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The Quality of Care for Depressive and Anxiety Disorders in the United States
Alexander S. Young, MD, MSHS;
Ruth Klap, PhD;
Cathy D. Sherbourne, PhD;
Kenneth B. Wells, MD, MPH
Arch Gen Psychiatry. 2001;58:55-61.
ABSTRACT
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Background Depressive and anxiety disorders are prevalent and cause substantial
morbidity. While effective treatments exist, little is known about the quality
of care for these disorders nationally. We estimated the rate of appropriate
treatment among the US population with these disorders, and the effect of
insurance, provider type, and individual characteristics on receipt of appropriate
care.
Methods Data are from a cross-sectional telephone survey conducted during 1997
and 1998 with a national sample. Respondents consisted of 1636 adults with
a probable 12-month depressive or anxiety disorder as determined by brief
diagnostic interview. Appropriate treatment was defined as present if the
respondent had used medication or counseling that was consistent with treatment
guidelines.
Results During a 1-year period, 83% of adults with a probable depressive or
anxiety disorder saw a health care provider (95% confidence interval [CI],
81%-85%) and 30% received some appropriate treatment (95% CI, 28%-33%). Most
visited primary care providers only. Appropriate care was received by 19%
in this group (95% CI, 16%-23%) and by 90% of individuals visiting mental
health specialists (95% CI, 85%-94%). Appropriate treatment was less likely
for men and those who were black, less educated, or younger than 30 or older
than 59 years (range, 19-97 years). Insurance and income had no effect on
receipt of appropriate care.
Conclusions It is possible to evaluate mental health care quality on a national
basis. Most adults with a probable depressive or anxiety disorder do not receive
appropriate care for their disorder. While this holds across diverse groups,
appropriate care is less common in certain demographic subgroups.
INTRODUCTION
DEPRESSIVE AND anxiety disorders are common and have a substantial impact
on functioning and quality of life. National treatment guidelines for major
depression document that effective treatments include antidepressant medications
and cognitive-behavioral and interpersonal psychotherapies.1, 2, 3, 4, 5
Research also supports the efficacy of these treatments for dysthymia, although
the literature is less well developed.5, 6, 7, 8, 9
In panic disorder, treatment guidelines strongly support the efficacy of cognitive-behavioral
psychotherapies, some antidepressant medications, and benzodiazepines.10, 11 In generalized anxiety disorder (GAD),
effective treatments include antidepressant medications, buspirone, benzodiazepines,
cognitive-behavioral psychotherapies, and probably relaxation and unstructured
therapy techniques.12, 13, 14, 15
Although these treatments are effective, patients frequently do not receive
them.16 However, there have been few national
studies of the quality of mental health care. Researchers have successfully
characterized national quality of care for a variety of medical disorders,17 and it is important to know whether similar research
in psychiatry can provide data to inform policy nationally. While the existing
literature suggests that quality of care for common psychiatric disorders
is moderate to poor across different types of treatment settings, national
data are limited and not clinically detailed, and it is unclear which populations
are at greatest risk for not receiving appropriate care.
The National Comorbidity Survey (NCS) surveyed a household probability
sample of persons between ages 14 and 55 years, and found that 27.7% of those
with major depression and 26.0% of those with dysthymia reported receiving
outpatient mental health services,18 while
35.2% with panic disorder and 31.8% with GAD reported receiving such services.
Although rates of use of antidepressant medication were low for persons with
major depression, the survey did not obtain information on actual names or
dosages of medications, so treatment appropriateness according to national
practice guidelines is uncertain.19 Furthermore,
NCS respondents only reported general medical visits that they thought included
care for mental health problems, and this approach could lead to undercounting
of mental health services since many general medical patients may not recognize
that they have an emotional problem.20 Otherwise,
studies of quality of care for depressive or anxiety disorders are limited
to reports from specific practice settings. For example, a study of primary
care practices in the 1980s found that 25% to 30% of those with major depression
received antidepressant medication during a 6-month period,16
and studies in a variety of other health care organizations have produced
similar results.21, 22, 23, 24
The rate of appropriate treatment for persons with anxiety disorder may also
be low, but there are few practice-based studies. Even in mental health specialty
settings, effective treatments for anxiety disorders may be underutilized.25, 26, 27, 28
Researchers have found lower rates of mental health treatment utilization
in men,29 ethnic minorities,30
and individuals with lower socioeconomic status.31
Also, black, young adult, and elderly individuals have been found to be less
likely to visit mental health specialists,32
and this may affect which treatments are received.33
With regard to insurance, the Epidemiologic Catchment Area Study found that
access to care was better under Medicaid than for the uninsured or those with
private insurance,34 and the Medical Outcomes
Study found that some aspects of treatment were worse in prepaid care.16 However, these results were based on coverage in
the 1980s and few recent studies have identified predictors of receiving appropriate
care among persons at risk for common psychiatric disorders.
This is a study of access to appropriate care among a representative
household sample of adults in the United States who had a symptomatic depressive
or anxiety disorder during a 1-year period in 1997 and 1998. The focus is
on individuals with probable major depression, dysthymia, panic disorder,
and GAD. We examine whether these individuals visit a health care provider,
whether those visiting a provider receive appropriate treatment, and, overall,
the probability of receiving appropriate care. We also analyze the effect
of demographic factors, insurance type, and provider visits on receipt of
appropriate treatment.
MATERIALS AND METHODS
SAMPLE
The sample is from HealthCare for Communities (HCC), which is part of
the Robert Wood Johnson Foundation's Health Tracking Initiative. Data are
from the HCC telephone survey, which was conducted during 1997 and 1998. The
design of HCC is described in detail elsewhere.35
HealthCare for Communities respondents were a stratified probability sample
of participants in the Community Tracking Study (CTS). The CTS was a nationally
representative study of the US civilian, noninstitutionalized population during
1996 and 1997, with a response rate of 65%.36
The sampling strategy in HCC was designed to improve our ability to study
people with low income and people with psychiatric disorders. This was done
by oversampling individuals with the following characteristics: family income
below $20 000, high psychological distress (measured using 2 items from
the 12-Item Short-Form Health Survey37), or
any mental health specialty visit during the prior year. Of the 14 985
CTS respondents selected for HCC, 9585 were reinterviewed, for a response
rate of 64%. Informed consent was obtained verbally before the interview.
In analyses, we weighted the data to be representative of the population of
the United States by using CTS data to adjust for probability of selection,
unit nonresponse, and nontelephone households.
MEASURES
Data are from the HCC survey, with the exception of some insurance information
and demographics from the CTS survey. Major depression, dysthymia, and GAD
during the past year and lifetime mania were assessed using short-form versions
of the Composite International Diagnostic Interview (CIDI),38
and are based on DSM-III-R criteria.39
Kessler and colleagues38 reported that the
sensitivity and specificity of CIDI short-form relative to full CIDI diagnosis
is excellent, with concordance ranging from 90% to 100%. Probable panic disorder
was assessed using screening items from the CIDI,40
supplemented by additional items from the full battery that were modified
for this study. To reduce potential false-positives on this instrument, for
panic we required limitation in social or role functioning using 2 items from
the 12-Item Short-Form Health Survey and 3 items from the Sickness Impact
Profile.41 Substance abuse was assessed using
the Alcohol Use Disorders Identification Test42
and items adapted from the CIDI. Chronic psychosis was assessed by asking
respondents whether they had ever been told they had schizophrenia or schizoaffective
disorder, or been hospitalized because of psychotic symptoms. Two hundred
forty respondents met criteria for chronic psychosis or mania and were excluded
from our analyses. Respondents were also asked whether, during the past year,
they had a need for emotional or mental health help, and whether they had
any of the following severe life difficulties: witnessing an assault, losing
custody of children, or being homeless, sexually assaulted, incarcerated,
or on parole or probation.
Use of health services during the prior 12 months was identified by
self-report. Primary care provider (PCP) visits included visits, for any reason,
to a primary care physician, family physician, general internist, nurse, physician
assistant, or chiropractor. Mental health specialist visits included visits
to a psychiatrist, psychologist, social worker, psychiatric nurse, or counselor,
for "emotional or mental health problems." Respondents provided daily dosage
and duration of use for medications taken "at least several times a week for
a month or more," and reported on the number of counseling sessions with specialists.
Counseling from PCPs was identified by asking whether the health care visit
included at least 5 minutes of counseling regarding an "emotional, mental
health, alcohol or drug problem."
Appropriate care for depressive and anxiety disorders was assessed for
respondents with a probable disorder, and was defined as use of either appropriate
psychotropic medication or appropriate counseling during the prior year. Appropriate
psychotropic medication was defined as a medication that was efficacious for
the individual's disorder and used at a dosage exceeding the minimum recommended
dosage for an adequate duration. Specifically, for major depressive and dysthymic
disorder (with or without anxiety), we used the lower end of the therapeutic
dosage range for each antidepressant medication from the Agency for Health
Care Policy and Research Guideline for Depression in Primary Care, updated
for newer medications,1 and required 2 or more
months of use during the prior 12 months. Examples of minimum dosages are
10 mg per day for fluoxetine and 75 mg per day for desipramine. For panic
disorder (with or without GAD), appropriateness criteria were based on proposed
guidelines for general practitioners.10 Medication
was appropriate if it included at least 2 months of an antidepressant medication
(other than bupropion) at a possibly adequate dosage, or a benzodiazepine.
For GAD, medication was considered appropriate if it included at least 2 months
of an antidepressant medication at an adequate dosage, buspirone, or a benzodiazepine.
For respondents with multiple disorders, appropriateness was evaluated for
their most "significant" clinical disorder, based on the following hierarchy
(from 1 to 4, in order of consideration by PCP): major depression (1), dysthymia
(2), panic disorder (3), and GAD (4). To illustrate the rationale behind this
hierarchy, an individual with comorbid major depression and panic disorder
has appropriate treatment for both disorders if he or she has any appropriate
treatment for depression (eg, an antidepressant); however, certain treatments
for panic disorder (eg, a benzodiazepine alone without counseling) would not
be sufficient.
Appropriate counseling was defined as at least 4 visits with a mental
health specialist or 4 visits with a PCP that included counseling for mental
health problems. A very similar counseling definition was used in the Medical
Outcomes Study, which found that appropriate counseling or medication use
was associated with improved 2-year functional outcomes in depression.43
STATISTICAL ANALYSES
Estimates were calculated using SUDAAN software,44 and take into account the complex survey design and
survey clustering. Differences between percentages were evaluated using Wald
statistics converted to F statistics.45 Multiple
logistic regression was used to examine the effect of individual, illness,
and insurance characteristics on both use of services and receipt of appropriate
care. The population for all the main models consisted of individuals with
probable depression, dysthymia, panic, or GAD. Dependent variables were dichotomous,
and indicated the presence of at least 1 service or appropriate care. Independent
variables were the same in each model, and included age, sex, ethnic group,
marital status, years of education, income, number of chronic medical disorders,
and presence of a severe life difficulty or alcohol or other drug problem.
Primary medical insurance was entered into the models as one of the following:
private health maintenance organization, other private insurance, Medicare,
Medicaid, uninsured, or other/unknown. Physical and mental health functioning
scores from the 12-Item Short-Form Health Survey were included in the models
to control for severity of illness. We calculated standardized predictions
for variables in the models by computing the average predicted probabilities
of obtaining quality care, controlling for other covariates, within sample
subgroups of interest.
We examined the sensitivity of our approach to changes in the methods
used to identify appropriate treatment. To do this, we developed alternative
regression models that had the same independent and dependent variables, but
examined a somewhat different population. First, since our main method could
have included respondents with mild illnesses, we restricted the population
identified as having a disorder to individuals with a limitation in social
or role functioning (as defined above). Second, since our main method may
have missed individuals who did not meet requirements for illness during the
past year because of successful treatment, we expanded the population identified
as having a disorder to include all individuals taking antidepressant medication.
RESULTS
There were 174 respondents with dysthymia alone, 831 with major depression
alone, and 317 with both disorders. There were 139 respondents with panic
disorder alone, 146 with GAD alone, and 29 with both anxiety disorders. In
total, 1636 respondents met criteria for 1 or more depressive or anxiety disorders,
and Table 1 presents the characteristics
of these individuals. Compared with other persons, individuals with a depressive
or anxiety disorder were significantly more likely to be female, unmarried,
unemployed, and to have problems with drugs or alcohol (P<.0001, for each comparison). They also had significantly fewer
years of education, lower family income, more life difficulties and chronic
medical disorders, and were more likely to have no medical insurance (P<.0001 for each comparison). While respondents provided
information on medical insurance, they were often unaware of their specific
mental health benefits, and hence this could not be assessed.
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Table 1. Characteristics, During 1997 and 1998, of People With and
People Without a Probable Depressive or Anxiety Disorder in the United States*
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VISITS TO PROVIDERS AND USE OF MENTAL HEALTH TREATMENTS
During a 1-year period, 80.8% of individuals with a probable anxiety
or depressive disorder saw a PCP. While 19.4% had seen a mental health specialist,
only 1.9% saw a specialist without seeing a PCP. Primary care provider contact
was most common with the anxiety disorders, and specialist contact was most
common when both anxiety and depressive disorders were present (Table 2). Although provider visits were common, receipt of mental
health treatment was not. Among individuals with a probable disorder, 25.6%
received some antidepressant or anxiolytic medication, and 20.6% received
appropriate medication; 31.3% received some counseling, and 17.6% received
appropriate counseling. In all, 30.4% received at least 1 appropriate treatment
for their disorder (95% CI, 27.7%-33.1%). The highest rates of treatment were
found in people with both an anxiety and a depressive disorder.
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Table 2. Adults With a Probable Depressive or Anxiety Disorder Who
Visited a Health Care Provider or Used Mental Health Treatment During a 1-Year
Period in 1997 and 1998
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FACTORS AFFECTING PROVIDER CONTACT AND TREATMENT QUALITY
Within people with a depressive or anxiety disorder, provider contact
was significantly more likely among individuals with more years of education
or a greater number of medical disorders, and was less likely among individuals
with no medical insurance (Table 3).
On the other hand, receipt of appropriate care was strongly influenced by
demographic factors and not by presence or type of insurance. As shown in Table 3, receipt of appropriate care was
affected by the same factors in people who had seen a provider as in the general
population. Specifically, the odds of receiving appropriate care varied significantly
by sex, ethnicity, age, and years of education, but not by income or insurance.
The standardized prediction of appropriate care was 33% for women, 26% for
men, 34% for whites, 24% for Hispanics, and 17% for blacks. In terms of age,
older and younger people were both less likely to receive appropriate care.
The standardized prediction of appropriate care was 20% for ages 18 to 29
years, 37% for ages 30 to 39 years, 32% for ages 40 to 49 years, 37% for ages
50 to 59 years, and 22% for 60 years and older.
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Table 3. The Effect, in Adults With a Probable Depressive or Anxiety
Disorder, of Individual Characteristics on Visiting a Health Care Provider
and Receiving Appropriate Care*
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Overall, poor-quality care (defined as no care or inappropriate care)
was quite common. Poor-quality care occurred in 80.5% of individuals with
PCP visits only (95% CI, 77.3%-83.8%), 11.4% of individuals with mental health
specialist visits only (95% CI, 0.0%-24.7%), and 10.1% of individuals with
both types of visits (95% CI, 5.1%-15.2%). Within patients seeing PCPs, those
receiving poor-quality care were less likely to report that mental health
problems were evaluated (35.6% vs 65.3%, P<.0001),
psychiatric medications were recommended (11.4% vs 55.7%, P<.0001), or a referral to a mental health specialist was made (4.1%
vs 23.5%, P<.0001). The overall population with
poor-quality care was much less likely to perceive a need for mental health
care (31.4% vs 70.0%, P<.0001).
COMMENT
This project indicates that it is possible to nationally evaluate and
monitor treatment quality for psychiatric conditions, just as quality has
been evaluated in other medical disorders. When care is examined, the rate
of access to appropriate treatment for depressive and anxiety disorders is
quite low, under 35% for the US adult population with a disorder, although
closer to 50% for those with both types of disorder. These findings reflect
practice and utilization patterns in 1997 and 1998, well within the era of
newer antidepressant medications and widespread dissemination of managed care
in primary and specialty care. The substantial problems with access to mental
health treatment occur even among persons receiving health care. In fact,
76% of individuals with poor-quality care had seen a health care professional
during a 1-year period. Most had been seen in primary care settings, making
these promising locations for identifying individuals who could benefit from
treatment. While the chances of appropriate care are much higher for individuals
who have mental health specialist contact, these are probably individuals
who are more accepting of psychiatric diagnosis and treatment. We found that
persons not receiving appropriate care were much less likely to think they
needed treatment for an emotional problem. Primary care providers carry the
burden of recognizing cases among patients not presenting for psychological
treatment, a task that mental health specialists may not have to face.
The policy significance of our findings is enhanced by identification
of individuals at highest risk for not receiving appropriate care for a depressive
or anxiety disorder. A large amount of the literature suggests that the effect
of insurance on quality is inconsistent.46
We found that insurance had a significant effect on whether an ill individual
would see a provider, but no effect on whether appropriate care would be received.
In part, this may have occurred because most visits were in primary care,
where the rate of appropriate treatment was low. We were unable to evaluate
generosity of specific coverage for mental health services because people
were too uncertain about this aspect of their insurance. This is an important
area for further study. In any case, our findings suggest that quality problems
exist across insurance types and the uninsured. This is consistent with previous
studies suggesting that simply providing insurance is unlikely to substantially
improve rates of appropriate care in people with mental health disorders.47 Rather, quality improvement programs may need to
be implemented within various types of insurance programs and in the public
sector to enhance awareness and utilization of appropriate treatment options.
Unlike insurance, demographic factors had little effect on whether an
individual would see a provider, but a large effect on whether appropriate
care would be received. For instance, despite the fact that blacks are as
likely as whites to see a provider, they are significantly less likely to
receive appropriate care. This ethnic disparity in quality of care is similar
to findings for a variety of other medical conditions.48
Overall, groups at very high risk include men, blacks, older adults, young
adults, and people with less than a high school education. Our findings are
consistent with numerous studies showing that women are much more likely than
men to use outpatient mental health services.29
We also find that lower socioeconomic status is strongly associated with not
receiving appropriate care. These risk factors hold in both in the general
population and in the population that sees a health care provider. Our findings
emphasize the salience of the surgeon general's current efforts to redress
differences in quality of care for major disease conditions based on socioeconomic
or ethnic status differences, and suggest that major psychiatric conditions
should be considered for such an effort.
An encouraging finding was that when an antidepressant or anxiolytic
medication is used, it is often used at a dosage and duration that may be
effective. This suggests that the main problem is identifying those in need,
offering them appropriate care, and helping them accept this care. This represents
a change from the 1980s, and may be because of the widespread availability
of selective serotonin reuptake inhibitor medications that are relatively
easy to use at an effective dosage. Indeed, we found that selective serotonin
reuptake inhibitors now account for 56% of all antidepressant medications
used for depression and anxiety, and are usually prescribed at an adequate
dosage. For counseling, there was a greater difference between using any counseling
and receiving appropriate care, with less than half of those with any counseling
receiving at least 4 sessions. With benefits declining and behavioral managed
care becoming more prevalent, it may be more difficult to obtain more than
a few visits, or there may be other barriers such as patients not perceiving
a need for ongoing counseling or experiencing financial barriers, such as
copayments.
One limitation of this study is that we used a brief diagnostic screening
instrument to identify people with a probable disorder. Indeed, brief measures
are required when implementing quality assessment in large national samples.
A recent study compared a similar brief diagnostic assessment with a structured,
clinical assessment, and found that the brief assessment was highly specific,
though not very sensitive.49 Therefore, one
would expect that most of the people we identified had, in fact, a depressive
or anxiety disorder. Also, to examine the sensitivity of our approach to variation
in severity of illness, we reran the model predicting appropriate care after
confining the population to those with a functional limitation (n = 1201).
In the population with a depressive or anxiety disorder plus a functional
limitation, the positive predictive value of our screeners should be even
higher (and need for treatment quite certain). The only substantive difference
between this model and the main model was that that having a chronic medical
disorder was more strongly associated with receiving appropriate care. Finally,
the Partners in Care Study50 examined persons
who met screening criteria for probable depressive disorder but did not have
current disorder based on full diagnostic assessment, and found that their
outcomes improved with a quality improvement program. Thus, rates of treatment
among a broader at-risk sample are meaningful to practice policy.
Our use of a cross-sectional strategy to select individuals with a disorder
means that we cannot distinguish chronic refractory illness from incident
conditions, or identify people who were successfully treated more than a year
before the interview, and had no symptoms for the past year because of continued
treatment. To examine the effect that this may have had, we ran sensitivity
analyses in a population that in included people with a depressive or anxiety
disorder plus people who had no disorder but were using antidepressant medication.
Using this alternative approach, the rate of appropriate care increased from
30.4% to 40.2%, but predictors of appropriate care did not change.
It is noteworthy that we found low rates of appropriate care, even though
we used a generous definition of appropriate counseling, requiring only 4
professional visits and only 5 minutes of discussion in a primary care visit.
We were unable to measure the content of counseling visits or to reliably
identify specific forms of effective treatments. Indeed, a criterion standard
for defining effective counseling in the context of usual practice does not
exist. Also, our reliance on self-report of service use could have led to
underreporting or misreporting of medication usage or counseling. However,
our model was robust to variation in our assumptions, and our major findings
were determined mostly by the presence of any potentially effective treatment.
Also, the method we used to measure appropriateness is very similar to that
used in the Medical Outcomes Study,16, 43
which demonstrated that this definition of treatment appropriateness affects
outcomes.
Another potential limitation of this study is that the accuracy of the
results may have been affected by the response rate, which is compounded by
the initial response rate in CTS. We adjusted our findings statistically for
response using detailed CTS information on nonrespondents. While we cannot
know the extent to which this adjustment was successful, features of our findings
are consistent with prior research. Compared with NCS, we found similar prevalence
estimates for disorders, similar rates of treatment utilization in anxiety,
and modestly higher rates of treatment utilization in depression. In primary
care, we found rates of mental health treatment use that are similar to those
reported by the Medical Outcomes Study using 1980s data.
Many factors can contribute to why people who need care do not receive
it.51 These include, for instance, perceived
need, willingness to accept care, insurance coverage, detection by providers,
and knowledge and beliefs of providers regarding effective treatment. Findings
from this study support efforts to improve care through either public education
or quality improvement interventions. Recent research suggests that while
a majority of the public identifies major depression as a mental illness,
psychiatric disorders continue to be strongly stigmatized.52
We found that people not receiving appropriate care were much less likely
to have had their mental health problems evaluated, and much less likely to
believe they needed mental health treatment. Public and patient education
efforts are needed to increase the extent to which people value treatment
for common psychiatric disorders and demand appropriate care. Quality improvement
efforts should focus on strategies that bring effective treatments to people—whether
through improving practice infrastructure, enhancing benefit design, or implementing
outreach programs. Clinical research has made substantial progress in establishing
efficacious treatments, and progress must now proceed on dissemination to
the public, especially for vulnerable subpopulations.
AUTHOR INFORMATION
Accepted for publication July 20, 2000.
This study was supported by a grant from the Robert Wood Johnson Foundation,
Princeton, NJ (Dr Wells); and by grant P50 MH 54623, from the National Institute
of Mental Health, Rockville, Md, to the University of California at Los Angeles–RAND
Research Center on Managed Care for Psychiatric Disorders, Los Angeles (Dr
Wells). Infrastructure support was provided by the Department of Veterans
Affairs VISN 22 Mental Illness Research, Education, and Clinical Center, Los
Angeles, Calif.
Presented in part at the Association of Health Services Research Annual
Meeting, Chicago, Ill, June 29, 1999; the Department of Veterans Affairs Health
Services Research and Development Annual Meeting, Washington, DC, March 23,
2000; and the American Psychiatric Association Annual Meeting, Chicago, Ill,
May 16, 2000.
We thank Lily Zhang, MS, for assistance with data analysis.
From the Department of Veterans Affairs VISN 22 Mental Illness Research,
Education, and Clinical Center, West Los Angeles Veterans Healthcare Center,
Los Angeles, Calif (Dr Young); the Department of Psychiatry, University of
California, Los Angeles (Drs Young and Wells); the Health Services Research
Center, University of California, Los Angeles (Dr Klap); and RAND, Santa Monica,
Calif (Drs Young, Sherbourne, and Wells).
Reprints: Alexander S. Young, MD, MSHS, UCLA Neuropsychiatric Institute,
Health Services Research Center, 10920 Wilshire Blvd, Suite 300, Los Angeles,
CA 90024-6505
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