Despite the existence of effective and relatively cost-effective depression treatments, many depressed patients do not receive appropriate care. The authors assessed opportunities for increasing the rate of effective depression treatment by investigating the market for such treatment in the Pittsburgh area.A conceptual framework was developed to evaluate the market for effective depression care. On the basis of the conceptual framework, interviews were conducted with representatives from seven large employers, two medical health insurance carriers, two behavioral health insurance carriers, four primary care providers, and four behavioral health care providers. Respondents were asked to assess the barriers to and opportunities for increasing the rates of depression treatment from their perspectives.The findings suggest that there is currently little demand among purchasers for improving depression care and little interest among insurers and providers for improving care in the absence of purchaser demand. Even stakeholders who identified depression as an important problem could not come to a consensus about who should be responsible for addressing the problem. Employers reported that they look primarily to their vendors to initiate quality improvement efforts, whereas insurers reported that such improvement efforts were more likely to occur if they were initiated by employers who purchase their health plans; providers, in turn, reported feeling powerless to initiate change.The absence of a clear locus of responsibility for improving depression care lends considerable inertia to the status quo. Because the currently low treatment rates are likely to be socially inefficient, researchers and policy makers should consider strategies to help overcome this inertia.
Abstract : Alcohol-related problems are a significant public health concern in the United States. Alcohol dependence, abuse, and problem drinking increase morbidity and mortality (McGinnis, 1993), and raise economic, social and health care costs (Institute for Health Policy, 1993; Rice, 1991; Manning, 1989; US Department of Health and Human Services, 1993). A recent study estimated that the total economic cost of alcohol-related problems was $148 billion in 1992: $18.8 billion in health care costs, $67.7 billion in lost productivity and $19.7 billion in crime (Harwood, 1998). Effective treatments exist for the entire spectrum of alcohol-related problems (Fleming, 1997; CSAT TIP #28; NIAAA, 1995), but fewer than half of those individuals who need treatment actually receive it (Institute of Medicine, 1990). One in 5 men and 1 in 10 women who visit their primary care providers meet the criteria for at-risk drinking, problem drinking or alcohol dependence (Manwell et al, 1998); (Flemming and Manwell, 1999). Primary care physicians (PCPs) are in an ideal position to screen for alcohol problems, begin treatment, and monitor progress. However, primary care systems are not set up to support PCPs in recognizing and treating alcohol use disorders. Since many of these patients do not consult alcohol treatment specialists on their own, important opportunities for identification and treatment are missed (Alcohol Research and Health, 2000). A recent national survey of primary care physicians and patients noted that more than nine in ten physicians fail to identify substance abuse in adults. The majority of patients with substance abuse say that their primary care physician did nothing to either assess or treat their substance abuse (CASA, 2000). A recent study of primary care physicians in Ohio in which 4454 patient visits were observed revealed that screening for alcohol problems took place during 3% of the visits, and only 1% of the patients received counseling on alcohol problems.
Abstract Depression is a common and heterogeneous condition with a chronic and recurrent natural course that is frequently seen in the primary care setting. Primary care providers play a central role in managing depression and concurrent physical comorbidities, and they face challenges in diagnosing and treating the condition. In this two part series, we review the evidence available to help to guide primary care providers and practices to recognize and manage depression. In this first of two reviews, we outline an approach to screening and diagnosing depression in primary care that evaluates current evidence based guidelines and applies the recommendations to clinical practice. The second review presents an evidence based approach to the treatment of depression in primary care, detailing the recommended lifestyle, drug, and psychological interventions at the individual level. It also highlights strategies that are being adopted at an organizational level to manage depression more effectively in primary care.
A clinical perspective on depression tends to focus on therapy and on medications or psychological interventions that may be helpful to individual patients. A broader view on the treatment enterprise, however, suggests that there are other dimensions to treatment and that opportunities for improving the quality of care and patient outcomes are not limited to innovation in therapeutics. This article examines several of the nonclinical facets of inpatient care, using the frame of a conceptual pyramid to explore the relationships between therapy and its professional, organizational, care-management, and economic concomitants. By drawing on a conceptual pyramid that elucidates several nonclinical dimensions of inpatient treatment for depression, we describe the potential for corresponding quality improvement activities among psychiatric providers. The pyramid suggests that there are multiple opportunities for future interventions to promote quality in inpatient psychiatric care, that those opportunities are considerably more varied than a purely clinical perspective might recognize, and that interventions in nonclinical aspects of the treatment system have the potential to cascade “downward” to affect clinical outcomes over time.
