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Objective: The authors investigated recent trends in the use of outpatient psychotherapy in the United States. Method: Service use data from two representative surveys of the U.S. general population, the 1998 (N=22,953) and 2007 (N=29,370) Medical Expenditure Panel Surveys, were analyzed, focusing on individuals who made more than one outpatient psychotherapy visit during that calendar year. The authors computed rates of any psychotherapy use; percentages of persons treated for mental health conditions with only psychotherapy, only psychotropic medication, or their combination; the mean number of psychotherapy visits of persons receiving psychotherapy; and psychotherapy expenditures. Results: The percentage of persons using outpatient psychotherapy was 3.37% in 1998 and 3.18% in 2007 (adjusted odds ratio=0.95, 95% CI=0.82-1.09). Among individuals receiving outpatient mental health care, use of only psychotherapy (15.9% and 10.5% in 1998 and 2007, respectively; adjusted odds ratio=0.66, 95% CI=0.48-0.90) as well as psychotherapy and psychotropic medication together (40.0% and 32.1%; adjusted odds ratio=0.73, 95% CI=0.59-0.90) declined while use of only psychotropic medication increased (44.1% and 57.4%; adjusted odds ratio=1.63, 95% CI=1.32-2.00). Declines occurred in annual psychotherapy visits per psychotherapy patient (mean values, 9.7 and 7.9; adjusted [beta]=1.53, p Conclusions: During the decade from 1998 to 2007, the percentage of the general population who used psychotherapy remained stable. Over the same period, however, psychotherapy assumed a less prominent role in outpatient mental health care as a large and increasing proportion of mental health outpatients received psychotropic medication without psychotherapy. doi: 10.1176/appi.ajp.2010.10040570

Objective: The authors sought to determine whether a significant association exists between the use of stimulants and the rare event of sudden unexplained death in children and adolescents. Method: A matched case-control design was performed. Mortality data from 1985-1996 state vital statistics were used to identify 564 cases of sudden death occurring at ages 7 through 19 years across the United States along with a matched group of 564 young people who died as passengers in motor vehicle traffic accidents. The primary exposure measure was the presence of amphetamine, dextroamphetamine, methamphetamine, or methylphenidate according to informant reports or as noted in medical examiner records, toxicology results, or death certificates. Results: In 10 (1.8%) of the sudden unexplained deaths it was determined that the youths were taking stimulants, specifically methylphenidate; in contrast, use of stimulants was found in only two subjects in the motor vehicle accident comparison group (0.4%), with only one involving methylphenidate use. A significant association of stimulant use with sudden unexplained death emerged from the primary analysis, which was based on exact conditional logistic regression (odds ratio=7.4, 95% CI=1.4 to 74.9). A comprehensive series of sensitivity analyses yielded qualitatively similar findings. Conclusions: This case-control study provides support for an association between the use of stimulants and sudden unexplained death among children and adolescents. Although sudden unexplained death is a rare event, this finding should be considered in the context of other data about the risk and benefit of stimulants in medical treatment.

Objective: This study attempted to estimate the relative risk of developing hyperlipidemia after treatment with antipsychotics in relation to no antipsychotic treatment. Method: A matched case-control analysis was performed with pharmacy and claims data from California Medicaid (Medi-Cal). Patients were excluded if they were treated for medical disorders or prescribed medications known to increase their risk of hyperlipidemia. Cases were ages 18 to 64 years with schizophrenia, major depression, bipolar disorder, or other affective psychoses and incident hyperlipidemia. Cases were matched to up to six control subjects by age, sex, race, and psychiatric diagnosis. Both groups were prescribed either no antipsychotic medication or had two or more prescriptions for one and only one antipsychotic medication during the 60 days prior to the first indication of hyperlipidemia (cases) or matched index date (controls) in the billing record. Conditional logistic regressions were used to derive odds ratios and 95% confidence intervals (95% Cls) of each antipsychotic medication in relation to no antipsychotic medication. Results: A total of 13,133 incident cases of hyperlipidemia were matched to 72,140 control subjects. As compared with no antipsychotic medication, treatment with clozapine (odds ratio: 1.82, 95% Cl: 1.61-2.05), risperidone (odds ratio: 1.53, 95% Cl: 1.43-1.64), quetiapine (odds ratio: 1.52, 95% Cl: 1.40-1.65), olanzapine (odds ratio: 1.56, 95% Cl: 1.47-1.67), ziprasidone (odds ratio: 1.40, 95% Cl: 1.19-1.65), and first-generation antipsychotics (odds ratio: 1.26, 95% Cl: 1.14-1.39), but not aripiprazole (odds ratio: 1.19, 95% Cl: 0.94-1.52) was associated with a significant increase in risk of incident hyperlipidemia. Conclusions: These findings suggest that most commonly prescribed antipsychotic medications increase the risk of developing hyperlipidemia in patients with schizophrenia or mood disorders.

Objective: Redesigning the fragmented U.S. mental health care system requires knowing how service sectors share responsibility for individuals' mental health needs. Method: Twelve-month DSM-IV mental disorders and their severity were assessed in respondents ages 15-54 from the National Comorbidity Survey (NCS) in 1990-1992 (N=5,388) and the NCS Replication in 2001-2003 (N=4,319). Six profiles involving potentially multiple service sectors were defined, including those in which pharmacotherapy plus psychotherapy (psychiatry profile, general medical with other mental health specialty profile), single modalities (general medical only profile, other mental health specialty only profile), or neither modality (human services only profile, complementary/alternative medicine only profile) could potentially have been received. The use of profiles was compared between surveys. Results: The general medical only profile experienced the largest proportional increase (153%) between surveys and is now the most common profile. The psychiatry profile also increased (29%), as did the general medical with other mental health specialty profile (72%). The other mental health specialty only (-73%), the complementary/alternative medicine only (-132%), and the human services only (-137%) profiles all decreased in use. The elderly, women, minorities, the less educated, and rural dwellers were less likely to use profiles capable of delivering pharmacotherapies and/or psychotherapies. Conclusions: How service sectors share responsibility for peoples' mental health care is changing, with more care falling to general medical providers rather than specialists. Efforts are required to ensure that people who would benefit have access to the necessary treatment modalities.

Objective: Continuation of antidepressant treatment for depression beyond the first months helps to consolidate treatment response and to reduce the risk of early relapse. The authors sought to characterize the rate and pattern of antidepressant discontinuation among adults initiating antidepressant treatment for depression. Method: Data were drawn from the household component of the Medical Expenditure Panel Survey for 1996-2001. Analysis was limited to data for adults age 18 years and older (N=829) who initiated antidepressant treatment for depression and who 1) discontinued treatment during the first 30 days of treatment, 2) completed the first 30 days of treatment and then discontinued treatment during the following 60 days, or 3) continued treatment for more than 90 days after treatment initiation. Results: A majority of the patients discontinued antidepressant therapy during the first 30 days (42.4%). Only 27.6% of the patients continued antidepressant therapy for more than 90 days. Antidepressant discontinuation during the first 30 days of treatment was significantly more common among Hispanics (53.8%) than non-Hispanics (41.3%); patients with fewer than 12 years of education (50.8%), compared with those with 12 or more years (39.3%); and patients with low family incomes (50.2%), compared with those with medium or high family incomes (38.6%). Patients were significantly more likely to continue antidepressant treatment beyond 30 days if they received psychotherapy (68.0% versus 43.7%), completed 12 or more years of education (64.8% versus 52.0%), or had private health insurance (60.1% versus S0.8%). Among those who continued antidepressants beyond 30 days, antidepressant continuity during the subsequent 60 days was significantly associated with fair or poor pretreatment self-rated mental health and physical health, treatment with a selective serotonin reuptake inhibitor or serotonin-norepinephrine reuptake inhibitor, and psychotherapy. Conclusions: Early discontinuation of antidepressant therapy is widespread in the community treatment of depression, especially among socioeconomically disadvantaged patients. Provision of psychotherapy and selection of an appropriate antidepressant medication may reduce the risk of discontinuation during the first 3 months of antidepressant treatment for depression.

Objective: This study estimated the proportion of patients attending an urban general medical practice with current major depression and a history of bipolar disorder and compared the history, presentation, and treatment of patients with unipolar and bipolar depression. Method: A group of 1,143 patients was assessed with measures of past and current mental health and treatment. Patients were partitioned into bipolar and unipolar groups based on a predefined cutoff on the Mood Disorder Questionnaire. The groups were compared on sociodemographic characteristics, depressive symptoms, comorbid mental disorders, and mental health treatment. Results: Approximately one-quarter of the patients with major depression had lifetime bipolar depression. Patients with unipolar and bipolar depression did not significantly differ on background or health characteristics. Patients with bipolar depression were significantly more likely to report hallucinations, current suicidal ideation, and low self-esteem than patients with unipolar depression but less likely to report disturbed appetite. Patients with bipolar depression were significantly more likely to have an alcohol use disorder and to report inpatient psychiatric care and antipsychotic treatment during the past month than patients with unipolar depression. Nearly one-half of the patients with bipolar depression had taken an anti-depressant in the last month, but most were not also being treated with an anti-psychotic or mood stabilizer. Conclusions: Bipolar depression is common in urban general medicine practice. When patients took antidepressants, they seldom received concurrent antimanic medications. Because of the risks of treating bipolar disorder with antidepressant monotherapy, physicians should assess their depressed patients for mania before prescribing antidepressants.

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

Objective: The authors examine national patterns in psychotherapy for older adults with a diagnosis of depression and analyze correlates of psychotherapy use that is consistent with Agency for Health Care Policy and Research guidelines for duration of treatment. Method: Linked Medicare claims and survey data from the 1992-1999 Medicare Current Beneficiary Survey were used. The data were merged with the Area Resource File to assess the effect of provider-supply influences on psychotherapy treatment. An episode-of-care framework approach was used to analyze psychotherapy use and treatment duration. Multiple logistic regression analysis was used to predict psychotherapy use and its consistency. Results: The authors identified 2,025 episodes of depression treatment between 1992 and 1999. Overall, psychotherapy was used in 25% (N-474) of the episodes, with 68% of episodes with psychotherapy involving services received only from psychiatrists. (Percentages were weighted for the complex design of the Medicare Current Beneficiary Survey.) Use of psychotherapy was correlated with younger patient age, higher patient educational attainment, and availability of local psychotherapy providers. Among episodes in which psychotherapy was used, only a minority (33%, N=141) involved patients who remained in consistent treatment, defined as extending for at least two-thirds of the episode of depression. Availability of local providers was positively correlated with consistent psychotherapy use. In analyses with adjustment for provider-related factors, patients' socioeconomic and demographic characteristics did not affect the odds of receiving consistent psychotherapy. Conclusions: Use of psychotherapy remains uncommon among depressed older adults despite its widely acknowledged efficacy. Some of the disparities in psychotherapy utilization suggest supply-side barriers. Increasing the geographic availability of mental health care providers may be one way of increasing access to psychotherapy for depressed older adults.

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

Objective: This article reports recent trends in the use of outpatient psychotherapy in the United States. Method: Data from the household sections of the 1987 National Medical Expenditure Survey and the 1997 Medical Expenditure Panel Survey were analyzed. Trends in the rate of psychotherapy use from these nationally representative samples are presented by age, sex, race/ethnicity, marital status, education, employment status, and income. Psychotherapy users are compared over time by provider specialty, concomitant psychotropic medication use, number of annual visits, and costs. In addition, trends in payment source and primary diagnosis are assessed for psychotherapy visits. Results: Between 1987 and 1997, there was no statistically significant change in the overall rate of psychotherapy use (3.2 per 100 persons in 1987 and 3.6 per 100 in 1997). However, significant increases were observed in psychotherapy use by adults aged 55-64 years and by unemployed adults. Among psychotherapy patients, there was a marked increase in the use of antidepressant medications (14.4% to 48.6%), mood stabilizers (5.3% to 14.5%), stimulants (1.9% to 6.4%), and psychotherapy provided by physicians (48.1% to 64.7%). A smaller proportion of patients made more than 20 psychotherapy visits in 1997 (10.3%)than in 1987 (15.7%). Over this period, psychotherapy visits for mood disorders became more common. In 1997, 9.7 million Americans spent $5.7 billion on outpatient psychotherapy. Conclusions: From 1987 to 1997, access to psychotherapy in the United States remained constant overall but was characterized by increased use by some socio-economically disadvantaged groups. However, the number of visits per user markedly decreased during this period. Psychotherapy was increasingly administered by physicians and provided in conjunction with psychotropic medications. These changes occurred during a period of expansion in the number of available psychotropic medications and growth in managed behavioral health care.

Objective: Although nonadherence with the antipsychotic medication regimen is a common barrier to the effective treatment for schizophrenia, knowledge is limited about how to improve medication adherence. This systematic literature review examined psychosocial interventions for improving medication adherence, focusing on promising initiatives, reasonable standards for conducting research in this area, and implications for clinical practice. Method: Studies were identified by computerized searches of MEDLINE and Psych-LIT for the years between 1980 and 2000 and by manual searches of relevant bibliographies and conference proceedings. Key articles were summarized. Results: Thirteen (33%) of 39 identified studies reported significant intervention effects. Although interventions and family therapy programs relying on psychoeducation were common in clinical practice, they were typically ineffective. Concrete problem solving or motivational techniques were common features of successful programs. Interventions targeted specifically to problems of nonadherence were more likely to be effective (55%) than were more broadly based treatment interventions (26%). One-half (four of eight) of the successful interventions not specifically focused on nonadherence involved an array of supportive and rehabilitative community-based services. Conclusions: Psychoeducational interventions without accompanying behavioral components and supportive services are not likely to be effective in improving medication adherence in schizophrenia. Models of community care such as assertive community treatment and interventions based on principles of motivational interviewing are promising. Providing patients with concrete instructions and problem-solving strategies, such as reminders, self-monitoring tools, cues, and reinforcements, is useful. Problems in adherence are recurring, and booster sessions are needed to reinforce and consolidate gains. (Am J Psychiatry 2002; 159:1653-1664)

Objective: The authors' goals were to estimate the prevalence of psychotic symptoms among adults attending an urban general medical practice that serves a low-income population and to describe the mental health, social and occupational functioning, and mental health treatment of these patients. Method: Data were drawn from a recent study of adult primary care patients (N= 1,005) in a large, urban, university-affiliated general medicine practice. During a medical visit, patients completed the psychotic disorders section of the Mini International Neuropsychiatric Interview, the Primary Care Evaluation of Mental Disorders, a drug use disorders screen, the Sheehan Disability Scale, and a questionnaire that probed demographic characteristics, health status, and mental health treatment. Results: Two hundred ten (20.9%) patients reported one or more psychotic symptoms, most commonly auditory hallucinations. There was an inverse correlation between family income and the prevalence of psychotic symptoms and a positive association between prevalence and Hispanic ethnicity. Compared with patients without psychotic symptoms, patients with psychotic symptoms were significantly more likely to have major depression (42.4% versus 12.6%), panic disorder (24.8% versus 4.0%), generalized anxiety disorder (38.6% versus 8.4%), and alcohol use disorder (12.9% versus 5.0%). They were also more likely to report current suicidal ideation (20.0% versus 3.5%), recent work loss (55.0% versus 35.6%), and marital distress (28.6% versus 13.0%). Approximately one-half of the patients with psychotic symptoms (47.6%) had taken a prescribed psychotropic medication during the last month. Conclusions: Psychotic symptoms were highly prevalent in this primary care practice. These patients were at risk for several common mental disorders and often reported impaired work and social functioning. Future research should clarify the extent to which psychotic symptom reports among Hispanic patients are affected by culturally patterned idioms of distress. Clinicians who work in primary care practices that serve low-income patient populations should routinely inquire about psychotic symptoms.

Objective: This study examined recent changes in the prescribing patterns for medications to treat bipolar disorder in office-based psychiatric practice. Method: The authors analyzed physician-reported data from the National Ambulatory Medical Care Survey for 1992-1995 and 1996-1999, focusing on physicians specializing in psychiatry. Demographic, clinical, and medication prescription characteristics of patients' visits were compared to identify changes between the periods. Logistic regression models were used to identify predictors of medication prescription, with adjustment for the presence of other covariates. Results: In both survey periods, over one-third of the total psychiatrist visits by patients with bipolar disorder did not include prescription of a mood stabilizer. There was a decrease in the use of lithium over time, accompanied by an increase in the use of valproic acid. Antipsychotic medication was prescribed more frequently for the bipolar manic and mixed subtypes, and there was a secular increase in the use of the newer antipsychotics. During each time period, prescription of antidepressants was common, often in the absence of a mood stabilizer. Conclusions: Despite important advances in the range of mood stabilizers available, the pharmacological treatment of bipolar disorder continues to be an area with substantial opportunity for quality improvement.

Objective: Reliance on the categorical model of psychiatric disorders has led to neglected study of posttraumatic sequelae that fall short of full criteria for posttraumatic stress disorder (PTSD). Substantial disability and suicidal risk is associated with subthreshold PTSD, but this association has not been well studied. In addition, no studies have examined the role of comorbidity in explaining disability and impairment in subthreshold PTSD. Method: On National Anxiety Disorders Screening Day 1997, 2,608 out of 9,358 individuals screened for affective and anxiety disorders at 1,521 sites across the United States reported at least one PTSD symptom of at least 1 month's duration. Impairment, comorbid anxiety disorders, major depressive disorder, and rates of suicidality were determined and compared for individuals with no, one, two, three, or four (full PTSD) symptoms on a screening questionnaire. Regression analyses examined the relative contribution of subthreshold PTSD and comorbid disorders to impairment and suicidal ideation. Results: Impairment, number of comorbid disorders, rates of comorbid major depressive disorder, and current suicidal ideation increased linearly and significantly with each increasing number of subthreshold PTSD symptoms. Individuals with subthreshold PTSD were at greater risk for suicidal ideation even after the authors controlled for the presence of comorbid major depressive disorder. Conclusions: Higher numbers of subthreshold PTSD symptoms were associated with greater impairment, comorbidity, and suicidal ideation. Disability and impairment found in previous studies of subthreshold PTSD symptoms may be related in part to the presence of comorbid disorders. However, the presence of subthreshold PTSD symptoms significantly raised the risk for suicidal ideation even after the authors controlled for major depressive disorder. Given the broad public health implications of these findings, more efforts are needed to identify subthreshold PTSD symptoms in clinical populations, epidemiologic surveys, and treatment studies. (Am J Psychiatry 2001; 158:1467-1473)

Objective: This study characterized the prevalence, characteristics, and impact of mental and general medical disabilities in the United States. Method: The 1994-1995 National Health Interview Survey of Disability was the largest disability survey ever conducted in the United States. A national sample was screened for disability, defined as limitation or inability to participate in a major life activity. Analyses compared cohorts who attributed their disability to physical, mental, or combined conditions. Results: Of 106,573 adults, 1.1% reported functional disability from mental conditions, 4.8% from general medical conditions, and 1.2% from combined mental and general medical conditions. Disabilities attributed to a mental condition were predominantly associated with social and cognitive difficulties, those attributed to general medical conditions with physical limitations, and combined disabilities with deficits spanning multiple domains. In multivariate models, comorbid medical and mental conditions were associated with a twofold increase in odds of unemployment and a two-thirds increase in odds of support on disability payments compared to respondents with a single form of disability. More than half the nonworking disabled reported that economic, social, and job-based barriers contributed to their inability to work. One-fourth of working disabled people reported discrimination on the basis of their disability during the past 5 years. Conclusions: An estimated three million Americans (one-third of disabled people) reported that a mental condition contributes to their disability. Mental, general medical, and combined conditions are associated with unique patterns of functional impairment. Social and economic factors and job discrimination may exacerbate the functional impairments resulting from clinical syndromes.

Objective: This article evaluates barriers to treatment reported by adults with social anxiety who participated in the 1996 National Anxiety Disorders Screening Day. Method: The background characteristics of screening day participants with symptoms of social anxiety (N=6,130) were compared with those of participants without social anxiety (N=4,507). Barriers to previous mental health treatment reported by participants with and without symptoms of social anxiety were compared. Results: Social anxiety was strongly associated with functional impairment, feelings of social isolation, and suicidal ideation. Compared to participants without social anxiety, those with social anxiety were significantly more likely to report that financial barriers, uncertainty over where to go for help, and fear of what others might think or say prevented them from seeking treatment. However, they were significantly less likely to report they avoided treatment because they did not believe they had an anxiety disorder. Roughly one-third (N=1,400 of 3,682, 38.0%) of the participants with symptoms of social anxiety who were referred for further evaluation were specifically referred for an evaluation for social phobia. Conclusions: Social anxiety is associated with a distinct pattern of treatment barriers. Treatment access may be improved by building public awareness of locally available services, easing the psychological and financial burden of entering treatment, and increasing health care professionals' awareness of its clinical significance.

Objective: The authors' goal was to determine the extent and pattern of blood serum monitoring of mood stabilizers in Medicaid patients with bipolar disorder. Method: Data were drawn from a Medicaid medical claims data set from Pittsburgh and the surrounding region. The authors identified bipolar patients using lithium, valproate, and carbamazepine (N = 718) and then examined the patient demographic, diagnostic, and service use variables associated with therapeutic drug monitoring. Results: A substantial proportion of lithium users (36.5%), valproate users (42.4%), and carbamazepine users (42.2%) with bipolar disorder diagnoses did not receive therapeutic drug level testing during the 12-month study period. Carbamazepine users who were male or in the 30-49-year age range were significantly less likely to be tested for serum drug level. Lithium users who did not receive partial-hospitalization psychiatric services and valproate users who received mental health case management were also less likely to be tested for serum drug level. Over one-half of the lithium users (54.1%) did not receive thyroid function tests, and few (4.2%) received renal function tests. Patients who did receive tests for serum drug level were likely to receive the other recommended tests. Conclusions: Many Medicaid patients with bipolar disorder received no therapeutic drug monitoring. Patient sociodemographic characteristics contributed little to explaining this omission, although some types of service utilization were related to rates of serum drug level testing.

Objective: The practice patterns of international medical graduate (IMG) and U.S. medical graduate (USMG) psychiatrists were compared. Method: Using data from the 1996 National Survey of Psychiatric Practice, the authors compared IMGs and USMGs in terms of demographic characteristics, practice settings, patients' clinical characteristics, and sources of reimbursement. Results: The IMGs surveyed tended to be older than USMGs, included a higher proportion of women, and were more racially heterogeneous. They worked longer hours, worked more frequently in the public sector, and treated a higher proportion of patients with psychotic disorders. The IMGs also received a higher percentage of their income than USMGs from Medicaid and Medicare, whereas the reverse was true of self-payment. Most of these differences remained significant after psychiatrist's age, gender, race, board certification, and work setting were controlled for. Conclusions: IMG and USMG psychiatrists have different practice patterns. Policies that substantially decrease the number of IMG psychiatrists may adversely affect the availability of psychiatrists to treat minorities and other underserved populations.

Objective: The authors examine trends in the composition and duration of visits to psychiatrists in office-based psychiatric practice. Method: An analysis was performed of physician-reported data from the 1985 and 1995 National Ambulatory Medical Care Surveys focusing on visits to physicians specializing in psychiatry. Secular changes in visit characteristics were assessed, and mean visit durations were determined for selected sociodemographic and clinical groups. Results: In the decade between 1985 and 1995, visits in office-based psychiatry became shorter, less often included psychotherapy, and more often included a medication prescription. The proportion of visits that were 10 minutes or less in length increased. A shortening in visit duration was most evident for younger patients, privately insured patients, and patients who were not prescribed a psychotropic medication. In the 1995 survey, 6.8% of the psychiatric visits included patient contact with another health care professional. Conclusions: Changing financial arrangements and new pharmacologic treatments may have contributed to these changes in practice style.

Objective: The authors describe the timing of the first treatment contact following new-onset DSM-III-R mood, anxiety, and addictive disorders in community samples from the United States and Ontario, Canada, before and after passage of the Ontario Health Insurance Plan. Method: The authors drew data from the National Comorbidity Survey (NCS) (N = 8,098) and the mental health supplement to the Ontario Health Survey (OHS) (N = 9,953). They assessed psychiatric disorders with a modified version of the Composite International Diagnostic Interview; they also assessed retrospectively age at disorder onset and first treatment contact. They used the Kaplan-Meier method to generate time-to-treatment curves and survival analysis to compare time-to-treatment intervals across the two surveys. Results: The overall time-to-treatment curves revealed substantial differences between disorders that were consistent across the two surveys. In both surveys, panic disorder had the highest probability of first-year treatment (NCS, 65.6%; OHS supplement, 52.6%), while phobia (NCS, 12.0%; OHS supplement: 6.5%) and addictive disorders (NCS, 6.4%; OHS supplement, 4.2%) had the lowest in both surveys. Retrospective subgroup analysis suggests that before the passage of the Ontario public insurance plan, the likelihood of receiving treatment in the year of disorder onset was greater in Ontario than in the United States but that this relationship reversed following passage of the Ontario plan. During this period, the authors observed no significant between-country differences in the probability of prompt treatment of adults with 12 or fewer years of education. Conclusions: These results challenge the assumption that the universal health insurance plan in Ontario promotes greater access to mental health services than is available in the United States for vulnerable groups. Marked differences between disorders in the speed to first treatment suggest that in both countries, clinical factors play an important role in the timing of the initial decision to seek treatment.

Objective: The authors used self-report data to study patterns and predictors of treatment contact after the first onset of DSM-III-R mood, anxiety, and addictive disorders. Method: Data from the National Comorbidity Survey, a general population survey of 8,098 respondents, were used. Disorders were assessed by using a modified version of the Composite International Diagnostic Interview. Age at onset and age at first treatment contact were assessed retrospectively. Results: There was great variation across disorders in lifetime probability of treatment contact. Most treatment contact was delayed; the median delay time was between 6 and 14 years across the disorders considered here. Probability of treatment contact was inversely related to age at onset and increased in younger cohorts. The effects of sociodemographic variables were modest and inconsistent across disorders. Conclusions: The majority of people with the disorders considered here eventually make treatment contact. However, delay was pervasive. Further research is needed on the determinants of delay and on the low probability of lifetime treatment contact among people with early-onset psychiatric disorders.

Objective: The authors' goals were to determine the frequency and distribution of ECT for general hospital inpatients with recurrent major depression and to estimate the effects of prompt ECT on the length and cost of inpatient care. Method: Data from the 1993 Healthcare Cost and Utilization Project were analyzed to determine the rate of ECT use for adult inpatients with a principal discharge diagnosis of major depression, recurrent. Associations between prompt initial use of ECT (in the first 5 hospital days) and length and cost of inpatient care were examined before and after control for sociodemographic, diagnostic, and hospital organizational characteristics. Results: An estimated 9.4% of general hospital adult inpatients with a principal diagnosis of recurrent major depression received ECT in the survey year. A majority (59.2%) of these received their initial ECT session within the first 5 days after hospital admission. In univariate analyses, the likelihood of receiving ECT was greater for older patients, whites, privately insured individuals, and patients who lived in more affluent areas. Patients who received ECT tended to have relatively long and costly admissions. After control for several demographic, diagnostic, and hospital organizational characteristics, prompt ECT (as compared with delayed ECT or none) was associated with significantly shorter and less costly inpatient care. Conclusions: The longer stays and higher treatment costs associated with ECT may be a consequence of patient selection. When patient selection is taken into account, prompt administration of ECT is associated with shorter and less costly hospital stays. Nonetheless, economically disadvantaged patients are relatively unlikely to receive this treatment.

Objective: This article examines social and occupational disability associated with several DSM-IV mental disorders in a group of adult primary care outpatients. Method: The subjects were 1,001 primary care patients (aged 18-70 years) in a large health maintenance organization. Data on each patient's sociodemographic characteristics and functional disability, including scores on the Sheehan Disability Scale, were collected at the time of a medical visit. A structured diagnostic interview for current DSM-IV disorders was then completed by a mental health professional over the telephone within 4 days of the visit. Results: The most prevalent disorders were phobias (7.7%), major depressive disorder (7.3%), alcohol use disorders (5.2 %), generalized anxiety disorder (3.7%), and panic disorder (3.0%). A total of 8.3 % of the patients met the criteria for more than one mental disorder. The proportion of patients with co-occurring mental disorders varied by index disorder from 50.0% (alcohol use disorder) to 89.2% (generalized anxiety disorder). Compared with patients who had a single mental disorder, patients with co-occurring disorders reported significantly more disability in social and occupational functioning. After adjustment for other mental disorders and demographic and general health factors, compared with patients with no mental disorder, only patients with major depressive disorder, bipolar disorder, phobias, and substance use disorders had significantly increased disability, as measured by the Sheehan Disability Scale. Conclusions: Primary care patients with more than one mental disorder are common and highly disabled. Individual mental disorders have distinct patterns of psychiatric comorbidity and disability.

Objective: The authors' goal was to assess the effects of facility ownership on the characteristics of psychiatric inpatients treated in public, private nonprofit, or proprietary general hospitals. Method: Data from the 1993 National Hospital Discharge Survey were analyzed to determine the number, sociodemographic and diagnostic composition, and treatment characteristics of patients with primary mental disorders discharged from public, private nonprofit, and proprietary general hospitals. Results: An estimated 1.83 million patients with a primary mental disorder diagnosis were discharged from general hospitals in 1993; the number of such discharges in the National Hospital Discharge Survey, which excluded federal general hospitals, was 13,086. These patients were unevenly distributed among public (9.4%), private nonprofit (78.9%), and proprietary (11.7%) hospitals. Psychiatric patients of public and private nonprofit hospitals were more likely to be diagnosed with schizophrenia (public: 23.4%, nonprofit: 18.8%, proprietary: 12.6%), a comorbid substance-related disorder (public: 29.9%, nonprofit: 31.0%, proprietary: 17.4%), a personality disorder (public: 11.6%, nonprofit: 11.3 %, proprietary: 4.7%), or a general medical disorder (public: 62.4 %, nonprofit: 57.4%, proprietary: 41.1%) than patients of proprietary hospitals. Uninsured psychiatric patients were far more common at public hospitals than at the other types of facilities (public: 17.0%, nonprofit: 9.9%, proprietary: 6.4%). Conclusions: Public general hospitals play an important role in caring for uninsured patients with severe mental illness. Before widespread closures occur in the public general hospital sector, it is critical that policy makers identify and develop resources to replace the care these institutions currently provide to poor patients with severe psychiatric disorders.

Objective: A national overview of outpatient mental health care in nonhospital settings is provided, focusing on the distribution of patients among psychiatrists, psychologists, general medical physicians, and other health professionals. Method: Data from the household section of the 1987 National Medical Expenditure Survey were analyzed to determine the volume and characteristics of patients receiving mental health care from these four professional groups. Results: In 1987 an estimated 4.1% of noninstitutionalized Americans (9.0 million) made 84 million outpatient mental health visits to nonhospital settings. Psychiatrists provided significantly more visits than psychologists for schizophrenia, bipolar disorder, substance abuse, and depression, but significantly fewer visits for anxiety disorders and symptoms such as 'nervousness.' General medical physicians provided the most visits for adjustment disorders and substance abuse, while the other professionals provided the most visits for childhood mental disorders and mental retardation. Conclusions: In 1987 important differences existed between the outpatients who received mental health care from psychologists, psychiatrists, general medical physicians, and other health professionals. (Am J Psychiatry 1996; 153:1353-1356)

Objective: The purpose of this article is to characterize the use of psychotherapy based on episode duration. Method: Data were analyzed from the household section of the 1987 National Medical Expenditure Survey. The authors determined the demographic characteristics, provider and reason for visit distribution, mental and physical health status, and expenditures associated with very short-term (one to two sessions), short-term (three to 10 sessions), intermediate-term (11 to 20 sessions), and long-term (>20 sessions) psychotherapy. Results: Long-term psychotherapy accounted for 15.7% of psychotherapy users and 62.9% of total psychotherapy expenditures. Age above 65 years, black race, and less than 12 years of education decreased the likelihood of receiving long-term psychotherapy. Whereas long-term psychotherapy episodes tended to be provided by the specialty sector (65.7%) for specific mental conditions (53.8%), very short-term episodes were predominantly provided by the general medical sector (72.2%) for general medical or unspecified conditions (68.3%). Psychotropic medication use and, to less extent, psychiatric hospitalization tended to be more common among longer- as opposed to shorter-term users. Conclusions: Long-term and short-term psychotherapy tend to be provided by different health care professionals for the treatment of different types of health conditions. To help ensure the future of third-party payment for long-term psychotherapy, research is needed to better define the conditions under which long-term psychotherapy achieves benefits that equal or surpass those of other medical services or procedures of similar cost.

Objective: This article provides an overview of the volume, composition, and costs of outpatient psychotherapy in the United States. Method: Data were analyzed from the household section of the 1987 National Medical Expenditure Survey. The authors determined the volume and distribution of psychotherapy visits by provider specialty, setting, source of expenditure, and reason for visit. An examination was made of the demographic characteristics, health status, and mental health utilization profile of psychotherapy users. Results: In 1987, Americans made 79.5 million outpatient psychotherapy visits at a total cost of $4.2 billion. Most of these visits were to mental health specialists (more than 80%) and were reported to be for the treatment of mental health conditions (63.5%). However, psychotherapy was not provided in a substantial proportion of the visits to mental health specialists (21.1%) or the visits to treat mental conditions (29.8%). Separated and divorced persons, females, whites, persons aged 35 to 49 years, and those with more than 15 years of education had a greater likelihood of using psychotherapy. Psychotherapy use was also greater among persons in poor general health and those reporting health-related functional impairments. General medical costs of psychotherapy users exceeded those of nonusers. Conclusions: Psychotherapy accounts for approximately 8% of outpatient medical care costs. Users of psychotherapy appear to be more distressed than is commonly assumed: they report poorer general health, higher general medical costs, and more functional impairment than nonusers. Although mental health specialists commonly provide psychotherapy to treat mental disorders, all mental health care is not psychotherapy.

Objective: This article examines some of the factors that influence the extent to which psychiatrists provide pharmacotherapy to their outpatients. Method: Data from the 1988-1989 APA Professional Activities Survey are used to define the characteristics of psychiatrists who prescribe medications to a high, medium, and low proportion of their outpatients in treatment. Outpatient assessments, evaluations, or consultations were excluded from this analysis. Correlations between psychiatric practice characteristics and rates of pharmacotherapy are examined. Results: One-third of psychiatrists prescribed medications to less than 46.7% of their outpatients, one-third prescribed medications to between 46.7% and 84.6%, and one-third prescribed medications to over 84.6% of their outpatients. The psychiatrists in the last group included a proportionately higher number of young psychiatrists, men, nonwhites, those without psychoanalytic or child psychiatry training, those with larger caseloads, and those who worked in the public sector. These psychiatrists also treated a disproportionately large number of patients with schizophrenia and related psychotic disorders. In a multivariate model, clinical, practice, and educational variables, but not demographic variables, were found to correlate with the extent of pharmacotherapy provided. Conclusions: Psychiatrists vary widely in the extent to which they are involved in prescribing psychotropic medications. The diagnostic composition of their caseload, their work setting, and their educational background, but not their demographic characteristics, appear to influence the extent of their involvement.

Objective: The authors develop a classification of psychiatric practice based on primary and secondary work settings. Method: Data from the 1988-1989 APA Professional Activities Survey were used to characterize seven practice groups: public psychiatrists, public psychiatrists with private secondary work settings, private psychiatric/general hospital psychiatrists, private office practice psychiatrists, private office practice psychiatrists with secondary private psychiatric/general hospital work settings, private office practice psychiatrists with secondary settings other than private hospitals, and psychiatrists in private organized outpatient settings. Psychiatrists primarily in government administrative agencies, medical schools, or nursing homes were among those excluded. Usable data were available from 16,135 psychiatrists (82.8% of the target respondents). Results: The largest groups were private psychiatric/general hospital psychiatrists (19.6%), private office practice psychiatrists with secondary settings other than private hospitals (18.9%), and private office practice psychiatrists with secondary private psychiatric/general hospital work settings (17.4%), followed by public psychiatrists with private secondary work settings (14.5%), private office practice psychiatrists (11.7%), public psychiatrists (11.4%), and psychiatrists in private organized outpatient settings (6.6%). During a typical week, the practice groups varied in the average proportion of their outpatients who received assessments, therapy and medication, therapy and no medication, and medication management. The groups also varied in the mean number of patients they treated each month with affective disorders, schizophrenia, anxiety disorders, and other disorders. Conclusions: Only about one in 10 clinical psychiatrists is engaged exclusively in office-based private practice, and approximately half of the outpatients treated by the average psychiatrist receive medication. Work setting appears to exert a powerful influence over whom psychiatrists treat and what services they provide. Because a majority of psychiatrists work in more than one setting, most psychiatrists serve a broad range of patients and provide a variety of treatments.

Objective: This paper describes the clinical roles of psychiatrists in U.S. organized outpatient mental health settings. Method: Data were analyzed from the 1986 National Institute of Mental Health Client/Patient Sample Survey. The authors determined the range, volume, and content of services provided to established outpatients treated by psychiatrists at six types of mental health organizations: state and county mental hospital clinics, general hospital mental health clinics, private psychiatric hospital clinics, U.S. Department of Veterans Affairs medical center mental health clinics, free-standing mental health clinics, and multiservice mental health organizations. Results: The psychiatrists treated nearly one-half (48.2%) of the established outpatients in organized settings, more than any other discipline. Most of the psychiatrists' patients (68.3%) were also treated by other mental health professionals. Psychiatrists treated a greater proportion of the patients at hospital-based clinics (60.7%) than at clinics without hospital affiliations (43.6%). They also treated larger proportions of the patients with schizophrenia (77.9%), affective disorders (50.6%), or anxiety disorders (59.2%) than those with adjustment disorders (23.7%), substance use disorders (34.3%), or childhood mental disorders (29.5%). The patients treated by psychiatrists commonly received psychotropic medications (77.3%) and individual therapy (66.3%) but less commonly received group (20.7%), skills (11.9%), or family (5.9%) therapy. Conclusions: In organized outpatient settings, psychiatrists typically work with other mental health professionals to treat a select group of severely ill patients. However, there is considerable variation in the extent to which different types of mental health organizations rely on psychiatrists to provide clinical care.

Objective: This study was done in an effort to determine whether there was a change over the past decade in the number and proportion of patients prescribed antidepressants by psychiatrists in private practice. Method: The authors analyzed data from the National Ambulatory Medical Care Survey for the years 1980, 1985, and 1989, focusing on visits by adults over the age of 18 years to physicians specializing in psychiatry and psychiatric subspecialties. Results: The number of visits that included prescribing an antidepressant medication grew from approximately 2.5 million in 1980 to 4.7 million in 1989, or from 17.9% to 30.4% of all office-based psychiatric visits. Fluoxetine, which first became available in 1988, accounted for 29.6% of the prescriptions for antidepressants in 1989. Increases in prescriptions for antidepressants were particularly evident for male patients, young adult patients, and patients with neurotic disorders. Conclusions: There was an increase in the 1980s in the use of antidepressants in office-based psychiatric practice. The advent of new agents and the broadening of the clinical usefulness of existing agents may have contributed to this increase.

Objective: The author's goal was to determine the frequency and distribution of neuropsychiatric diagnostic tests provided to general hospital patients with mental disorders. Method: Data from the 1989 National Hospital Discharge Survey were analyzed to determine the number, proportion, and general characteristics of 11,628 discharged patients with primary diagnoses of mental disorders who underwent computerized tomography (CT) scanning of the head, EEG, and magnetic resonance imaging (MRI) of the brain. Results: Of the discharged patients with mental disorders, 5.1% had received CT scans, 2.8% had received EEGs, and 0.7% had received MRI. These rates were below the rates for patients discharged with primary diagnoses of neurological disorders but above the rates for patients discharged with primary diagnoses of other medical disorders. Among the patients discharged with mental disorder diagnoses, the likelihood of receiving a CT scan or an EEG was greater if the primary diagnosis was an organic disorder or if the secondary diagnosis was a medical disorder. Patients over age 65 were also more likely to have received a CT scan. Hospital size and location had a modest influence on the likelihood of receiving a CT scan or EEG, but the ownership of the hospital and the patient's source of payment were not significant influences. Conclusions: Neuropsychiatric diagnostic testing is selectively utilized in the routine treatment of general hospital psychiatric inpatients. Clinical variables rather than institutional or financial variables appear to be the most powerful predictors of which patients are selected to receive these tests.

Objective: The purpose of this paper is to explore possible consequences of recent changes in the Medicare payment schedule for office-based psychiatric services. Method: Psychiatric office visits from the 1985 National Ambulatory Medical Care Survey were categorized in a manner that approximates commonly used codes of the Physicians' Current Procedural Terminology. An analysis was conducted of the frequency and clinical characteristics of various types of services, focusing particularly on visits of under 20 minutes in length that included a medication prescription (medication visits) and other visits of 35 minutes or less in duration (brief visits). Results: Medication visits and brief visits together accounted for more than one-quarter (27.3%) of all U.S. psychiatric office visits. The relative risk of receiving these short visits was greater for patients who paid with public resources, were over 65 years of age, were nonwhite in race (brief visits only), received a prescription for an antipsychotic medication, or were diagnosed as having a psychotic disorder. Conclusions: Short office visits are provided to a particularly vulnerable patient population. The reduction in Medicare copayments for medication management services should increase the patient demand for these short visits. However, where the new Medicare schedule has lowered physician fees for these services, the financial incentive to provide short visits will decrease and patient access may become limited. (Am J Psychiatry 1992; 149:1492-1498)

Objective: This study examined the effect of self-reported anxiety on the number of days persons with various general medical conditions spend in bed owing to disability. Method: Self-reported medical illness and disability data from a nationally representative household survey sample (N = 20,884) were analyzed. Results: Among respondents with general medical conditions, those with self-reported anxiety had a nearly fourfold greater length of disability (mean = 18.0 bed days) than the nonanxious respondents (mean = 4.8 bed days). After adjustment for differences in demographic characteristics and burden of general medical illness, anxiety was associated with an additional 3.8 bed days. Conclusions: Self-reported anxiety in combination with general medical conditions may be associated with extensive functional impairment.

Objective: The goal of this study was to characterize primary care patients with false positive results on screens for mental disorders. Method: A sample of 1,001 primary care patients completed self-administered screens and structured interviews for DSM-IV diagnoses. Results: A substantial proportion of the patients with false positive screen results for at least one diagnosis met the diagnostic criteria for other psychiatric disorders. They also had significantly greater functional impairment and higher rates of recent use of mental health services than the subjects with true negative results on the screens. Conclusions: Although the positive predictive values of screens for specific mental disorders are in line with those of other medical screens, false positive results are not uncommon. This may be due in part to the sensitivity of brief screening instruments to nonspecific symptoms. The results suggest that as with other screens used in primary care, patients with false positive results on screens for mental disorders should receive clinical attention.

Objective: The authors' goal was to determine whether treatment of panic attacks has a protective effect on the risk of major depression in the community. Method: Data were drawn from the National Comorbidity Survey, a community-based household sample representative of the U.S. adult population. A Cox proportional hazard model was used to estimate the association between risk of first-onset major depression and panic among subjects who had or had not received treatment for panic. Results: A significantly smaller proportion of individuals who received treatment for panic (19%) than those who did not receive treatment (45%) developed major depression. This difference remained significant in a Cox proportional hazard analysis adjusted for age at onset of panic and differences in demographic characteristics. Conclusions: Detection and treatment of panic may reduce the risk of developing major depression. (Am J Psychiatry 2001; 158:1146-1148)

Objective: Assessment of functional status is increasingly important in clinical trials and outcome research. Although several scales for assessing functioning are widely used, they vary in coverage, and direct comparisons among them are rare. Comparative information is useful in guiding selection of appropriate scales for research applications. Method: Results from three scales that measure functioning--the Medical Outcomes Study 36-item Short-Form Health Survey, the Social Adjustment Scale Self-Report, and the Social Adaptation Self-Evaluation Scale--were compared in a consecutively selected sample of 211 patients coming to primary care. Patients also received psychiatric assessments. Results: All three scales were acceptable to patients, showed few significant correlations with demographic variables, and were able to differentiate psychiatrically ill and well patients. Correlations among scales, even among scale items that assessed similar domains of functioning, were modest. Conclusions: Although all three scales are presumed to assess functional status, their item content and coverage differ. Selection of a scale requires a review of the scale items and consideration of research priorities and the characteristics of the study group. If functional status is a critical outcome measure, use of more than one scale may be necessary. (Am J Psychiatry 2001; 158:460-466)

Objective: The substantial failure of psychiatric patients to engage in outpatient specialty mental health care after an acute hospitalization at a time when managed care companies and others increasingly hold hospitals accountable for outcomes underscores the importance of identifying patients at high risk for not completing referrals. This study explored patient risk factors for not completing referrals and examined the success of several interventions targeted to achieving linkage with outpatient cares. Method: A clinically detailed, structured form was used in abstracting information from the medical records of 229 inpatients with a primary psychiatric diagnosis. Clinicians and staff at outpatient programs were contacted to determine whether patients completed their referrals. Results: Approximately two-thirds (65%) of the patients failed to attend scheduled or rescheduled initial outpatient mental health appointments after a hospital discharge. At high risk for unsuccessful linkage to outpatient care were patients with a persistent mental illness and those who had no prior public psychiatric hospitalization, were admitted involuntarily, and had longer lengths of stay. Controlling for risk factors, three clinical interventions used during the hospital stay more than tripled the odds of successful linkage to outpatient care: communication about patients' discharge plans between inpatient staff and outpatient clinicians, patients' starting outpatient programs before discharge, and family involvement during the hospital stay. Conclusions: Effective clinical bridging strategies can be used to avoid unnecessary gaps in the delivery of psychiatric services. Incorporating these strategies into routine care would enhance continuity of care, especially for some high-risk patients. (Am J Psychiatry 2000; 157:1592-1598)