Medication management of depression in the United States and Ontario
Cite this article as: Katz, S.J., Kessler, R.C., Lin, E. et al. J GEN INTERN MED (1998) 13: 77. doi:10.1046/j.1525-1497.1998.00022.x Abstract OBJECTIVE: To compare rates of contact for mental problems and receipt of appropriate antidepressant medication management for persons in the general population with major depression in the United States and Ontario, Canada. DESIGN: Survey using the U.S. National Comorbidity Survey and the Mental Health Supplement of the Ontario Health Survey. PARTICIPANTS: All persons with major depression as described in DSM-III-R in the previous 12 months, from a multistage random sample of persons aged 21 to 54 years living in households in the United States ( n=574) and Ontario ( n=250) in 1990. MEASUREMENTS AND MAIN RESULTS: Self-reported contact with general medical or mental health specialty providers for mental problems and appropriate medication management, defined as a combination of antidepressant medication use and four or more visits to any provider within the previous 12 months, were the main outcome measures. The proportion of depressed persons receiving appropriate management was lower in the United States than in Ontario (7.3% vs 14.9% in Ontario, adjusted odds ratio [AOR] 95% CI 0.4; 95% confidence interval [CI] 0.2, 0.8). This difference was largely the result of fewer Americans than Canadians having any mental health care from general medical physicians (9.6% in the United States vs 25.8% in Ontario; AOR 0.3; 95% CI 0.1, 0.5) rather than from specialty providers (20.8% in the United States vs 28.9% in Ontario; AOR 0.7; 95% CI 0.4, 1.1). These between-country differences were much greater for the poor than for those with higher incomes. The Ontario-United States AOR of making contact with either type of clinical provider was 7.5 (95% CI 2.7, 20.7) for lowest-income persons but 2.1 (95% CI 0.3, 5.6) for highest-income persons. The proportions of depressed recipients of any mental health care who received appropriate management were similar between countries (23.9% in the United States vs 27.7% in Ontario; AOR 0.8; 95% CI 0.3, 1.7). CONCLUSIONS: Most persons with depression in the United States and Ontario do not receive appropriate medication management. The rate of appropriate medication management in the United States relative to Ontario is lower largely because there is less contact with general medical physicians for mental problems, especially for the poor. Economic barriers, rather than knowledge and attitudinal factors, appear to explain this difference. Key words mental health medication management major depression
Preparation of this report was supported by a Robert Wood Johnson Foundation Generalist Physician Faculty Scholars Award to Dr. Katz and a research scientist award to Dr. Kessler (grant MH00507) and Dr. Wells. The National Comorbidity Study is supported by the National Institute of Mental Health (grants MH46376 and MH49098) with supplemental support from the National Institute of Drug Abuse (through a supplement to MH46376) and the W. T. Grand Foundation (grant 90135190). Ronald C. Kessler is the principal investigator. The Mental Health Supplement to the Ontario Health Surveyor is supported by the Ontario Ministries of Health and Community and Social Services through the Ontario Mental Health Foundation. David R. Offord is the principal investigator.
Collaborating National Comorbidity Study sites and investigatiors are The Addiction Research Foundation (Robin Room), Duke University Medical Center (Dan Blazer, Marvin Swartz), Harvard University (Richard Frank), Johns Hopkins University (James Anthony, William Eaton, Philip Leaf), the Max Planck Institute of Psychiatry—Clinical Institute (Hans-Ulrich Wittchen), the Medical College of Virginia (Kenneth Kendler), the University of Michigan (Lloyd Johnston, Ronald Kessler, Roderick Little), New York University (Patrick Shrout), SUNY Stony Brook (Evelyn Bromet), The University of Toronto (R. Jay Turner), and Washington University School of Medicine (Linda Cottler, Andrew Heath).
Collaborating Mental Health Supplement to the Ontario Health Survey agencies and investigators are The Ontario Mental Health Foundation (Dugal Campbell), The Clarke Institute of Psychiatry (Paula Goering, Elizabeth Lin), McMaster University (Michael Boyle, David Offord), and the Ontario Ministry of Health (Gary Catlin).
Arons BS, Frank RG, Goldman HH, McGuire TG, Stephens S. Mental health and substance abuse coverage under health reform. Health Aff (Millwood). 1994;13(1):192–205.
Koyanagi C, Maines J. What did the health care reform debate mean for mental health policy? Health Aff (Millwood). 1995;14(3): 124–9.
Congress agrees on new health benefits, mandates. The Week in Medicine (Chicago, Ill). Marketplace. Oct 7, 1996.
Weissman MM, Bland RC, Canino GJ, et al. Cross-national epidemiology of major depression and bipolar disorder. JAMA. 1996;276:293–9.
Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51(1):8–19.
Sturm R, Wells KB. How can care for depression become more cost effective? JAMA. 1995;273:51–8.
Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER. Depression: a neglected major illness. J Clin Psychiatry. 1993;54:419–24.
Mintz J, Mintz LI, Arruda MJ, Hwang SS. Treatments of depression and the functional capacity to work. Arch Gen Psychiatry. 1992;49:761–8.
McGlynn EA. Choosing chronic disease measures for HEDIS: conceptual framework and review of seven clinical areas. Manag Care Q. 1996;4:54–77.
Frank RG, Goldman HH, McQuire TG. A model mental health benefit in private insurance. Health Aff (Millwood). 1992; 11(3):98–117.
Ontario Ministry of Health. Putting People First: The Reform of Mental Health Services in Ontario. Toronto, Ont: Queen’s Printer for Ontario; 1993.
McIntyre JS, Zarin DA, Pincus AJ. The role of psychotherapy and the treatment of depression: review of two practice guidelines. Arch Gen Psychiatry. 1996;53:291–3.
Wells KB, Sturm R. Care for depression in a changing environment. Health Aff (Millwood). 1995;14(3):78–89.
World Health Organization. Composite International Diagnostic Interview. Geneva, Switzerland: World Health Organization; 1990. Report No. CIDI, Version 1.0.
Leaf PJ, Livingston MM, Tischler GL, Weissman MM, Holzer CE, Myers JK. Contact with health professionals for the treatment of psychiatric and emotional problems. Med Care. 1985;23:1322–37.
Wells KB, Manning WG, Duan N, Newhouse JP, Ware JE Jr. Sociodemographic factors and the use of outpatient mental health services. Med Care. 1986;24(1):75–85.
Aday LA. Indicators and predictors of health services utilization. In: Williams SJ, Torrens PR, eds. Introduction to Health Services. 4th ed. Albany, NY: Delmar Publishers Inc.; 1993:59.
Leaf PJ, Bruce ML, Tischler GL, et al. Factors affecting the utilization of speciality and general medical mental health services. Med Care. 1988;26:9–26.
Organization for Economic Cooperation and Development. National Accounts: Main Aggregates I. Paris, France: Organization for Economic Cooperation and Development; 1992:157.
Katz SJ, Kessler RC, Frank RG, Leaf P, Lin B. Mental health service use and socioeconomic status in the United States and Ontario. Inquiry. 1997;34(1):38–49.
Binder DA. On the variances of asymptomatically normal estimators from complex surveys. Int Stat Rev. 1983;51:279–92.
Graling PR, Grant JM. Demographics and patient treatment choice in stage I breast cancer. AORN J. 1995;62(3):376–84.
Narrow WE, Regier DA, Rae DS, Manderscheid RW, Locke BZ. Use of services by persons with mental and addictive disorders: findings from the National Institute of Mental Health epidemiologic catchment area program. Arch Gen Psychiatry. 1993;50:95–107.
Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The defacto U.S. addictive disorders service system: ECA prospective one-year prevalence and service use rates. Arch Gen Psychiatry. 1993;50:85–94.
Katz SJ, Kessler RC, Frank RG, Leaf P, Lynn B, Edlund M. The use of outpatient mental health services in the United States and Ontario: the impact of mental health morbidity and perceived need for care. Am J Pub Health. 1997;87:1136–43.
Kessler RC, Frank RG, Edlund N, Katz SJ, Lynn B, Leaf P. Differences in the use of psychiatric outpatient services between United States and Ontario. N Engl J Med. 1997;336:551–7.
Klerman GL, Olfson M, Leon AC, Weisman MM. Measuring the need for mental health care. Health Aff (Millwood). 1992;11(3):23–33.
Wells KB, Katon W, Rogers B, Camp P. Use of minor tranquilizers and antidepressant medications by depressed outpatients: results from the medical outcomes study. Am J Psychiatry. 1994;151(5):694–700.
Persons JB, Thase ME, Crits-Christoph P. The role of pyschotherapy in the treatment of depression: review of true practice guidelines. Arch Gen Psychiatry. 1996;53(4):283–90.
Katon W, Von Korff M, Lynn E. et al. Adequacy and duration of anti-depressant treatment in primary care. Med Care. 1992;30:67–76.
Perez-Stable EJ, Miranda J, Munoz RF, Ying YW. Depression in medical outpatients. Underrecognition and misdiagnosis. Arch Intern Med. 1990;150(5):1083–8.
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