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Biomedical subjects

Steven C Marcus

Publications and source records attributed to Steven C Marcus.

At least 37 records · Page 2Linked to original sources
PubMed2005

National trends in hospitalization of youth with intentional self-inflicted injuries.

OBJECTIVE: The authors examined national trends from 1990 to 2000 in the utilization of community hospital inpatient services by young people (5-20 years of age) with intentional self-inflicted injuries. METHOD: Discharge abstracts from a nationally representative sample of community hospitals were analyzed, with a focus on youth discharges (N=10,831) with a diagnosis of intentional self-inflicted injury (ICD-9-CM: E950-E959). Census data were used to derive national population-based rates of self-inflicted injuries requiring inpatient treatment. Overall population-based trends in hospitalizations for self-inflicted injury were calculated and stratified by gender and age. Among youths hospitalized with a self-inflicted injury, trends were also calculated for length of stay, inpatient costs, method of injury, and associated mental disorder diagnoses. RESULTS: The annual hospitalization rate of youths with self-inflicted injuries declined from 49.1 per 100,000 in 1990 to 44.9 per 100,000 in 2000, and the mean length of inpatient stay significantly declined from 3.6 days to 2.7 days. Among the hospitalized patients, there were increases in the rate of cutting (4.3% to 13.2%) and ingestion of acetaminophen (22.1% to 26.9%), antidepressants (10.0% to 14.0%), and opiates (2.3% to 3.3%) as a cause of injury, whereas there were decreases in the ingestion of salicylates (14.9% to 10.2%) and barbiturates (1.5% to 0.7%). There were significant increases in the proportion of subjects with primary mental disorder discharge diagnoses of depressive disorder (29.2% to 46.0%), bipolar disorder (1.3% to 8.2%), and substance use disorder (5.4% to 10.7%) and significant decreases in the rate of adjustment disorders (22.2% to 11.4%) and nonmental disorders (31.9% to 13.6%). After excluding cutting, which may be more closely related to self-mutilation than suicidal self-injury, the annual hospitalization rate of youths with self-inflicted injuries declined from 47.2 per 100,000 in 1990 to 39.4 per 100,000 in 2000. CONCLUSIONS: Over the decade of study, young people admitted to community hospitals with self-inflicted injuries tended to have more severe psychiatric diagnoses and to be treated during shorter inpatient stays. These trends suggest that the role of youth inpatient care has narrowed, becoming focused on those with severe psychiatric disorders.

Adolescent↗
PubMed2004

Effectiveness of electroconvulsive therapy in community settings.

BACKGROUND: Clinical trials indicate that electroconvulsive therapy (ECT) is the most effective treatment for major depression, but its effectiveness in community settings has not been examined. METHODS: In a prospective, naturalistic study involving 347 patients at seven hospitals, clinical outcomes immediately after ECT and over a 24-week follow-up period were examined in relation to patient characteristics and treatment variables. RESULTS: The sites differed markedly in patient features and ECT administration but did not differ in clinical outcomes. In contrast to the 70%-90% remission rates expected with ECT, remission rates, depending on criteria, were 30.3%-46.7%. Longer episode duration, comorbid personality disorder, and schizoaffective disorder were associated with poorer outcome. Among remitters, the relapse rate during follow-up was 64.3%. Relapse was more frequent in patients with psychotic depression or comorbid Axis I or Axis II disorders. Only 23.4% of ECT nonremitters had sustained remission during follow-up. CONCLUSIONS: The remission rate with ECT in community settings is substantially less than that in clinical trials. Providers frequently end the ECT course with the view that patients have benefited fully, yet formal assessment shows significant residual symptoms. Patients who do not remit with ECT have a poor prognosis; this underscores the need to achieve maximal improvement with this modality.

Adult↗
PubMed2004

Association of utilization management and treatment plan modifications among practicing U.S. psychiatrists.

OBJECTIVE: This study examined the relationship between utilization management techniques and psychiatrists' treatment plan modifications. METHOD: Nationally representative data on 1,843 patients treated by 615 psychiatrists participating in the American Psychiatric Institute for Research and Education's Practice Research Network were used to examine the demographic and clinical characteristics of patients whose care was subjected to utilization management and to assess the association between utilization management and psychiatrists' treatment plan modifications. RESULTS: Approximately half of all patients had treatment that was subject to utilization management (52.6%). For the patients whose treatment was not subject to utilization management, 15.5% had their treatment plan changed compared to the 31.5% who were subject to utilization management. Overall, after adjustment for differences in patients, settings, and psychiatrist characteristics, the patients subject to utilization management were 2.6 times more likely to have their treatment changed than the patients who were not subject to utilization management. These patients were 3.7 times more likely to have their type of treatment changed and 2.3 times more likely to have their frequency or number of visits changed. Psychiatrists in individual practice settings and those with nonsalaried income sources were more likely to modify treatment decisions for their patients when subject to utilization management. CONCLUSIONS: The presence of utilization management is highly associated with changes in psychiatrists' treatment decisions. When compared to evidence-based treatment recommendations, these changes seem likely to result in less than optimal care.

Adolescent↗
PubMed2004

Use of psychotropic medications before and after Sept. 11, 2001.

OBJECTIVE: This study examined patterns of psychotropic medication use after the Sept. 11, 2001, terrorist attacks. METHOD: It drew from two large pharmacy data sets, one providing nationally representative aggregate projections for all U.S. prescriptions (156.9 million claims for psychotropic medications during the study period) and a second from the nation's largest pharmacy benefit management organization (36.4 million enrollees per month), 4.1% of whom had a prescription for a psychotropic medication during the study period. Analyses examined use of antidepressant, antipsychotic, anxiolytic, and hypnotic medications in the 12 weeks before and after Sept. 11, 2001, compared with the same weeks during 2000. RESULTS: Nationally and in Washington, D.C., there was no evidence of an increase in overall prescriptions, new prescriptions, or daily doses for psychotropic medications. In New York City, there was an increase in the proportion of existing users with psychotropic dose increases in the weeks after the attacks (16.9% in 2001 versus 13.6% in 2000) but no significant increase in the rate of new psychotropic prescriptions. CONCLUSIONS: For most of the nation, the distress associated with the terrorist attacks was not accompanied by a commensurate increase in the use of psychotropic medications. In New York City, there was a statistically significant but modest increase in the proportion of individuals with dose increases in their psychotropic medications.

District of Columbia↗
PubMed2004

Depression and the ability to work.

OBJECTIVE: Depression can have a serious impact on a person's ability to work. The purpose of this study was to describe depressed persons who work and depressed persons who do not work and to identify factors related to depressed persons' working. METHODS: The combined 1994 and 1995 National Health Interview Survey Disability Supplement was used to identify persons aged 18 to 69 with depression. Sociodemographic, health, functional, and disability characteristics of working depressed persons and nonworking depressed persons were compared with use of a chi square test of significance. After adjustment for sociodemographic variables, multiple logistic regression analysis was used to identify factors associated with work among depressed persons. RESULTS: Approximately half of the persons who reported major depression were in the labor force. Compared with nonworking depressed persons, working depressed persons tended to be younger, to be male, to be better educated, to have a higher income, to live alone or with a nonrelative, and to live in an urban or suburban location. They less often perceived themselves as unable to work or as disabled and were healthier and less impaired by social, cognitive, and physical limitations than their nonworking counterparts. After sociodemographic factors were controlled for, health and functional characteristics were strongly associated with depressed persons' working. CONCLUSIONS: Depressed persons who work and who do not work differed across sociodemographic, health, functional, and disability factors. Understanding the factors associated with depressed persons' working and not working may help policy makers, employers, and clinicians shape health care benefits packages, employee assistance programs, disability programs, and treatment programs appropriately. In particular, it may be important to focus on individuals with depression and comorbid general health conditions.

Adolescent↗
PubMed2004

National trends in the outpatient treatment of anxiety disorders.

BACKGROUND: Recent advances in psychotherapy and pharmacotherapy have increased the number of treatment options for anxiety disorders. This article examines changes in outpatient treatment of anxiety disorders in the United States between 1987 and 1999. METHOD: Analyses are presented of service utilization data from 2 nationally representative surveys of the general population: the 1987 National Medical Expenditure Survey and the 1999 Medical Expenditure Panel Survey. Respondents were selected who made 1 or more outpatient visits for the treatment of an anxiety disorder (ICD-9/DSM-IV: 300.0, 300.2, 300.3, or 308.3). The rates of treatment, psychotropic medication use, psychotherapy, number of outpatient treatment visits, type of provider, and source of payment were determined. RESULTS: The rate of outpatient treatment for anxiety disorders increased from 0.43 per 100 persons in 1987 to 0.83 in 1999 (p <.001). Among those treated for an anxiety disorder, the proportion that received psychotropic medications increased from 52.1% to 69.9% (p =.008). Among treated patients, antidepressant use increased from 18.3% to 44.9% (p <.0001), while use of benzodiazepines (42.3% to 31.7%, p =.09) and psychotherapy (60.5% to 48.0%, p =.07) tended to decline. A decreasing proportion of mean treatment expenditures was covered by self-payment (53.2% to 31.5%, p <.0001). CONCLUSION: Between 1987 and 1999, there was an increase in the proportion of the population who received outpatient treatment for anxiety disorders. Among patients receiving care, treatment became characterized by greater use of psychotropic medications, especially antidepressant medications, with nonsignificant trends toward less common use of psychotherapy.

Adolescent↗
PubMed2003

Trends in care by nonphysician clinicians in the United States.

BACKGROUND: The 1990s saw rising numbers of graduates of training programs for nonphysician clinicians, passage of legislation expanding their scope of practice, and a proliferation of managed-care models that emphasized the use of these providers as a strategy for containing health care costs. METHODS: We used two nationally representative surveys to examine trends in outpatient care provided by physicians and nonphysician clinicians between 1987 and 1997, adjusting for the case mix. Analyses examined care provided by 10 categories of nonphysician clinicians: chiropractors, midwives, nurses or nurse practitioners, optometrists, podiatrists, physician assistants, physical or occupational therapists, psychologists, social workers, and others. RESULTS: Between 1987 and 1997, the proportion of patients who saw a nonphysician clinician rose from 30.6 percent to 36.1 percent (adjusted relative risk for 1997 as compared with 1987, 1.42 [95 percent confidence interval, 1.35 to 1.50]). The trend was driven by an increase in the proportion of persons who visited both a physician and a nonphysician clinician (from 23.5 percent to 30.9 percent; adjusted relative risk, 1.49 [95 percent confidence interval, 1.40 to 1.58]), rather than an increase in the proportion who saw only a nonphysician clinician (from 7.2 percent to 5.3 percent; adjusted relative risk, 0.81 [95 percent confidence interval, 0.70 to 0.93]). This pattern was consistent in analyses of specific medical conditions and specific types of nonphysician clinicians. There was an increase in the proportion of patients obtaining preventive services from nonphysician clinicians and a decline in the proportion receiving acute care services from such clinicians. CONCLUSIONS: From 1987 to 1997, there was a degree of differentiation between physicians and nonphysician clinicians with respect to the services they provided but not with respect to the patients they treated. The implications of these findings hinge on the degree to which the increase in conjoint service delivery represents growing coordination or fragmentation of care.

Adolescent↗
PubMed2003

Outpatient treatment of child and adolescent depression in the United States.

BACKGROUND: Although psychotherapy has traditionally been the dominant form of treatment for children and adolescents with depression, there has been a recent increase in the prescription of antidepressants for this age group. OBJECTIVE: To describe patterns of outpatient treatment for children and adolescents with depression. DESIGN AND SETTING: Analysis of health service-use data from 4 consecutive years (1996-1999) of the Medical Expenditure Panel Survey, a nationally representative annual survey of the general population that is sponsored by the Agency for Healthcare Quality and Research, Rockville, Md. Subjects Patients aged 6 to 18 years who made 1 or more outpatient visits for the treatment of depression. MAIN OUTCOME MEASURES: Rate of treatment, mental health problems, psychotropic medication use, psychotherapy use, number of outpatient treatment visits, and type of provider. RESULTS: Across the 4 survey years, the mean annual rate of outpatient treatment for depression was 0.93 per 100 individuals. The rate of treatment was especially low for African American individuals (0.23 per 100) and uninsured individuals (0.43 per 100). Approximately three quarters (79%) of treated children and adolescents received psychotherapy and more than half (56.9%) were prescribed antidepressant medications. The mean number of treatment visits for depression was 7.8 per year. As compared with children and adolescents with depression who were treated without antidepressants, those who received antidepressants were significantly more likely to have evidence of anhedonia, to live in large urban communities, to have parents who graduated from high school, and to have health insurance. CONCLUSIONS: The rate and pattern of treatment suggest that serious gaps exist in access to community outpatient treatment for children and adolescents with depression. At the same time, antidepressant medications are used far more commonly than would be expected on the basis of published treatment recommendations.

Adolescent↗
PubMed2003

Relationship between antidepressant medication treatment and suicide in adolescents.

CONTEXT: A decade of increasing antidepressant medication treatment for adolescents and corresponding declines in suicide rates raise the possibility that antidepressants have helped prevent youth suicide. OBJECTIVE: To evaluate the relationship between regional changes in antidepressant medication treatment and suicide in adolescents from 1990 to 2000. DESIGN: Analysis of prescription data from the nation's largest pharmacy benefit management organization, national suicide mortality files, regional sociodemographic data from the 1990 and 2000 US Census, and regional data on physicians per capita. PARTICIPANTS: Youth aged 10 to 19 years who filled a prescription for antidepressant medication and same-aged completed suicides from 588 three-digit ZIP code regions in the United States. MAIN OUTCOME MEASURES: The relationship between regional change in antidepressant medication treatment and suicide rate stratified by sex, age group, regional median income, and regional racial composition. RESULTS: There was a significant adjusted negative relationship between regional change in antidepressant medication treatment and suicide during the study period. A 1% increase in adolescent use of antidepressants was associated with a decrease of 0.23 suicide per 100 000 adolescents per year (beta = -.023, t = -5.14, P<.001). In stratified adjusted analyses, significant inverse relationships were present among males (beta = -.032, t = -3.81, P<.001), youth aged 15 to 19 years (beta = -.029, t = -3.43, P<.001), and regions with lower family median incomes (beta = -.023, t = -3.73, P<.001). CONCLUSIONS: An inverse relationship between regional change in use of antidepressants and suicide raises the possibility of a role for using antidepressant treatment in youth suicide prevention efforts, especially for males, older adolescents, and adolescents who reside in lower-income regions.

Adolescent↗
PubMed2003

Parental depression, child mental health problems, and health care utilization.

BACKGROUND: Small controlled studies suggest that depression and other mental health problems are more common in children of parents with depression than in children of parents without depression. OBJECTIVES: This article examines relationships between parental depression and children's mental health problems and health care utilization in a nationally representative household sample of parents and their children. RESEARCH DESIGN: Cross sectional comparisons of sociodemographic characteristics, mental health problems and health expenditures of children whose parents either do or do not report depression in the 1997 Medical Expenditure Panel Survey data. SUBJECTS: A nationally representative sample of children, 3 to 18 years of age (n = 8,360) with one or more parents living in the household. MEASURES: Mental health problems, total health expenditures, and mental health expenditures. RESULTS: Children of parents with depression were approximately twice as likely as children of parents without depression to have a variety of mental health problems and were 2.8 times more likely to use mental health services in adjusted analyses. Among children with health and mental health expenditures, those whose parents report depression had significantly higher mean total annual child health expenditures ($282 vs. $214, t = 3.5, P = 0.0006) and child mental health expenditures ($513 vs. $338, t = 2.0, P = 0.05) than children whose parents did not report depression. CONCLUSIONS: Children of parents with depression are at increased risk for a range of health problems. Parental depression is also related to an increased child health and mental health service utilization and expenditure.

Adolescent↗
PubMed2003

National trends in the treatment of attention deficit hyperactivity disorder.

OBJECTIVE: Nationally representative descriptive data were presented regarding recent trends in the outpatient treatment of attention deficit hyperactivity disorder (ADHD) in children. METHOD: Service use data were analyzed in children ages 3 to 18 years from two nationally representative surveys of the U.S. general population, the 1987 National Medical Expenditure Survey, and the 1997 Medical Expenditure Panel Survey. Trends in the rates of treatment for ADHD were presented by age, gender, race, family income, and health insurance status. Trends in ADHD treatment were also determined by annual numbers of visits, use of pharmacotherapies, and types of health care professionals. RESULTS: The rate of outpatient treatment for ADHD increased from 0.9 per 100 children in 1987 to 3.4 per 100 children in 1997. Significant increases in the rates of treatment for ADHD were evident across nearly all sociodemographic groups, with the largest increases among children from poor, near-poor, and low-income families and children ages 12 to 18. Among children who received treatment for ADHD, there was a significant decrease in the number of treatment visits but an increase in the number of stimulant prescriptions between 1987 and 1997. CONCLUSIONS: During the decade, there was a marked and broad expansion in access to treatment of children with ADHD but a decline in intensity of treatment, as measured by number of visits. These changes occurred during a period of expanding access to special education services, growth of managed behavioral healthcare, and increased public acceptance of effective psychotropic medications.

Adolescent↗
PubMed2003

The New York-New York housing initiative and use of public shelters by persons with severe mental illness.

OBJECTIVE: The study examined changes in the use of shelters in New York City by mentally ill persons with a history of homelessness who received housing placements through the New York-New York (NY/NY) housing initiative between 1990 and 1999 and the impact of the initiative on the overall demand for shelter beds in the city. METHODS: Computerized service records on housing, shelter use, and health care services were linked to create an integrated data set for 3,167 persons who received NY/NY housing placements, which provided mental health services, and for a matched control group of persons with mental illness who used shelters but did not receive housing placements. Regression analyses were used to assess the relationships between shelter use and receipt of a placement. Differences in postplacement shelter use between NY/NY housing recipients and the matched control group were then examined at an individual level and a population level. RESULTS: Heavy users of the shelter system were more likely to be placed in NY/NY housing. In the two-year postplacement period, persons who received a NY/NY housing placement used, on average, 128.2 fewer shelter days than those in the control group. In 1996, the NY/NY housing initiative reduced the average nightly census in New York City shelters by an estimated 4.6 percent. CONCLUSIONS: Providing housing combined with mental health services is an effective approach to reducing shelter use among mentally ill persons who have a history of homelessness.

Adolescent↗
PubMed2002

National trends in the outpatient treatment of depression.

CONTEXT: Recent advances in pharmacotherapy and changing health care environments have focused increased attention on trends in outpatient treatment of depression. OBJECTIVE: To compare trends in outpatient treatment of depressive disorders in the United States in 1987 and 1997. DESIGN AND SETTING: Analysis of service utilization data from 2 nationally representative surveys of the US general population, the 1987 National Medical Expenditure Survey (N = 34 459) and the 1997 Medical Expenditure Panel Survey (N = 32 636). PARTICIPANTS: Respondents who reported making 1 or more outpatient visits for treatment of depression during that calendar year. MAIN OUTCOME MEASURES: Rate of treatment, psychotropic medication use, psychotherapy, number of outpatient treatment visits, type of health care professional, and source of payment. RESULTS: The rate of outpatient treatment for depression increased from 0.73 per 100 persons in 1987 to 2.33 in 1997 (P<.001). The proportion of treated individuals who used antidepressant medications increased from 37.3% to 74.5% (P<.001), whereas the proportion who received psychotherapy declined (71.1% vs 60.2%, P =.006). The mean number of depression treatment visits per user declined from 12.6 to 8.7 per year (P =.05). An increasingly large proportion of patients were treated by physicians for their condition (68.9% vs 87.3%, P<.001), and treatment costs were more often covered by third-party payers (39.3% to 55.2%, P<.001). CONCLUSIONS: Between 1987 and 1997, there was a marked increase in the proportion of the population who received outpatient treatment for depression. Treatment became characterized by greater involvement of physicians, greater use of psychotropic medications, and expanding availability of third-party payment, but fewer outpatient visits and less use of psychotherapy. These changes coincided with the advent of better-tolerated antidepressants, increased penetration of managed care, and the development of rapid and efficient procedures for diagnosing depression in clinical practice.

Adult↗
PubMed2002

National trends in the use of psychotropic medications by children.

OBJECTIVES: Little information exists on national trends in the use of psychotropic medication by children and adolescents. The objective of this report is to compare patterns and predictors of psychotropic medication use by children and adolescents in the United States in 1987 and 1996. METHOD: An analysis of medication use data is presented from two nationally representative surveys of the general population focusing on children 18 years of age and younger who used one or more prescribed psychotropic medication during the survey years. Rates of stimulant, antidepressant, and other psychotropic medication use are reported. RESULTS: The overall annual rate of psychotropic medication use by children increased from 1.4 per 100 persons in 1987 to 3.9 in 1996 (p < .0001). Significant increases were found in the rate of stimulant use (0.6 per 100 persons to 2.4 per 100 persons), antidepressant use (0.3 per 100 persons to 1.0 per 100 persons), other psychotropic medications (0.6 per 100 persons to 1.2 per 100 persons), and coprescription of different classes of psychotropic medications (0.03 per 100 persons to 0.23 per 100 persons), especially antidepressants and stimulants. Rates of antipsychotic and benzodiazepine use remained stable. In 1996, stimulant use was especially common in children aged 6 to 14 years (4.1 per 100), and antidepressant use was common in children aged 15 to 18 years (2.1 per 100 persons). CONCLUSION: Between 1987 and 1996, there was a marked expansion in use of psychotropic medications by children, especially stimulants and antidepressants.

Adolescent↗
PubMed2002

Effects of provider networks on health care costs for workers with short-term injuries.

OBJECTIVES: This study examines the effects of preferred provider networks on health care costs and service utilization in the treatment of work-related injuries. RESEARCH DESIGN: A retrospective comparison of workers' compensation claims treated by network and non-network providers was conducted. Pairwise matches of individual cases are used to control for differences in case mix and severity of injury between network patients and a non-network comparison group. Cost differentials are separated into a price effect, the difference in costs attributed to network price discounts, holding services constant; and a utilization effect, the difference in costs attributed to differences in service utilization, holding prices constant. SUBJECTS: Data include approximately 87,000 workers' compensation claims, from California, Connecticut, and Texas, with injury dates between 1995 and 1997. The samples are restricted to five common injury types and work absences of less than 7 days. Workers treated solely by network providers are compared with a matched group of workers treated solely by non-network providers. RESULTS: Average health care costs are lower for network claims than for matched non-network claims. Price discounts explain a large part of the cost differentials for all injury groups studied, but differences in service utilization are also important for back cases and cumulative stress injuries. CONCLUSIONS: Networks bring the traditionally high costs of health care for work-related injuries closer to the costs of health care for off-the-job injuries. The network savings primarily reflect price discounts for the same services, thereby representing an increase in the cost-effectiveness of care.

California↗