Chartbook on Effective Treatment

Measures

• Process: Treatment for depression.
• Outcome: Suicide deaths.
• Process: Treatment for illicit drug use or alcohol problem.
• Process: Completion of substance abuse treatment.
• Outcome: Emergency department visits with a principal diagnosis related to mental health, alcohol, or substance abuse, by age and income.

Treatment for Depression

• Treatment for depression can reduce symptoms and associated illnesses and return individuals to a productive lifestyle.
• Sequenced Treatment Alternatives to Relieve Depression (STAR*D), the largest clinical trial ever of depression treatment, was funded by the National Institute of Mental Health:
  • It involved both primary care and specialty care settings.
  • Participants included people with complex health conditions, such as multiple concurrent medical and psychiatric conditions.
  • The study found that 28% to 33% of participants were symptom free after the first round of medication, and nearly 70% achieved remission after 12 months (Insel & Wang, 2009).
• Cost-benefit analyses showed that compared with usual care, strategies for treating depression in primary care settings, such as the collaborative care model, have produced positive net social benefits (Glied, et al., 2010).

Outcomes of Treatment for Depression

• About 50% to 60% of patients have symptoms even after adequate firstline treatment for depression.
• Patients’ thinking and behavior play a huge role in determining outcomes, making them candidates for psychosocial treatment.
  • Evidence-based psychological therapies can help patients overcome interpersonal difficulties, health beliefs, stigmas, medication nonadherence, anhedonia (inability to feel pleasure), and rumination.
  • Psychological therapies can help modify health beliefs, treat comorbid anxiety and other disorders, and incorporate environmental and contextual factors, thus enabling patients to facilitate their recovery (Casey, et al., 2013).

Barriers to High-Quality Mental Health Care

• Barriers to high-quality mental health care include:
  • Cost of care.
  • Lack of sufficient insurance for mental health services.
  • Discrimination and negative attitudes toward mental health problems.
  • Lack of culturally and linguistically competent providers.
  • Fragmented organization of services.
  • Mistrust of providers.
• In rural and remote areas, limited availability of skilled care providers is also a major problem.

Adults Who Received Treatment for Depression

Adults with a major depressive episode in the past year who received treatment for depression in the past year, by race/ethnicity and sex, 2008-2013

Left Chart:

Race/Ethnicity	2008	2009	2010	2011	2012	2013
Total	68.3	64.4	68.2	68.1	68.0	68.6
White	71.8	68.7	71.8	73.1	72.0	71.9
Black	56.1	53.2	54.5	54.3	62.1	64.6
Hispanic	57.4	49.3	64.2	53.2	55.6	57.7

Right Chart:

Sex	2008	2009	2010	2011	2012	2013
Male	60.9	59.0	59.8	61.0	60.3	60.1
Female	72.1	67.4	72.9	71.8	72.4	73.6

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2008-2013.
Denominator: Adults age 18 and over with a major depressive episode in the past year.
Note: Major depressive episode is defined as a period of at least 2 weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities and had a majority of the symptoms of depression described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. Treatment for depression is defined as seeing or talking to a medical doctor or other professional or using prescription medication in the past year for depression. White and Black are non-Hispanic; Hispanic includes all races.

• Importance: The United States Preventive Services Task Force (USPSTF) recommends screening adults for depression when staff-assisted depression care supports are in place to ensure accurate diagnosis, effective treatment, and followup (USPSTF, 2015a).
• Overall Rate: In 2013, 68.6% of adults with a major depressive episode received treatment for depression.
• Trends:
  • From 2008 to 2013, the percentage of adults with a major depressive episode who received treatment for depression improved among non-Hispanic Blacks.
  • Changes over time were not statistically significant in the overall population, among men and women, and among non-Hispanic Whites and Hispanics.
• Groups With Disparities:
  • In every year except 2010, Hispanic adults with depression were less likely than White adults to receive treatment.
  • Until 2012, Black adults with depression were less likely than White adults to receive treatment.
  • In all years, men with a major depressive episode were less likely than women to receive treatment.
  • No disparities related to race/ethnicity or sex were getting smaller over time.

Adolescents Who Received Treatment for Depression

Adolescents with a major depressive episode in the past year who received treatment for depression in the past year, by race/ethnicity and sex, 2008-2013

Left Chart:

Race/Ethnicity	2008	2009	2010	2011	2012	2013
Total	37.7	34.7	37.8	38.4	37.0	38.1
White	43.1	37.6	41.1	41.4	40.7	41.6
Black	32.6	25.4	23.0	41.0	33.5	28.6
Hispanic	30.3	33.1	38.4	29.4	30.8	36.9

Right Chart:

Sex	2008	2009	2010	2011	2012	2013
Male	33.8	29.3	32.0	35.3	28.3	29.7
Female	39.2	37.0	40.1	39.5	40.1	40.9

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2008-2013.
Denominator: Adolescents ages 12-17 with a major depressive episode in the past year.
Note: Major depressive episode is defined as a period of at least 2 weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities and had a majority of the symptoms of depression described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. Treatment for depression is defined as seeing or talking to a medical doctor or other professional or using prescription medication in the past year for depression. White and Black are non-Hispanic; Hispanic includes all races.

• Importance:
  • Outpatient mental health treatment and psychotropic medication use in children and adolescents increased in the United States between 1996-1998 and 2010-2012 (Olfson, et al., 2015).
  • The USPSTF recommends screening adolescents ages 12-18 years for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and followup (USPSTF, 2015b).
• Overall Rate: In 2013, 38.1% of adolescents with a major depressive episode received treatment for depression.
• Trends: From 2008 to 2013, there no statistically significant changes overall, for either sex, or for any racial/ethnic group in the percentage of adolescents with a major depressive episode who received treatment for depression.
• Groups With Disparities:
  • In 4 of 6 years (2008, 2009, 2010, 2013), Black adolescents with depression were less likely than White adolescents to receive treatment.
  • In 4 of 6 years (2009, 2010, 2012, 2013), females with depression were more likely than males to receive treatment.
  • No disparities related to race/ethnicity or sex narrowed over time.

Suicide Deaths

• Suicide may be prevented when its warning signs are detected and treated.
  • The growing use of standardized screening instruments and electronic medical records will likely increase clinicians’ ability to identify suicidal ideas and plans among individuals being treated for depression.
  • A recent study found that about half of people who died by suicide made a health care visit within 4 weeks of death. Only 24% had a mental health diagnosis (Ahmedani, et al., 2014).

Probability of Suicide

• Risk factors for suicide include:
  • Psychotic experiences (DeVylder, et al., 2015).
    • Individuals with psychotic experiences are about 5 times more likely to report suicidal ideation and nearly 10 times more likely to report a suicide attempt (DeVylder, et al., 2015). Assessing psychotic experiences among individuals with suicidal ideation could reduce suicide attempts.
  • Suicidal ideation (Han, et al., 2015):
    • About 13% of suicidal ideators in a given year attempt suicide during that year. Suicidal ideation is the strongest known clinical predictor for death by suicide.
    • Progression from ideation to suicide attempt varies by suicide plan and major depression status.
    • Research needs to explore factors that affect suicide attempts and death by suicide among high-risk individuals with suicidal ideation.
• Positive responses to the item “Thoughts that you would be better off dead, or of hurting yourself in some way” on the Patient Health Questionnaire for depression (Simon, et al., 2013).

Suicide Prevention

• Suicide prevention is multifaceted, including:
  • Educating physicians and keeping lethal weapons away from suicidal people (Mann, et al., 2005).
  • Using cognitive-behavioral therapy (Tarrier, et al., 2008).
  • Implementing various strategies, depending on risk:
    • Universal strategies that target entire populations (e.g., public education and awareness programs).
    • Selective strategies that address at-risk populations (e.g., peer "natural helpers" and accessible crisis services).
    • Indicated strategies that address high-risk individuals (e.g., case management and parent support programs) (Nordentoft, 2011).
• Ongoing research shows promising results for Internet-based cognitive-behavioral therapy and psychoeducation in treating individuals with conditions such as mood, eating, and sleep disorders (Thorndike, et al., 2013).
• As "mobile health" interventions become more sophisticated, they can be adapted to be culturally specific and sensitive (Burns, et al., 2013).

Suicide Rate

Suicide deaths per 100,000 population age 12 and over, by race/ethnicity and sex, 2008-2013

Left Chart:

Race	2008	2009	2010	2011	2012	2013
Total	14.0	14.2	14.6	14.9	15.2	15.2
White	15.7	15.9	16.4	16.8	17.1	17.2
Black	6.3	6.2	6.2	6.4	6.7	6.5
API	6.7	7.1	7.6	7.2	7.6	7.1
AI/AN	12.2	12.1	13.1	12.8	13.1	14.1

Right Chart:

Sex	2008	2009	2010	2011	2012	2013
Male	23.0	23.2	23.9	24.2	24.6	24.5
Female	5.7	5.9	6.0	6.3	6.5	6.6

2008 Achievable Benchmark: 9 per 100,000 Population.

Key: API = Asian and Pacific Islander; AI/AN = American Indian or Alaska Native.
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System—Mortality, 2008-2013.
Note: For this measure, lower rates are better. Estimates are age adjusted to the 2000 U.S. standard population.

• Overall Rate: In 2013, the overall suicide death rate was 15.2 per 100,000 population age 12 and over.
• Trends: From 2008 to 2013, suicide death rates worsened for the total population, both sexes, and all racial/ethnic groups.
• Groups With Disparities:
  • In all years, Blacks, Asians and Pacific Islanders (APIs), and American Indians and Alaska Natives (AI/ANs) had lower suicide death rates than Whites.
  • In all years, males had higher suicide death rates than females. The gap between male and females suicide death rates is growing larger over time.
• Achievable Benchmark:
  • The 2008 top 5 State achievable benchmark was 9 suicide deaths per 100,000 population. The top 5 States that contributed to the achievable benchmark are Connecticut, District of Columbia, Massachusetts, New Jersey, and New York.
  • APIs, Blacks, and females have achieved the benchmark.
  • The total population, AI/ANs, Whites, and males are moving away from the benchmark.

Treatment for Substance Abuse Disorders

• Substance abuse disorders can lead to:
  • Addiction.
  • Increased risk of certain cancers.
  • Damage to the liver, brain, and other organs.
  • Birth defects, such as fetal alcohol spectrum disorders.
  • Increased risk of death from car crashes and other injuries.

Importance of Treatment

• In 2011, about 2.5 million emergency department visits resulted from medical emergencies involving drug misuse or abuse:
  • 1.25 million involved illicit drugs.
  • 1.24 million involved nonmedical use of pharmaceuticals.
  • 0.61 million involved drugs combined with alcohol (SAMHSA, 2014).
• Substance abuse disorders can be effectively treated at specialty facilities.

Treatment Needs

• In 2013, nearly 23 million Americans age 12 years and over needed treatment for substance abuse.
• An estimated 2.5 million people received treatment at a specialty facility (hospital [inpatient], drug or alcohol rehabilitation [inpatient or outpatient], and mental health centers), but more than 20 million people who needed this type of treatment did not receive it (SAMSHA, 2014).

People Who Received Treatment for Illicit Drug Use or an Alcohol Problem

People age 12 and over who needed treatment for illicit drug use or an alcohol problem and who received such treatment at a specialty facility in the last 12 months, by race/ethnicity and age, 2008-2013

Left Chart:

Race/Ethnicity	2008	2009	2010	2011	2012	2013
Total	9.9	10.7	11.2	10.8	10.8	10.9
White	10.3	10.8	11.7	10.5	11.0	10.8
Black	13.2	14.7	12.8	14.3	12.7	12.5
Hispanic	5.4	7.4	8.1	10.2	8.1	10.5

Right Chart:

Age	2008	2009	2010	2011	2012	2013
12-17	7.4	8.3	7.6	8.4	10.0	9.1
18-44	9.4	10.7	10.4	10.3	10.1	10.3
45-64	12.4	12.0	16.2	13.7	14.8	13.9

2011 Achievable Benchmark: 15%.

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2008-2013.
Denominator: Civilian noninstitutionalized population age 12 and over who needed treatment for illicit drug use or an alcohol problem.
Note: Treatment refers to treatment at a specialty facility, such as a drug and alcohol inpatient and/or outpatient rehabilitation facility, inpatient hospital setting, or mental health center. White and Black are non-Hispanic. Hispanic includes all races.

• Overall Rate: In 2013, only 10.9% of people age 12 and over who needed treatment for illicit drug use or an alcohol problem received such treatment at a specialty facility in the last 12 months.
• Trends: From 2008 to 2013, there no statistically significant change overall or for any racial/ethnic or age groups in the rates of treatment.
• Groups With Disparities: There were no consistent differences between racial/ethnic or age groups.
• Achievable Benchmark:
  • The 2011 top 6 State achievable benchmark was 15%. The top 6 States that contributed to the achievable benchmark are Alabama, Alaska, Delaware, Maryland, Oregon, and Utah.
  • At the current rate, the time to benchmark for the total population is 30 years. People ages 12-17 would take 14 years to reach the benchmark while people ages 18-44 would take 6 years and people ages 45-64 could reach the benchmark within 1 year.
  • Whites would take 5 years to reach the benchmark.
  • There is no progress toward the benchmark for Blacks and Hispanics.

Adults Who Visited a Physician for Mental Health or Alcohol Problems

Adults who visited their primary care physician or psychiatrist for mental health or alcohol/drug problems in the past 12 months, by Hispanic and Asian granular ethnicities, 2011-2013 combined

2011 Achievable Benchmark: 15%.

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey, 2011-2013.

• Groups With Disparities: There is considerable variable in physician visits for mental health or alcohol/drug problems among Hispanic and API granular ethnicities.
• Achievable Benchmark:
  • The 2011 top 6 State achievable benchmark was 15%. The top 6 States that contributed to the achievable benchmark are Alabama, Alaska, Delaware, Maryland, Oregon, and Utah.
  • Data are insufficient to determine time to benchmark.

Completion of Substance Abuse Treatment

• For patients receiving treatment for substance abuse, studies have shown that increased length of treatment correlates with improved outcomes (McLellan, et al., 1996), such as long-term abstinence.
• Dropout from treatment often leads to relapse and return to substance use.

People Who Completed Substance Abuse Treatment

People age 12 and over treated for substance abuse who completed treatment course, by age and sex, 2005-2011

Left Chart:

Age	2005	2006	2007	2008	2009	2010	2011
Total	45	47.5	45.1	46.6	46.7	44.1	43.7
12-19	41.3	42.6	40.1	41.0	40.1	38.7	39.1
20-39	42.7	45.2	43.2	44.9	44.4	41.7	41.1
40+	49.4	52.0	49.4	50.8	51.9	49.3	48.8

Right Chart:

Sex	2005	2006	2007	2008	2009	2010	2011
Male	47.1	49.3	47.1	48.5	48.8	46.3	46.2
Female	40.4	43.5	41.0	42.6	42.1	39.8	39.3

2008 Achievable Benchmark: 74%.

Source: Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set, Discharge Data Set, 2005-2011.
Denominator: Discharges age 12 and over from publicly funded substance abuse treatment facilities.
Note: White and Black are non-Hispanic. Hispanic includes all races.

• Overall Rate: In 2011, 43.7% of people age 12 and over treated for substance abuse completed their treatment course.
• Groups With Disparities:
  • In all years, people ages 12-19 and 20-39 who were treated for substance abuse were less likely than those age 40 and over to complete treatment.
  • In all years, females who were treated for substance abuse were less likely than males to complete treatment.
• Achievable Benchmark:
  • The 2008 top 5 State achievable benchmark was 74%. The top 5 States that contributed to the achievable benchmark are Colorado, Connecticut, District of Columbia, Mississippi, and Texas.
  • No group showed progress toward the benchmark.

Adults Who Completed Treatment for Mental, Emotional, Alcohol, or Drug Problems

Adults who visited a professional for mental, emotional, alcohol, or drug problems during the past 12 months who completed the recommended full course of treatment, by Hispanic and Asian granular ethnicities, 2011-2013, combined

2008 Achievable Benchmark: 74%.

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey, 2011-2013.

• Groups With Disparities: There is considerable variable in completion of treatment for mental health or substance abuse problems among Hispanic and API granular ethnicities.
• Achievable Benchmark:
  • The 2008 top 5 State achievable benchmark was 74%. The top 5 States that contributed to the achievable benchmark are Colorado, Connecticut, District of Columbia, Mississippi, and Texas.
  • Most groups are far away from the benchmark.

Potentially Avoidable Emergency Department Visits

• About one in three individuals has had a mental health or substance abuse (MHSA) condition within the last 12 months.
• In 2007, 12 million ED visits involved a diagnosis related to MHSA, accounting for 12.5% of all ED visits in the United States.
• Health care providers are concerned about the rise in ED visits for MHSA, as ED overcrowding can reduce quality of care and increase the likelihood of medical error (Owens, et al., 2010).

Emergency Department Visits Related to Mental Health, Alcohol, or Substance Abuse

Emergency department visits with a principal diagnosis related to mental health, alcohol, or substance abuse, by age and neighborhood income, 2007-2013

Left Chart:

Age	2007	2008	2009	2010	2011	2012	2013
Total	1527.8	1624.1	1687.4	1738.7	1766.8	1841	1883
0-17	621.8	684	663.3	655.3	697.5	746	749
18-44	2244.1	2379.5	2471.1	2576	2607.4	2671	2789
45-64	1720.1	1824.4	1966.4	2037.4	2077.5	2165	2190
65-84	773.7	807.6	826.5	824.4	828.8	915	904
85+	769.5	790.8	748.6	757.5	757.9	843	852

Right Chart:

Income	2007	2008	2009	2010	2011	2012	2013
Q1 (Lowest)	1961.1	2114.5	2263.2	2347.8	2242.6	2,467	2,510
Q2	1576.4	1756.3	1834.2	1821.4	1838	1,881	1,989
Q3	1396.7	1422.3	1471.4	1492.6	1600.9	1,702	1,681
Q4 (Highest)	1153.7	1203.8	1168.4	1288.3	1386.5	1,315	1,362

Key: Q = quartile.
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Emergency Department Sample, and HCUPnet query, 2007-2013.

• Trends:
  • From 2007 to 2013, the overall rate of ED visits with a principal diagnosis related to mental health, alcohol, or substance abuse significantly increased from 1,528 to 1,883 per 100,000 population.
  • Rates increased for people ages 18-44 and 45-64.
  • Rates increased for residents of all area income groups.
• Groups With Disparities:
  • In all years, individuals ages 0-17 and age 45 and over were significantly less likely to have an ED visit with a principal diagnosis related to mental health, alcohol, or substance abuse than individuals ages 18-44.
  • In all years, individuals living in the two lowest income quartile neighborhoods were more likely to have an ED visit with a principal diagnosis related to mental health, alcohol, or substance abuse than individuals living in neighborhoods in the highest income quartile.
  • No disparities related to age or area income were getting smaller over time.

References

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