 |
|
National Trends in the Outpatient Treatment of Depression
Mark Olfson, MD,MPH;
Steven C. Marcus, PhD;
Benjamin Druss, MD;
Lynn Elinson, PhD;
Terri Tanielian, MA;
Harold Alan Pincus, MD
JAMA. 2002;287:203-209.
ABSTRACT
| |
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.
INTRODUCTION
Depressive disorders are highly prevalent in the United States.1-2 Results from 2 large community-based mental health surveys, the National Institute of Mental Health Epidemiologic Catchment Area (ECA) survey (1980-1982) and the National Comorbidity Survey (NCS) (1990-1992), suggest that the 1-year prevalence of major depression in the adult population is between 5.0%1 and 10.3%.2 Cross-national epidemiologic research further suggests that major depression is common in Europe, Canada, New Zealand, and, to a lesser extent, Taiwan and Korea.3
Depressive disorders often impair social, occupational, and role functions.4-6 The detrimental effects of depression on quality of life and daily function match those of heart disease and exceed those of diabetes, arthritis, and peptic ulcer disease.7 According to the Global Burden of Disease Study,8 unipolar major depression is the fourth leading cause of worldwide disability and is expected to become the second leading cause by 2020.
Controlled clinical trials demonstrate that antidepressants and some psychotherapies significantly reduce the symptoms of depression.9-11 Antidepressant medications are clinically effective across the full range of severity of major depressive disorders.12-13 In addition, specific forms of time-limited psychotherapy are as effective as antidepressants for mild to moderate depressions.13-14
Most individuals with depression receive no treatment for their symptoms.1, 15-16 According to a recent report of the surgeon general, promoting treatment for people with depression is an even more significant problem than developing more effective treatments.17 In comparison to the extensive literature on the efficacy of psychotherapy and pharmacologic treatments, remarkably little is known about access to treatment for depression and the treatment experiences of those who gain access. The late 1980s and first half of the 1990s was a period of significant change in the delivery of mental health services, including the growth of managed care and the development of selective serotonin reuptake inhibitor (SSRI) medications. Given these changes, there is a dearth of information regarding changes over time in characteristics of persons treated for depression.
In this article, we examine national trends in the care of outpatients with depression using data from the 1987 National Medical Expenditure Survey (NMES) and the 1997 Medical Expenditure Panel Survey (MEPS). These surveys provide large, nationally representative samples and use methods that permit comparisons to be made across the 2 points in time.
METHODS
Sources of Data
Data were drawn from the household component of the 1987 NMES18 and 1997 MEPS.19 Both surveys were sponsored by the Agency for Healthcare Research and Quality to provide national estimates of the use, expenditures, and financing of health services. The NMES and MEPS were conducted as national probability samples of the US civilian, noninstitutionalized population and were designed to provide nationally representative estimates to be compared over time.
Study Samples
The 1987 NMES used a sampling design in which 15 590 households were selected from within 165 geographic regions across the United States. A sample of 34 459 individuals was included in the study, representing a response rate of 80.1%. The 1997 MEPS household component was drawn from a nationally representative subsample of the 1995 National Health Interview Survey, which used a sampling design similar to that of the 1987 NMES. A sample of 32 636 participants from 14 147 households was interviewed. This represents a 74.1% response rate. For both surveys, a designated informant was queried about all related persons who lived in the household.
The Agency for Healthcare Research and Quality devised weights to adjust for the complex survey design and yield unbiased national estimates. The sampling weights also adjust for nonresponse and poststratification to population totals based on US census data. More complete discussions of the design, sampling, and adjustment methods are presented elsewhere.19-20
Structure of Survey
Households selected for the 1987 NMES household survey were interviewed 4 times to obtain health care utilization information for the 1987 calendar year.18 The 1997 MEPS included a series of 3 in-person interviews for 1997.19 In both surveys, respondents were asked to record medical events as they occurred in a calendar or diary, which was reviewed in-person during each interview. Written permission was obtained from survey participants to contact medical practitioners they or household members reported seeing during the survey period to verify service use, medications, charges, and sources and amounts of payment. Verification procedures were implemented for all pharmacy purchases, health maintenance organization visits, and outpatient hospital visits and for half of office-based visits.
Visits for Depression
Respondents were asked the reason for every outpatient visit during the reference period. Conditions were recorded by interviewers as verbatim text and then subsequently coded by professional coders according to the International Classification of Diseases, Ninth Revision (ICD-9), as revised for the National Health Interview Survey.21 Interviewers each underwent 80 hours of training, and coders all had degrees in nursing or medical record administration. A total of 5% of records were rechecked for errors; error rates in these rechecks were less than 2.5%. A staff psychiatric nurse established mental disorder diagnoses in cases of diagnostic ambiguity or uncertainty. Respondents who made 1 or more outpatient visits coded for the purpose of major depressive disorder, single episode (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV]/ICD-9 code 296.2); major depressive disorder, recurrent (DSM-IV/ICD-9 code 296.3); dysthymic disorder (DSM-IV/ICD-9 code 300.4); or depressive disorder, not otherwise specified (DSM-IV/ICD-9 code 311) were defined as having received treatment for depression.
Health Care Practitioners
The MEPS and NMES booklets solicit information on the type of health care professionals providing treatment at each visit. We classified health care professionals into the following groups: physicians of all specialties (a breakdown by physician specialty was not available for 1997), social workers, psychologists, and a residual group of other providers that included nurses, nurse practitioners, physician assistants, chiropractors, and other health care practitioners.
Psychotherapy
The NMES and MEPS asked respondents the type of care provided during each outpatient visit using a flash card with various response categories. Visits that included a specific indication that "psychotherapy/mental health counseling" was provided are considered psychotherapy visits.
Medications
The NMES and MEPS asked for all prescribed medicines associated with each health care visit. Respondents were asked to supply the names of any prescribed medications purchased or otherwise obtained, the first and last dates taken, the number of times obtained, and the conditions associated with each medicine. We focus on prescribed psychotropic medications associated with visits for the treatment of depression. Psychotropic medications were classified as antidepressants, anxiolytics, antipsychotics, mood stabilizers, or stimulants according to the 1997 Physicians' Desk Reference.22 A subcategory of antidepressants was created for SSRIs that included fluoxetine hydrochloride, sertraline hydrochloride, paroxetine, and fluvoxamine maleate. A subcategory of newer antipsychotics included clozapine, olanzapine, and risperidone.
Analysis Plan
Rates of treatment for depression per 100 persons for each survey year were computed stratified by sociodemographic characteristics. We then examined sociodemographic characteristics of respondents who reported 1 or more health care visits for depression in either survey. The  2 test was used to examine the strength of association between rates of treatment of depression within sociodemographic categories and across survey years. Wald F tests were used to identify differences in means of continuous variables between the 2 survey years. An examination was also made of treatment characteristics of individuals ("patients") who reported receiving treatment for depression in each survey year.
We used a logistic regression model to evaluate the association between survey year and psychotropic medication prescription. To adjust for changes in patient characteristics between the survey years, we controlled for respondent age, sex, race, marital status, education, employment status, and insurance status. Logistic regression models were also used to estimate the effect of survey year on rate of psychotherapy, antidepressant medication, and the combination of psychotherapy and medication treatment. A multiple linear regression model was used to evaluate the association between survey year and number of psychotherapy visits, controlling for the various sociodemographic covariates. All statistical analyses were performed using the SUDAAN software package23 to accommodate the complex sample design and the weighting of observations. The  value was set at .05 and all tests were 2-sided.
RESULTS
Rate of Treatment
Between 1987 and 1997, there was a significant increase in the overall rate of outpatient treatment of depression. The rate of treatment increased from 0.73 per 100 persons in 1987 to 2.33 in 1997 (Table 1). In contrast, there was little change during the study period in the rate within the general population of persons who received any outpatient general medical treatment (74.1% in 1987 and 72.4% in 1997).
|
|
|
|
Table 1. National Rates of Treatment of Depression in 1987 and 1997 Stratified by Sociodemographic Characteristics*
|
|
|
Sociodemographic Groups and Characteristics
A significant increase in the rate of outpatient treatment of depression occurred across all sociodemographic groups examined. As a proportion of the baseline rate of treatment, Hispanic and black persons experienced slightly larger increases than white persons (Table 1). However, the rate of outpatient treatment for Hispanics and blacks remained well below the rate of whites. The highest rates of treatment were for divorced, separated, or widowed individuals, those with at least a high school education, and unemployed persons (Table 1).
In both survey years, most patients who received outpatient treatment for depression were between 18 and 64 years of age, white, female, employed, and privately insured. Slightly less than half were married or had more than a high school education (Table 2).
|
|
|
|
Table 2. Sociodemographic Characteristics of Persons Treated for Depression in 1987 and 1997*
|
|
|
Insurance
There was a significant increase in the rate of outpatient treatment for depression regardless of insurance status. However, the rate of treatment among individuals without insurance remained below that of individuals with either private or public insurance (Table 1).
Pharmacologic Treatment
The proportion of individuals treated for depression who received a prescribed psychotropic medication increased from 44.6% in 1987 to 79.4% in 1997 (Table 3). After controlling for the possible confounding effects of sociodemographic characteristics, individuals treated for depression were 4.5 times more likely to be treated with a psychotropic medication in 1997 than in 1987 (Table 4). During this period, the proportion of pharmacy costs paid by third-party payers increased from 39.3% to 55.2% (Table 3).
|
|
|
|
Table 3. Treatment Characteristics of Persons Treated for Depression in 1987 and 1997*
|
|
|
|
|
|
|
Table 4. Adjusted Year Effect of Psychotherapy, Psychopharmacotherapy, Combined Treatment, Antidepressant Treatment, and Number of Psychotherapy Visits for Treatment of Depression*
|
|
|
Antidepressants were the most commonly prescribed medications for the treatment of depression. After adjusting for confounding sociodemographic factors, patients treated for depression were 4.8 times more likely to receive an antidepressant in 1997 than in 1987 (Table 4). The increase in antidepressant use was primarily attributable to SSRIs, a class of antidepressant medication that was unavailable in 1987. Selective serotonin reuptake inhibitors were prescribed to more than half (58.3%) of individuals who received outpatient treatment for depression in 1997.
Anxiolytics were the second most commonly prescribed class of psychotropic medication in both survey years, but were prescribed to fewer than 1 in 7 patients treated for depression. Anxiolytics were followed by mood stabilizers and antipsychotics. Stimulants were rarely prescribed (Table 3).
Psychotherapy
With the increase in rate of outpatient treatment for depression, there was a corresponding increase in the rate of psychotherapy for depression. However, among persons treated for depression, the percentage who received psychotherapy declined from 71.1% (1987) to 60.2% (1997) (Table 3). Among those who received psychotherapy, the mean annual number of psychotherapy visits declined from 12.6 visits in 1987 to 8.7 visits in 1997. This decline remained statistically significant after controlling for the effects of patient sociodemographic characteristics (Table 4). During this period, there was an increase in the proportion of psychotherapy costs borne by third-party payers (Table 3).
Combined Treatment
The proportion of patients treated for depression who received at least 1 psychotherapy visit along with a prescription for a psychotropic medication increased from 28.8% in 1987 to 48.1% in 1997. The comparable proportions who received at least 1 psychotherapy visit and a prescription for an antidepressant were 23.2% in 1987 and 45.2% in 1997. Treated patients in 1997 were almost twice as likely to receive psychotherapy and a psychotropic medication than they were in 1987 after controlling for confounding sociodemographic factors (odds ratio, 2.0) (Table 4). They were also 2.4 times more likely to receive psychotherapy and an antidepressant medication.
Provider Type
During the study period, there was a significant increase in the proportion of patients whose treatment of depression involved visits to a physician (Table 3). By 1997, more than 8 (87.3%) of 10 patients who received outpatient treatment of depression were treated by a physician compared with 68.9% in 1987. Conversely, the percentage who received treatment from psychologists declined (29.8% vs 19.1%). Treatment of depression by social workers remained little changed and relatively uncommon.
COMMENT
Significant growth occurred in the number of Americans who received treatment for depression during the past decade, and at the same time the treatments they received underwent a profound transformation. Antidepressant medications became established as a mainstay, psychotherapy sessions became less common and fewer among those receiving treatment, and physicians assumed a more prominent role. These changes suggest that access to mental health services has increased and that there has been an increased emphasis on pharmacologic treatments.
Several factors may have contributed to these trends. Beginning with the introduction of fluoxetine in late 1987 and followed by several other SSRIs and antidepressants with atypical mechanisms of action, there has been a steady broadening of the pharmacologic options available to treat depression. The new medications tend to have fewer adverse effects,24-25 require less complicated dosing regimens, and pose less danger when taken in overdose than the older tricyclic antidepressants. The comparative safety and ease of prescribing SSRIs and the other newer antidepressants may have led physicians to lower the symptom severity threshold at which they decide to prescribe an antidepressant.26 If the availability of the newer medications tipped the balance in favor of diagnosing and treating depression, this would help explain both the increase in the overall rate of treatment and the increase in the proportion of treated cases who filled prescriptions for antidepressant medications.
The pharmaceutical industry also engaged in a concerted effort to promote the increased sale of these new antidepressant medications through vigorous advertising campaigns directed at physicians, other health care professionals, and more recently the general public.27-28 In addition, medications to treat depression have been a featured topic of lead articles in national news magazines, best-selling books, and widely watched television talk shows. A new generation of screening and diagnostic instruments, developed through partnerships between industry and academia, has also become available to facilitate the rapid and efficient detection of depression in routine practice.29-31
Beginning in late 1987, the federal government embarked on a public health campaign to educate the public and the medical community about the recognition and treatment of depression.32 In 1991, the National Depression Screening Day program was inaugurated to increase awareness and treatment of depression. By 1997, there were more than 2800 screening sites in the 50 states and Canada.33 These campaigns have underscored the importance of pharmacologic treatments. In addition, there have been institutional efforts to improve the diagnosis of depression and influence physician prescribing practices through the publication of treatment guidelines.12-13
As a result of these developments, the public may have become more accepting of pharmacologic treatment of depression. According to a 1986 Roper poll,34 only 12% of respondents indicated that they would be willing to take medication for depression, whereas 78% stated they would live with the depression until it passed. An ABC News poll35 conducted in April 2000 found that 28% of adults would be willing to take antidepressants for depression for an extended period even though they were informed that safety studies had not been conducted on long-term use of these medications. This suggests that the pharmacologic treatment of depression is becoming less stigmatized.
The growth in managed mental health care and the concepts of disease management36 and medical necessity37 may have further spurred the pharmacologic treatment of depression. In many plans, comprehensive pharmacy benefits encourage medication management visits over psychotherapy visits, which are not reimbursed as generously. Managed care generally seeks to shift patient care from specialty to primary care physicians who are able and may be more likely to use pharmacologic treatments rather than psychotherapy to manage depression. In addition, mental disorders that require ongoing treatment are increasingly managed in behavioral health care "carve outs" that seek to reduce costs by lowering the number of visits per depressed individual.38-39
The comparatively low rate of treatment among black and Hispanic individuals, those with less education, and those without health insurance suggests that an unmet need for treatment may be especially great within these groups. Epidemiologic data indicate that the rate of major depression is inversely related to income and educational achievement and that depression is more common among Hispanics than whites or blacks.1, 40 These findings suggest, but cannot confirm, that individuals within these minority groups are vulnerable to undertreatment.
According to the NCS (1990-1992), 3.1% of adults 15 to 54 years of age received outpatient health care treatment in 1 year for a mood disorder.15 The earlier ECA (1980-1982) survey reported that 3.6% of adults have an affective disorder and receive mental health treatment in the health system during 1 year.1 These NCS and ECA findings exceed the corresponding findings from the NMES (1987) (0.7%). This disparity may be related to important methodologic differences between the studies. For example, although the ECA figures include treatment for any mental health or addictive symptoms by adults who meet criteria for an affective disorder, the NMES figures include only outpatient treatment reported for depression. Methodologic differences between the studies stem from underlying differences in their primary aims: to quantify psychopathology in the community (ECA and NCS) and to measure service use over time (NMES and MEPS).
One consequence of increased pharmacologic treatment of depression is that larger numbers of depressed individuals are being treated with both pharmacotherapy and psychotherapy. Recent research suggests that the combination of an antidepressant and cognitive behavioral psychotherapy is more efficacious than either treatment alone for chronic forms of major depression.41 In milder depressions, psychotherapy alone may be nearly as effective as the combination of antidepressants and psychotherapy.42 The extent to which combined treatments confer meaningful advantages over single-modality treatments in clinical practice awaits detailed longitudinal practice-based outcomes research.
The current study is constrained by several limitations. Both the NMES and MEPS collect data from household informants who may not be fully aware of all of the services used by household members. Stigma, recall problems, and problems distinguishing the different provider groups pose threats to the reporting and classification of the survey data. Some respondents, especially those with less education, may not be able to identify "psychotherapy/mental health counseling" when they receive it. Without an independent measure of symptoms, it is not possible to determine whether patients who received treatment actually met diagnostic criteria for the selected conditions. Finally, the 1997 survey did not break out providers by physician specialty, thereby limiting our ability to determine whether the observed changes in treatment patterns occurred primarily in the general medical or specialty mental health sector.
In recent years, a growing number of Americans have received treatment for depression. During this period, antidepressant medications have gained popularity and physicians have extended their involvement in care. For the promise of increased access to treatment to be fully realized, available treatments must be provided in a safe, timely, and effective manner. An important challenge ahead is to characterize the community treatment of depression with greater specificity and relate variations in these treatments to critical patient outcomes.
AUTHOR INFORMATION
Author Contributions: Study concept and design: Olfson, Marcus, Druss, Elinson, Pincus.
Analysis and interpretation of data: Olfson, Marcus, Druss, Tanielian, Pincus.
Drafting of the manuscript: Olfson.
Critical revision of the manuscript for important intellectual content: Olfson, Marcus, Druss, Elinson, Tanielian.
Statistical expertise: Marcus.
Obtained funding: Pincus.
Administrative, technical, or material support: Tanielian.
Study supervision: Olfson, Pincus.
Funding/Support: Preparation of this article was assisted by a grant from The Robert Wood Johnson Foundation, Princeton, NJ.
Acknowledgment: We would like to thank Nancy A. Krauss, Agency for Healthcare Research and Quality/Center for Cost and Financing, for providing technical assistance with this project.
Corresponding Author and Reprints: Mark Olfson, MD, MPH, Department of Psychiatry, New York State Psychiatric Institute, College of Physicians and Surgeons of Columbia University, 1051 Riverside Dr, New York, NY 10032 (e-mail: olfsonm{at}child.cpmc.columbia.edu).
Author Affiliations: Department of Psychiatry, New York State Psychiatric Institute, College of Physicians and Surgeons of Columbia University, New York City (Dr Olfson); University of Pennsylvania School of Social Work, Philadelphia (Dr Marcus); Department of Psychiatry, Yale University School of Medicine, New Haven, Conn (Dr Druss); and National Institute of Occupational Safety and Health, Pittsburgh Research Laboratory (Dr Elinson), RAND Corporation (Ms Tanielian and Dr Pincus), and Department of Psychiatry, University of Pittsburgh (Dr Pincus), Pittsburgh, Pa.
REFERENCES
| |
1. Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto US mental and addictive disorders service system: Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry. 1993;50:85-94.
FREE FULL TEXT
2. 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;51:8-19.
FREE FULL TEXT
3. Weissman MM, Bland RC, Canino GJ, et al. Cross-national epidemiology of major depression and bipolar disorder. JAMA. 1996;276:293-299.
FREE FULL TEXT
4. Wells KB, Sherbourne CD. Functioning and utility for current health of patients with depression or chronic medical conditions in managed, primary care practices. Arch Gen Psychiatry. 1999;56:897-904.
FREE FULL TEXT
5. Hirschfeld RM, Montgomery SA, Keller MB, et al. Social functioning in depression: a review. J Clin Psychiatry. 2000;61:268-275.
ISI
| PUBMED
6. Spitzer RL, Kroenke K, Linzer M, et al. Health-related quality of life in primary care patients with mental disorders: results from the PRIME-MD 1000 Study. JAMA. 1995;274:1511-1517.
FREE FULL TEXT
7. Wells KB, Stewart A, Hays RD, et al. The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA. 1989;262:914-919.
FREE FULL TEXT
8. Murray CJ, Lopez AD. Evidence-based health policy-lessons from the Global Burden of Diesease Study. Science. 1996;274:740-743.
FREE FULL TEXT
9. Nelson JC. A review of the efficacy of serotonergic and noradrenergic reuptake inhibitors for treatment of major depression. Biol Psychiatry. 1999;46:1301-1308.
FULL TEXT
|
ISI
| PUBMED
10. Schatzberg AF. Noradrenergic versus serotonergic antidepressants: predictors of treatment response. J Clin Psychiatry. 1998;59(suppl 14):15-18.
11. Markowitz JC. Developments in interpersonal psychotherapy. Can J Psychiatry. 1999;44:556-561.
ISI
| PUBMED
12. American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder (revision). Am J Psychiatry. 2000;157(suppl):1-45.
13. Depression Guideline Panel. Depression in Primary Care, Volume 2: Treatment of Major Depression. Rockville, Md: Public Health Service, US Dept of Health and Human Services; 1993. AHCPR publication 93-0551.
14. Persons JB, Thase ME, Crits-Christoph P. The role of psychotherapy in the treatment of depression: review of two practice guidelines. Arch Gen Psychiatry. 1996;53:283-290.
FREE FULL TEXT
15. Kessler RC, Zhao S, Katz SJ, et al. Past-year use of outpatient services for psychiatric problems in the National Comorbidity Survey. Am J Psychiatry. 1999;156:115-123.
FREE FULL TEXT
16. 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.
FREE FULL TEXT
17. Mental Health: A Report of the Surgeon General. 2000. Available at: http://www.surgeongeneral.gov/library/mentalhealth/home.html. Accessed July 25, 2001.
18. Edwards WS, Berlin M. National Medical Expenditure Survey: Questionnaires and Data Collection Methods for the Household Survey and Survey of American Indians and Alaska Natives. Washington, DC: US Dept of Health and Human Services; 1989. Publication (PHS) 89-3450.
19. Cohen SB. Sample Design of the 1997 Medical Expenditure Panel Survey Household Component. Rockville, Md: Agency for Healthcare Research and Quality; 2000. MEPS Methodology Report 11. AHRQ publication 01-0001.
20. Cohen S, DiGaetano R, Waksberg J. Sample Design of the 1987 Household Survey, National Medical Expenditure Survey Methods 3. Rockville, Md: Agency for Healthcare Research and Quality; 1991. AHCPR publication 91-0037.
21. International Classification of Diseases, Ninth Revision, Clinical Modification. Washington, DC: Public Health Service, US Dept of Health and Human Services; 1988.
22. Physicians' Desk Reference. Montvale, NJ: Medical Economics Co Inc; 1997.
23. Shah BV, Barnwell BG, Dieler GS. SUDAAN User's Manual, Release 7.5. Research Triangle Park, NC: Research Triangle Institute; 1997.
24. Peretti S, Judge R, Hindmarch I. Safety and tolerability considerations: tricyclic antidepressants vs selective serotonin reuptake inhibitors. Acta Psychiatr Scand Suppl. 2000;403(suppl):17-25.
25. Trindade E, Menon D, Topfer LA, Coloma C. Adverse effects associated with selective serotonin reuptake inhibitors and tricyclic antidepressants: a meta-analysis. CMAJ. 1998;159:1245-1252.
ABSTRACT
26. Olfson M, Marcus SC, Pincus HA, Zito JM, Thompson JW, Zarin DA. Antidepressant prescribing practices of outpatient psychiatrists. Arch Gen Psychiatry. 1998;55:310-316.
FREE FULL TEXT
27. Nikelly AG. Drug advertisements and the medicalization of unipolar depression in women. Health Care Women Int. 1995;16:229-242.
PUBMED
28. Goldman R, Montagne M. Marketing "mind mechanics": decoding antidepressant advertisements. Soc Sci Med. 1986;22:1047-1058.
FULL TEXT
|
ISI
| PUBMED
29. Spitzer RL, Williams JB, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study. JAMA. 1994;272:1749-1756.
FREE FULL TEXT
30. Leon AC, Olfson M, Weissman MM, et al. Brief screens for mental disorders in primary care. J Gen Intern Med. 1996;11:426-430.
ISI
| PUBMED
31. Zimmerman M, Lish JD, Farber NJ, et al. Screening for depression in medical patients. Is the focus too narrow? Gen Hosp Psychiatry. 1994;16:388-396.
FULL TEXT
|
ISI
| PUBMED
32. Regier DA, Hirschfeld RM, Goodwin FK, Burke JF, Lazar JB, Judd LL. The NIMH Depression Awareness, Recognition, and Treatment Program: structure, aims, and scientific basis. Am J Psychiatry. 1988;145:1351-1357.
FREE FULL TEXT
33. Greenfield SF, Reizes JM, Muenz LR, Kopans B, Kozloff RC, Jacobs DG. Treatment for depression following the 1996 National Depression Screening Day. Am J Psychiatry. 2000;157:1867-1869.
FREE FULL TEXT
34. Roper Reports: To Medicate: What People Do for Minor Health Problems. New York, NY: Roper Organization; October 1986. Roper Reports 86-88.
35. Langer F. Use of anti-depressants is a long-term practice. April 10, 2000. Available at: http://abcnews.com. Accessed December 17, 2000.
36. Kihlstrom LC. Managed care and medication compliance: implications for chronic depression. J Behav Health Serv Res. 1998;25:367-376.
FULL TEXT
|
ISI
| PUBMED
37. Dana RH, Conner MG, Allen J. Quality of care and cost-containment in managed mental health: policy, education, research, advocacy. Psychol Rep. 1996;79:1395-1422.
ISI
| PUBMED
38. Frank RG, Huskamp HA, McGuire TG, Newhouse JP. Some economics of mental health "carve-outs." Arch Gen Psychiatry. 1996;53:933-937.
FREE FULL TEXT
39. Sturm R. Tracking changes in behavioral health services: how have carve-outs changed care? J Behav Health Serv Res. 1999;26:360-371.
FULL TEXT
|
ISI
| PUBMED
40. Blazer DG, Kessler RC, McGonagle KA, Swartz MS. The prevalence and distribution of major depression in a National Community Sample: the National Comorbidity Survey. Am J Psychiatry. 1994;151:979-986.
FREE FULL TEXT
41. Keller MB, McCullough JP, Klein DN, et al. A comparison of nefazadone, the cognitive-behavioral analysis system of psychotherapy, and their combination for the treatment of chronic depression. N Engl J Med. 2000;342:1462-1470.
FREE FULL TEXT
42. Thase ME, Greenhouse JB, Frank E, et al. Treatment of major depression with psychotherapy or psychotherapy-pharmacotherapy combinations. Arch Gen Psychiatry. 1997;54:1009-1015.
FREE FULL TEXT
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati  Twitter
What's this?
RELATED LETTER
Changes in the Treatment of Depression in the United States: 1987-1997
William Rifkin, David Lester, Mark Olfson, Steven Marcus, Benjamin Druss, Teri Tanielian, and Harold Alan Pincus
JAMA. 2002;287(14):1803-1804.
EXTRACT
| FULL TEXT
RELATED ARTICLE
January 9, 2002
JAMA. 2002;287(2):255-256.
EXTRACT
| FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Explaining the rise in antidepressant prescribing: a descriptive study using the general practice research database
Moore et al.
BMJ 2009;339:b3999-b3999.
ABSTRACT
| FULL TEXT
Americans' Attitudes Toward Psychiatric Medications: 1998-2006
Mojtabai
Psychiatr. Serv. 2009;60:1015-1023.
ABSTRACT
| FULL TEXT
Trends in Mental Health Admissions to Nursing Homes, 1999-2005
Fullerton et al.
Psychiatr. Serv. 2009;60:965-971.
ABSTRACT
| FULL TEXT
Stigma: a social, cultural and moral process
Kleinman and Hall-Clifford
J. Epidemiol. Community Health 2009;63:418-419.
FULL TEXT
Planning the Future Mental Health Workforce: With Progress on Coverage, What Role Will Psychiatrists Play?
Vernon et al.
Acad. Psychiatry 2009;33:187-192.
FULL TEXT
Trends in Antidepressant Utilization From 2001 to 2004
Harman et al.
Psychiatr. Serv. 2009;60:611-616.
ABSTRACT
| FULL TEXT
Service Implications of Providing Intensive Monitoring During High-Risk Periods for Suicide Among VA Patients With Depression
Valenstein et al.
Psychiatr. Serv. 2009;60:439-444.
ABSTRACT
| FULL TEXT
Unmet Need for Treatment of Major Depression in the United States
Mojtabai
Psychiatr. Serv. 2009;60:297-305.
ABSTRACT
| FULL TEXT
Changing Perceptions of Depression: Ten-Year Trends From the General Social Survey
Blumner and Marcus
Psychiatr. Serv. 2009;60:306-312.
ABSTRACT
| FULL TEXT
Adherence to Practice Guidelines, Clinical Outcomes, and Costs Among Medicaid Enrollees With Severe Mental Illnesses
Stiles et al.
Eval Health Prof 2009;32:69-89.
ABSTRACT
Use Of Medical Care For Chronic Conditions
Decker et al.
Health Aff (Millwood) 2009;28:26-35.
ABSTRACT
| FULL TEXT
Persistent Depression and Anxiety in the United States: Prevalence and Quality of Care
Young et al.
Psychiatr. Serv. 2008;59:1391-1398.
ABSTRACT
| FULL TEXT
Mental Health of College Students and Their Non-College-Attending Peers: Results From the National Epidemiologic Study on Alcohol and Related Conditions
Blanco et al.
Arch Gen Psychiatry 2008;65:1429-1437.
ABSTRACT
| FULL TEXT
Pharmacologic Treatment of Posttraumatic Stress Disorder Among Privately Insured Americans
Harpaz-Rotem et al.
Psychiatr. Serv. 2008;59:1184-1190.
ABSTRACT
| FULL TEXT
Predictors of Major Depression Six Months After Admission for Outpatient Treatment
Weinberger et al.
Psychiatr. Serv. 2008;59:1211-1215.
ABSTRACT
| FULL TEXT
National Trends in Psychotherapy by Office-Based Psychiatrists
Mojtabai and Olfson
Arch Gen Psychiatry 2008;65:962-970.
ABSTRACT
| FULL TEXT
Prevalence, Correlates, Disability, and Comorbidity of DSM-IV Alcohol Abuse and Dependence in the United States: Results From the National Epidemiologic Survey on Alcohol and Related Conditions
Hasin et al.
Arch Gen Psychiatry 2007;64:830-842.
ABSTRACT
| FULL TEXT
Americans' Attitudes Toward Mental Health Treatment Seeking: 1990-2003
Mojtabai
Psychiatr. Serv. 2007;58:642-651.
ABSTRACT
| FULL TEXT
Cognitive Therapy and Interpersonal Psychotherapy: 30 Years Later
Weissman
Am. J. Psychiatry 2007;164:693-696.
FULL TEXT
Trends in the Use of Psychotropic Drugs in Taiwan: A Population-Based National Health Insurance Study, 1997-2004
Chien et al.
Psychiatr. Serv. 2007;58:554-557.
ABSTRACT
| FULL TEXT
Major Depression Symptoms in Primary Care and Psychiatric Care Settings: A Cross-Sectional Analysis
Gaynes et al.
Ann Fam Med 2007;5:126-134.
ABSTRACT
| FULL TEXT
Changes in the Quality of Care for Bipolar I Disorder During the 1990s
Busch et al.
Psychiatr. Serv. 2007;58:27-33.
ABSTRACT
| FULL TEXT
Antidepressant Utilization in British Columbia From 1996 to 2004: Increasing Prevalence but Not Incidence
Raymond et al.
Psychiatr. Serv. 2007;58:79-84.
ABSTRACT
| FULL TEXT
Correlates of Past-Year Mental Health Service Use Among Latinos: Results From the National Latino and Asian American Study
Alegria et al.
AJPH 2007;97:76-83.
ABSTRACT
| FULL TEXT
US Suicide Rates by Age Group, 1970-2002: An Examination of Recent Trends
McKeown et al.
AJPH 2006;96:1744-1751.
ABSTRACT
| FULL TEXT
Three decades of antidepressant, anxiolytic and hypnotic use in a national population birth cohort
Colman et al.
Br. J. Psychiatry 2006;189:156-160.
ABSTRACT
| FULL TEXT
Changing Profiles of Service Sectors Used for Mental Health Care in the United States
Wang et al.
Am. J. Psychiatry 2006;163:1187-1198.
ABSTRACT
| FULL TEXT
TREAD: TReatment with Exercise Augmentation for Depression: study rationale and design
Trivedi et al.
Clin Trials 2006;3:291-305.
ABSTRACT
Preparing for preventive clinical trials: the Predict-HD study.
Paulsen et al.
Arch Neurol 2006;63:883-890.
ABSTRACT
| FULL TEXT
Self-injurious behaviors in a college population.
Whitlock et al.
Pediatrics 2006;117:1939-1948.
ABSTRACT
| FULL TEXT
Treatment Seeking for Depression in Canada and the United States
Mojtabai and Olfson
Psychiatr. Serv. 2006;57:631-639.
ABSTRACT
| FULL TEXT
Child Maltreatment Trends in the 1990s: Why Does Neglect Differ From Sexual and Physical Abuse?
Jones et al.
Child Maltreat 2006;11:107-120.
ABSTRACT
Sertraline for Prevention of Depression Recurrence in Diabetes Mellitus: A Randomized, Double-blind, Placebo-Controlled Trial.
Lustman et al.
Arch Gen Psychiatry 2006;63:521-529.
ABSTRACT
| FULL TEXT
Patterns of Adult Psychotherapy in Psychiatric Practice
Wilk et al.
Psychiatr. Serv. 2006;57:472-476.
ABSTRACT
| FULL TEXT
Inequity in Mental Health Care Under Canadian Universal Health Coverage
Steele et al.
Psychiatr. Serv. 2006;57:317-324.
ABSTRACT
| FULL TEXT
Implications of part d for mentally ill dual eligibles: a challenge for medicare.
Morden and Garrison
Health Aff (Millwood) 2006;25:491-500.
ABSTRACT
| FULL TEXT
Datapoints: Antidepressant Medication Use in Private Insurance Health Plans, 2002
Larson et al.
Psychiatr. Serv. 2006;57:175-175.
FULL TEXT
Predictors of Adequacy of Depression Management in the Primary Care Setting
Joo et al.
Psychiatr. Serv. 2005;56:1524-1528.
ABSTRACT
| FULL TEXT
Demand for Mental Health Care and Changes in Service Use Patterns in the Netherlands, 1979 to 1995
ten Have et al.
Psychiatr. Serv. 2005;56:1409-1415.
ABSTRACT
| FULL TEXT
Trends in Contacts With Mental Health Professionals and Cost Barriers to Mental Health Care Among Adults With Significant Psychological Distress in the United States: 1997-2002
Mojtabai
AJPH 2005;95:2009-2014.
ABSTRACT
| FULL TEXT
The Rise In Health Care Spending And What To Do About It
Thorpe
Health Aff (Millwood) 2005;24:1436-1445.
ABSTRACT
| FULL TEXT
The Impacts Of Mental Health Parity And Managed Care In One Large Employer Group: A Reexamination
Zuvekas et al.
Health Aff (Millwood) 2005;24:1668-1671.
ABSTRACT
| FULL TEXT
The Prevalence of DSM-IV Personality Disorders in Psychiatric Outpatients
Zimmerman et al.
Am. J. Psychiatry 2005;162:1911-1918.
ABSTRACT
| FULL TEXT
Efficacy and Safety of Second-Generation Antidepressants in the Treatment of Major Depressive Disorder
Hansen et al.
ANN INTERN MED 2005;143:415-426.
ABSTRACT
| FULL TEXT
Prevalence and Treatment of Mental Disorders, 1990 to 2003
Kessler et al.
NEJM 2005;352:2515-2523.
ABSTRACT
| FULL TEXT
Education and Training in Psychopharmacology
Blanco et al.
Acad. Psychiatry 2005;29:124-127.
FULL TEXT
Failure and Delay in Initial Treatment Contact After First Onset of Mental Disorders in the National Comorbidity Survey Replication
Wang et al.
Arch Gen Psychiatry 2005;62:603-613.
ABSTRACT
| FULL TEXT
Twelve-Month Use of Mental Health Services in the United States: Results From the National Comorbidity Survey Replication
Wang et al.
Arch Gen Psychiatry 2005;62:629-640.
ABSTRACT
| FULL TEXT
Trends in Suicide Ideation, Plans, Gestures, and Attempts in the United States, 1990-1992 to 2001-2003
Kessler et al.
JAMA 2005;293:2487-2495.
ABSTRACT
| FULL TEXT
Depression, Correlates of Depression, and Receipt of Depression Care Among Low-Income Women With Breast or Gynecologic Cancer
Ell et al.
JCO 2005;23:3052-3060.
ABSTRACT
| FULL TEXT
Economic Grand Rounds: Access to Psychiatrists in the Public Sector and in Managed Health Plans
Wilk et al.
Psychiatr. Serv. 2005;56:408-410.
FULL TEXT
An Economic Evaluation of Inpatient Residential Treatment Programs in the Department of Veterans Affairs
Wagner and Chen
Med Care Res Rev 2005;62:187-204.
ABSTRACT
Depression Treatment in Primary Care
Robinson et al.
J Am Board Fam Med 2005;18:79-86.
ABSTRACT
| FULL TEXT
Screening for Bipolar Disorder in a Primary Care Practice
Das et al.
JAMA 2005;293:956-963.
ABSTRACT
| FULL TEXT
The Relationship Between Antidepressant Medication Use and Rate of Suicide
Gibbons et al.
Arch Gen Psychiatry 2005;62:165-172.
ABSTRACT
| FULL TEXT
Trends in Diagnosis Rates for Autism and ADHD at Hospital Discharge in the Context of Other Psychiatric Diagnoses
Mandell et al.
Psychiatr. Serv. 2005;56:56-62.
ABSTRACT
| FULL TEXT
Patterns and Quality of Treatment for Patients With Major Depressive Disorder in Routine Psychiatric Practice
West et al.
Focus 2005;3:43-50.
FULL TEXT
Prescription Drugs And The Changing Patterns Of Treatment For Mental Disorders, 1996-2001
Zuvekas
Health Aff (Millwood) 2005;24:195-205.
ABSTRACT
| FULL TEXT
Cost-Utility Analysis Studies of Depression Management: A Systematic Review
Pirraglia et al.
Am. J. Psychiatry 2004;161:2155-2162.
ABSTRACT
| FULL TEXT
Antidepressants, Suicide, and the FDA: A Loose Association
Finley
The Annals of Pharmacotherapy 2004;38:1739-1742.
FULL TEXT
Telephone Psychotherapy and Telephone Care Management for Primary Care Patients Starting Antidepressant Treatment: A Randomized Controlled Trial
Simon et al.
JAMA 2004;292:935-942.
ABSTRACT
| FULL TEXT
Which Factors Influence Psychiatrists' Selection of Antidepressants?
Zimmerman et al.
Am. J. Psychiatry 2004;161:1285-1289.
ABSTRACT
| FULL TEXT
Treatment Of People With Mental Illness: A Decade-Long Perspective
Mechanic and Bilder
Health Aff (Millwood) 2004;23:84-95.
ABSTRACT
| FULL TEXT
Treatment of Depression in Cancer
Fisch
J Natl Cancer Inst Monogr 2004;2004:105-111.
ABSTRACT
| FULL TEXT
Datapoints: Patients' Early Discontinuation of Antidepressant Prescriptions
Lewis et al.
Psychiatr. Serv. 2004;55:494-494.
FULL TEXT
Exploratory Evidence on the Market for Effective Depression Care in Pittsburgh
Schoenbaum et al.
Psychiatr. Serv. 2004;55:392-395.
ABSTRACT
| FULL TEXT
Benzodiazepine Use Among Depressed Patients Treated in Mental Health Settings
Valenstein et al.
Am. J. Psychiatry 2004;161:654-661.
ABSTRACT
| FULL TEXT
Self-Reported Depression and Use of Antidepressants After Stroke: A National Survey
Eriksson et al.
Stroke 2004;35:936-941.
ABSTRACT
| FULL TEXT
Paroxetine-Induced Hyponatremia in Older Adults: A 12-Week Prospective Study
Fabian et al.
Arch Intern Med 2004;164:327-332.
ABSTRACT
| FULL TEXT
Economic Grand Rounds: Financial Disincentives for the Provision of Psychotherapy
West et al.
Psychiatr. Serv. 2003;54:1582-1588.
FULL TEXT
Pattern of antidepressant use and duration of depression-related absence from work
Dewa et al.
Br. J. Psychiatry 2003;183:507-513.
ABSTRACT
| FULL TEXT
Recognition and Treatment of Depression in Parkinson's Disease
Weintraub et al.
J Geriatr Psychiatry Neurol 2003;16:178-183.
ABSTRACT
Increased Medical Costs of a Population-Based Sample of Depressed Elderly Patients
Katon et al.
Arch Gen Psychiatry 2003;60:897-903.
ABSTRACT
| FULL TEXT
The Occupational Transformation Of The Mental Health System
Scheffler and Kirby
Health Aff (Millwood) 2003;22:177-188.
ABSTRACT
| FULL TEXT
Trends In Medication Use And Functioning Before Retirement Age: Are They Linked?
Freedman and Aykan
Health Aff (Millwood) 2003;22:154-162.
ABSTRACT
| FULL TEXT
The Epidemiology of Major Depressive Disorder: Results From the National Comorbidity Survey Replication (NCS-R)
Kessler et al.
JAMA 2003;289:3095-3105.
ABSTRACT
| FULL TEXT
Cost of Lost Productive Work Time Among US Workers With Depression
Stewart et al.
JAMA 2003;289:3135-3144.
ABSTRACT
| FULL TEXT
Depression--A Cardiac Risk Factor in Search of a Treatment
Frasure-Smith and Lesperance
JAMA 2003;289:3171-3173.
FULL TEXT
Mental Health Services Received by Depressed Persons Who Visited General Practitioners and Family Doctors
Wang et al.
Psychiatr. Serv. 2003;54:878-883.
ABSTRACT
| FULL TEXT
Fluoxetine Versus Placebo in Advanced Cancer Outpatients: A Double-Blinded Trial of the Hoosier Oncology Group
Fisch et al.
JCO 2003;21:1937-1943.
ABSTRACT
| FULL TEXT
Use of Antidepressants Among Canadian Workers Receiving Depression-Related Short-Term Disability Benefits
Dewa et al.
Psychiatr. Serv. 2003;54:724-729.
ABSTRACT
| FULL TEXT
Who Shall Lead: Is There a Future for Population Health?
Mechanic
Journal of Health Politics, Policy and Law 2003;28:421-442.
ABSTRACT
Use of Psychotropic Medications Among HIV-Infected Patients in the United States
Vitiello et al.
Am. J. Psychiatry 2003;160:547-554.
ABSTRACT
| FULL TEXT
The Future of Behavioral Health and Primary Care: Drowning in the Mainstream or Left on the Bank?
Pincus
Psychosomatics 2003;44:1-11.
FULL TEXT
Collaborative Care Management of Late-Life Depression in the Primary Care Setting: A Randomized Controlled Trial
Unutzer et al.
JAMA 2002;288:2836-2845.
ABSTRACT
| FULL TEXT
A Three-Component Model for Reengineering Systems for the Treatment of Depression in Primary Care
Oxman et al.
Psychosomatics 2002;43:441-450.
ABSTRACT
| FULL TEXT
Clinical Computing: The Diffusion of Innovations Into Psychiatric Practice
Freedman
Psychiatr. Serv. 2002;53:1539-1540.
FULL TEXT
Mental Health Service Use Among Adult Cancer Survivors: Analyses of the National Health Interview Survey
Hewitt and Rowland
JCO 2002;20:4581-4590.
ABSTRACT
| FULL TEXT
National Trends in the Use of Outpatient Psychotherapy
Olfson et al.
Am. J. Psychiatry 2002;159:1914-1920.
ABSTRACT
| FULL TEXT
Resolvins: A Family of Bioactive Products of Omega-3 Fatty Acid Transformation Circuits Initiated by Aspirin Treatment that Counter Proinflammation Signals
Serhan et al.
JEM 2002;196:1025-1037.
ABSTRACT
| FULL TEXT
Changes in the Treatment of Depression in the United States: 1987-1997
Rifkin et al.
JAMA 2002;287:1803-1804.
FULL TEXT
Placebo Response in Studies of Major Depression: Variable, Substantial, and Growing
Walsh et al.
JAMA 2002;287:1840-1847.
ABSTRACT
| FULL TEXT
Placebo in Clinical Trials for Depression: Complexity and Necessity
Kupfer and Frank
JAMA 2002;287:1853-1854.
FULL TEXT
Americans More Willing To Seek Out Treatment
Kupersanin
Psychiatr. News 2002;37:1-30.
FULL TEXT
|
