblacks. Multivariable analyses that adjusted for patient and clinical factors revealed that compared with nonblacks, blacks were significantly less likely to receive lithium and SSRIs and significantly more likely to receive first-generation antipsychotics and any antipsychotic. CONCLUSIONS: These findings suggest that efforts should be made to reduce disparities in access to pharmacotherapy among patients with bipolar disorder.

Bipolar Disorder↗
PubMed2006

Depression and primary care: drowning in the mainstream or left on the banks?

OBJECTIVE: To discuss the treatment, barriers, and successful strategies to treat depression in a primary care setting. SUMMARY: Historical, conceptual, and individual barriers hinder the treatment of depression. Additionally, a lack of clarity about whether the responsibility for care lies with primary care or behavioral health providers further leads to fragmented and uncoordinated systems. Depression is a chronic illness, not unlike diabetes, heart failure, and asthma. Therefore, disease models used to treat these chronic illnesses can also be applied to successfully treat depression. CONCLUSION: Appropriately managing patients with depression and other behavioral health conditions will require changing the entire health care system. Future strategies should include developing a continual quality improvement process, developing bridges between behavioral health and primary care, eliminating clinical and financial barriers between systems, and viewing the mind and body as a whole.

Adolescent↗
PubMed2005

Prevalence and treatment of mental disorders, 1990 to 2003.

BACKGROUND: Although the 1990s saw enormous change in the mental health care system in the United States, little is known about changes in the prevalence or rate of treatment of mental disorders. METHODS: We examined trends in the prevalence and rate of treatment of mental disorders among people 18 to 54 years of age during roughly the past decade. Data from the National Comorbidity Survey (NCS) were obtained in 5388 face-to-face household interviews conducted between 1990 and 1992, and data from the NCS Replication were obtained in 4319 interviews conducted between 2001 and 2003. Anxiety disorders, mood disorders, and substance-abuse disorders that were present during the 12 months before the interview were diagnosed with the use of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). Treatment for emotional disorders was categorized according to the sector of mental health services: psychiatry services, other mental health services, general medical services, human services, and complementary-alternative medical services. RESULTS: The prevalence of mental disorders did not change during the decade (29.4 percent between 1990 and 1992 and 30.5 percent between 2001 and 2003, P=0.52), but the rate of treatment increased. Among patients with a disorder, 20.3 percent received treatment between 1990 and 1992 and 32.9 percent received treatment between 2001 and 2003 (P<0.001). Overall, 12.2 percent of the population 18 to 54 years of age received treatment for emotional disorders between 1990 and 1992 and 20.1 percent between 2001 and 2003 (P<0.001). Only about half those who received treatment had disorders that met diagnostic criteria for a mental disorder. Significant increases in the rate of treatment (49.0 percent between 1990 and 1992 and 49.9 percent between 2001 and 2003) were limited to the sectors of general medical services (2.59 times as high in 2001 to 2003 as in 1990 to 1992), psychiatry services (2.17 times as high), and other mental health services (1.59 times as high) and were independent of the severity of the disorder and of the sociodemographic characteristics of the respondents. CONCLUSIONS: Despite an increase in the rate of treatment, most patients with a mental disorder did not receive treatment. Continued efforts are needed to obtain data on the effectiveness of treatment in order to increase the use of effective treatments.

Adult↗
PubMed2005

Concomitant pharmacotherapy among youths treated in routine psychiatric practice.

OBJECTIVES: The aim of this study was to assess rates and correlates of concomitant pharmacotherapy in children and adolescents treated by psychiatrists in a broad range of clinical settings. METHODS: Cross-sectional data on 392 child and adolescent patients aged 2-17 years from the 1997 and 1999 American Psychiatric Practice Research Network Study of Psychiatric Patients and Treatments were used, and weighted estimates are provided. RESULTS: Findings indicate that 84% of child and adolescent patients received one or more psychopharmacologic medications; 52% of patients treated with medications received concomitant pharmacotherapy (i.e., two or more medications). Patients who were treated with psychopharmacologic treatments received a median of 2 medications (range, 1-6). Highest rates of concomitant pharmacotherapy were among patients with bipolar disorder (87%). Correlates of concomitant pharmacotherapy included: (1) having a diagnosis of bipolar disorder, (2) having co-occurring Axis I or II disorders or general medical conditions, and (3) currently receiving treatment in an inpatient setting. CONCLUSIONS: Over 40% of child and adolescent patients of psychiatrists were prescribed two or more psychopharmacologic medications. Patients with chronic and clinically complex conditions were more likely to receive concomitant pharmacotherapy. Most often, efficacy of U.S. Food and Drug Administration (FDA)-approved medications has been examined as monotherapy, and cautions on drug interactions and off-label use derived from multiple sources accompany each product. With high rates of concomitant pharmacotherapy among children and adolescents in psychiatric care, additional research on efficacy and safety of this treatment strategy is necessary.

Adolescent↗
PubMed2005

Terrorism's psychologic effects and their implications for primary care policy, research, and education.

This paper examines primary care physicians' (PCP) roles in helping the nation prepare for, respond to, and recover from the psychologic consequences of chemical, biologic, radiologic, or nuclear (CBRN) terrorism. First, we discuss the psychologic consequences of a CBRN attack and PCPs' roles in responding to these consequences. Second, we analyze these roles in light of the known barriers to delivering high-quality, primary care-based, mental health care. Third, we offer recommendations for mitigating these barriers and preparing PCPs to respond to the psychosocial consequences of a CBRN weapon. Importantly, our recommendations provide dual-use benefits to PCPs faced with the daily concerns of primary care mental health, including improved linkages and electronic connectivity with mental health, information technology, and decision support for providers, and needed education and research.

Communication↗
PubMed2005

Review of treatment recommendations for persons with a co-occurring affective or anxiety and substance use disorder.

OBJECTIVE: The authors review and evaluate the literature and guidelines on care for individuals with a co-occurring affective or anxiety disorder and substance use disorder. METHODS: MEDLINE and PsycINFO computerized searches of the English language literature were conducted for the period 1990-2002. These articles were supplemented with searches of the Cochrane Database of Systematic Reviews (1990 to 2002) and with articles that were sent to the authors by experts in the field to review. Bibliographies of selected papers were hand searched for additional articles. From these searches a total of 219 articles were found, of which 127 were selected for review. RESULTS AND DISCUSSION: The literature shows that, over the past several decades, treatment for co-occurring disorders has undergone a broad shift in approach, from treating substance abuse before providing mental health care to providing simultaneous treatment for each disorder, regardless of the status of the comorbid condition. Many treatment recommendations are supported by a broad consensus. However, despite this broad agreement, recommendations are often not specific enough to guide clinical care. Most recommendations with specificity are for acute pharmacotherapy, but even specific recommendations lag behind current clinical practice. Although the use of psychotropic medication for mental illness is encouraged, experts disagree as to whether it is necessary to wait for abstinence before beginning pharmacotherapy. In addition, most diagnosis-specific guidelines are silent as to whether the specific treatment recommendation applies to co-occurring disorders. Finally, empirical evidence is lacking for most recommendations. The authors conclude that the mental health and substance abuse treatment fields need to consider its research priorities and how to address the multitude of potential combinations of disorders.

Anxiety Disorders↗
PubMed2004

Translating evidence-based depression management services to community-based primary care practices.

Randomized controlled trials have demonstrated the efficacy and cost-effectiveness of using treatment models for major depression in primary care settings. Nonetheless, translating these models into enduring changes in routine primary care has proved difficult. Various health system and organizational barriers prevent the integration of these models into primary care settings. This article discusses barriers to introducing and sustaining evidence-based depression management services in community-based primary care practices and suggests organizational and financial solutions based on the Robert Wood Johnson Foundation Depression in Primary Care Program. It focuses on strategies to improve depression care in medical settings based on adaptations of the chronic care model and discusses the challenges of implementing evidence-based depression care given the structural, financial, and cultural separation between mental health and general medical care.

Community Health Services↗
PubMed2004

Out-of-pocket healthcare expenditures of older Americans with depression.

The objective of this study was to estimate mean annual out-of-pocket (OOP) healthcare expenditures of Americans aged 65 and older with self-reported depression and compare these expenditures with the OOP expenditures of older Americans with hypertension, heart disease, diabetes mellitus, and arthritis. Data from the 1999 Medical Expenditure Panel Survey, which employs a nationally representative stratified random sample of households in the United States, were used to estimate mean OOP expenditures for health care during 1999. The data were limited to observations on individuals aged 65 and older living in households in the United States included in the 1999 Medical Expenditure Panel Survey sample (N=2,730). Mean OOP expenditures for older Americans with depression were $1,835 in 1999. Most of the spending ($1,090) was for prescription drugs in this population. For patients with depression, only 8% of total OOP spending was for depression-specific services and treatments. Mean OOP spending was greater for persons with depression than it was for older Americans with hypertension ($1,181) and arthritis ($1,190), whereas OOP spending for depression was similar to spending of older Americans with heart disease ($1,412) and diabetes mellitus ($1,527). Older Americans with depression have high OOP expenditures, with most of this spending for health services and drugs to treat general medical conditions.

Age Factors↗
PubMed2004

The volume-quality relationship of mental health care: does practice make perfect?

OBJECTIVE: An extensive literature has demonstrated a relationship between hospital volume and outcomes for surgical care and other medical procedures. The authors examined whether an analogous association exists between the volume of mental health delivery and the quality of mental health care. METHOD: The study used data for the 384 health maintenance organizations participating in the Health Employer Data and Information Set (HEDIS), covering 73 million enrollees nationwide. Analyses examined the association between three measures of mental health volume (total annual ambulatory visits, inpatient discharges, and inpatient days) and the five HEDIS measures of mental health performance (two measures of follow-up after psychiatric hospitalization and three measures of outpatient antidepressant management), with adjustment for plan and enrollee characteristics. RESULTS: Plans in the lowest quartile of outpatient and inpatient mental health volume had an 8.45 (95% CI [confidence interval]=4.97-14.37) to 21.09 (95% CI=11.32-39.28) times increase in odds of poor 7- and 30-day follow-up after discharge from inpatient psychiatric hospitalization. Low-volume plans had a 3.49 (95% CI=2.15-5.67) to 5.42 (95% CI=3.21-9.15) times increase in odds of poor performance on the acute, continuation, and provider measures of antidepressant treatment. CONCLUSIONS: The large and consistent association between mental health volume and performance suggests parallels with the medical and surgical literature. As with that previous literature, further work is needed to better understand the mechanisms underlying this association and the potential implications for using volume as a criterion in plan choice.

Adolescent↗
PubMed2004

Clinical utility as a criterion for revising psychiatric diagnoses.

OBJECTIVE: Changes in DSM-IV were guided by empirical data that mostly focused on improving diagnostic validity and reliability. Although many changes were made explicitly to improve clinical utility, no formal effort was made to empirically determine actual improvements in clinical utility. The authors propose that future revisions of DSM empirically demonstrate improvement in clinical utility to clarify whether the advantages of changing the diagnostic criteria outweigh potential negative consequences. METHOD: The authors provide a formal definition of clinical utility and then suggest that the merits of a proposed change to DSM be evaluated by considering 1) its impact on the use of the diagnostic system, 2) whether it enhances clinical decision making, and 3) whether it improves clinical outcome. RESULTS: Evaluating a change based on its impact on use considers both user acceptability and accuracy in application of the diagnostic criteria. User acceptability can be measured by surveying users' reactions, assessing user acceptability in a field trial setting, and measuring the effects on ease of use. Assessment of the correct application of diagnostic criteria entails comparing the clinician's diagnostic assessment to expert diagnostic assessment. Assessments of the impact on clinical decision making use methods developed for evaluating adherence to practice guidelines. Improvement in outcome entails measuring reduction in symptom severity or improvement in functioning or in documenting the prevention of a future negative outcome. CONCLUSIONS: Empirical methods should be applied to the assessment of changes that purport to improve clinical utility in future revisions of DSM.

Attitude of Health Personnel↗