BACKGROUND: The 1990's witnessed a new wave of state and federal legislation affecting mental health insurance in the United States. Although patient advocacy groups have hailed the passage of numerous "parity" laws that require insurance coverage for mental illnesses to equal that for physical ailments, it is unclear whether this activity represents a major improvement in insurance benefits among mentally ill or significantly increases their access to care. AIMS: This paper contrasts how insurance coverage has changed among individuals with mental health problems in states with and without parity legislation. METHODS: National survey data from 1996 to 1998, subset to a panel of 1220 individuals exceeding clinical screeners for a mental health disorder. Dependent variables are change in insurance status, insurance generosity and perception of access to care. The analysis contrasts changes in dependent variables between states with and without parity legislation (a difference-in-differences analysis). RESULTS: There are no statistical significant effects of state parity; point estimates suggest that parity mandates are associated with a slightly higher number of mentally ill reporting improved insurance generosity and access to care, but also with a higher number of mentally ill losing all insurance coverage in parity states. The estimated effects are too small to be statistically significant, although the sample size is limited and the study had only good statistical power to detect large effects. DISCUSSION: At the population level, state parity legislation appears to have not had large effects on the insurance coverage of the group that was intended as the primary beneficiary of legislation. Likely reasons include the limited scope of the actual legal requirements and large numbers of mentally ill that are not covered by health insurance subject to such legislation. The results do not exclude the possibility that some subgroups experienced substantial improvements in their insurance coverage. At the population level, large effects experienced by small subgroup are diluted by groups that experienced no similar changes. However, parity legislation was not considered a minor issue by advocates and opponents and this analysis has the statistical power to detect the sizeable differences that were argued in the policy debate. IMPLICATIONS FOR HEALTH POLICIES: While state parity legislation may have improved insurance benefits for some, it appears not to have resulted in substantial improvements for the mentally ill as a whole. The results could be very different, however, if strong federal legislation were passed that has a broader scope than state legislation. IMPLICATIONS FOR RESEARCH: The parity debate provides an important reminder of how little research is available to inform policy. This study provides a crude picture, but it is far from being a conclusive evaluation. The most urgent need is for data that continue to track changes in markets and policies.

BACKGROUND: The Global Burden of Disease study has suggested that mental disorders are the leading cause of disability burden in the world. This study takes the leading cause of mental disorder burden, depression, and trials an approach for defining the present and optimal efficiency of treatment in an Australian setting. AIMS OF THE STUDY: To examine epidemiological and service use data for depression to trial an approach for modelling (i) the burden that is currently averted from current care, (ii) the burden that is potentially avertable from a hypothetical regime of optimal care, (iii) the efficiency or cost-effectiveness of both current and optimal services for depression and (iv) the potential of current knowledge for reducing burden due to depression, by applying the WHO five-step method for priorities for investment in health research and development. METHODS: Effectiveness and efficiency were calculated in disability adjusted life years (DALYs) averted by adjusting the disability weight for people who received efficacious treatment. Data on service use and treatment outcome were obtained from a variety of secondary sources, including the Australian National Survey of Mental Health and Wellbeing, and efficacy of individual treatments from published meta-analyses expressed in effect sizes. Direct costs were estimated from published sources. RESULTS: Fifty-five percent of people with depression had had some contact with either primary care or specialist services. Effective coverage of depression was low, with only 32% of cases receiving efficacious treatment that could have lessened their severity (averted disability). In contrast, a proposed model of optimal care for the population management of depression provided increased treatment contacts and a better outcome. In terms of efficiency, optimal care dominated current care, with more health gain for less expenditure (28 632 DALYs were averted at a cost of AUD295 million with optimal care, versus 19 297 DALYs averted at a cost of AUD720 million with current care). However, despite the existence of efficacious technologies for treating depression, only 13% of the burden was averted from present active treatment, primarily because of the low effective coverage. Potentially avertable burden is nearly three times this, if effective treatments can be delivered in appropriate amounts to all those who need it. DISCUSSION: This paper reports a method to calculate the burden currently averted from cross-sectional survey data, and to calculate the burden likely to be averted from an optimal programme estimated from randomized controlled trial data. The approach taken here makes a number of assumptions: that people are accurate in reporting their service use, that effect sizes are a suitable basis for modelling improvements in disability and that the method used to translate effect sizes to disability weight change is valid. The robustness of these assumptions is discussed. Nonetheless it would appear that while optimal care could do more than present services to reduce the burden of depression, current technologies for treating depression are insufficient. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: There is an urgent need to educate both clinicians (primary and specialist) and the general public in the effective treatments that are available for depression. IMPLICATIONS FOR HEALTH POLICIES: Over and above implementing treatments of known efficacy, more powerful technologies are needed for the prevention and treatment of depression. IMPLICATIONS FOR FURTHER RESEARCH: Modelling burden averted from a variety of secondary sources can introduce bias at many levels. Future research should examine the validity of approaches that model reductions in disability burden. A powerful treatment to relieve depression and prevent relapse is needed.

BACKGROUND: The economic costs of depression are significant, both the direct medical costs of care and the indirect costs of lost productivity. Empirical studies of antidepressant cost-effectiveness suggest that the use of selective serotonin reuptake inhibitors (SSRIs) may be no more costly than tricyclic antidepressants (TCAs), will improve tolerability, and is associated with longer therapy duration. However the success of depression care usually involves multiple factors, including source of care, type of care, and patient characteristics, in addition to drug choice. The cost-effective mix of antidepressant therapy components is unclear. AIMS OF THE STUDY: Our study evaluates cost and antidepressant-continuity outcomes for depressed patients receiving antidepressant therapy. Specifically, we determined the impact of provider choice for initial care, concurrent psychotherapy, and choice of SSRI versus TCA-based pharmacotherapies on the joint outcome of low treatment cost and continuous antidepressant therapy. METHODS: A database of private health insurance claims identifies 2678 patients who received both a diagnosis of depression and a prescription for an antidepressant during 1990-1994. Patients each fall into one of four groups according to whether their health care charges are high versus low (using the median value as the break point) and by whether their antidepressant usage pattern is continuous versus having discontinued pharmacotherapy early (filling fewer than six prescriptions). A bivariate probit model controlling for patient characteristics, co-morbidities, type of depression and concurrent treatment is the primary multivariate statistical vehicle for the cost-effective treatment situation. RESULTS: SSRIs substantially reduce the incidence of patients discontinuing pharmacotherapy while leaving charges largely unchanged. The relative effectiveness of SSRIs in depression treatment is independent of the patient's personal characteristics and dominates the consequences of other treatment dimensions such as seeing a mental health specialist and receiving concurrent psychotherapy. Initial provider specialty is irrelevant to the continuity of pharmacotherapy, and concurrent psychotherapy creates a tradeoff through reduced pharmacotherapy interruption with higher costs. DISCUSSION: Longer therapy duration is associated with SSRI-based pharmacotherapy (relative to TCA-based pharmacotherapy) and with concurrent psychotherapy. High cost is associated with concurrent psychotherapy and choice of a specialty provider for initial care. In our study cost-effective care includes SSRI-based pharmacotherapy initiated with a non-specialty provider. Previous treatment history and other unobserved factors that might affect antidepressant choice are not included in our model. IMPLICATIONS FOR HEALTH CARE PROVISION: The decision to use an SSRI-based pharmacotherapy need not consider carefully the patient's personal characteristics. Shifting depressed patients' pharmacotherapy away from TCAs to SSRIs has the effect of improving outcomes by lowering the incidence of discontinuation of pharmacotherapy while leaving largely unchanged the likelihood of having high overall health care charges. Targeted use of concurrent psychotherapy may be additionally cost-effective. IMPLICATIONS FOR HEALTH POLICIES: The interaction of various components of depression care can alter the cost-effectiveness of antidepressant therapy. Our results demonstrate a role for the non-specialty provider in initiating care and support increased use of SSRIs as first-line therapy for depression as a way of providing cost-effective care that is consistent with APA guidelines for continuous antidepressant treatment. IMPLICATIONS FOR FURTHER RESEARCH: Further research that improves our understanding of how decisions regarding provider choice, concurrent psychotherapy, and drug choice are made will improve our understanding of the effects treatment choices on the cost-effectiveness of depression care. We have suggested that targeted concurrent psychotherapy may prove to be cost-effective; research to determine groups most likely to benefit from the additional treatment would further enable clinicians and healthcare policy makers to form a consensus regarding a model for treating depression.

The temptation is great, but premature, to conclude from the Sturm study that parity mandates had no effect on access and insurance coverage for the mentally ill. The study lacks statistical power for those directly covered by the mandates, and it is unlikely adequate power exists for those only indirectly affected. The inclusion of the uninsured, Medicaid enrollees, and privately covered individuals not subject to the mandates, and the imprecise outcome measures, increase the likelihood that other factors dominate parity. The timing of implementation in some states is also problematic. But Sturm asks the right questions and future waves of the Healthcare for Communities survey and other data will be better able to address them.arkets and policies.

Background: The economic costs of depression are significant, both the direct medical costs of care and the indirect costs of lost productivity. Empirical studies of antidepressant cost-effectiveness suggest that the use of selective serotonin reuptake inhibitors (SSRIs) may be no more costly than tricyclic antidepressants (TCAs), will improve tolerability, and is associated with longer therapy duration. However the success of depression care usually involves multiple factors, including source of care, type of care, and patient characteristics, in addition to drug choice. The cost-effective mix of antidepressant therapy components is unclear. Aims of the Study: Our study evaluates cost and antidepressant-continuity outcomes for depressed patients receiving antidepressant therapy. Specifically, we determined the impact of provider choice for initial care, concurrent psychotherapy, and choice of SSRI versus TCA-based pharmacotherapies on the joint outcome of low treatment cost and continuous antidepressant therapy. Methods: A database of private health insurance claims identifies 2678 patients who received both a diagnosis of depression and a prescription for an antidepressant during 1990–1994. Patients each fall into one of four groups according to whether their health care charges are high versus low (using the median value as the break point) and by whether their antidepressant usage pattern is continuous versus having discontinued pharmacotherapy early (filling fewer than six prescriptions). A bivariate probit model controlling for patient characteristics, co-morbidities, type of depression and concurrent treatment is the primary multivariate statistical vehicle for the cost-effective treatment situation. Results: SSRIs substantially reduce the incidence of patients discontinuing pharmacotherapy while leaving charges largely unchanged. The relative effectiveness of SSRIs in depression treatment is independent of the patient's personal characteristics and dominates the consequences of other treatment dimensions such as seeing a mental health specialist and receiving concurrent psychotherapy. Initial provider specialty is irrelevant to the continuity of pharmacotherapy, and concurrent psychotherapy creates a tradeoff through reduced pharmacotherapy interruption with higher costs. Discussion: Longer therapy duration is associated with SSRI-based pharmacotherapy (relative to TCA-based pharmacotherapy) and with concurrent psychotherapy. High cost is associated with concurrent psychotherapy and choice of a specialty provider for initial care. In our study cost-effective care includes SSRI-based pharmacotherapy initiated with a non-specialty provider. Previous treatment history and other unobserved factors that might affect antidepressant choice are not included in our model. Implications for Health Care Provision: The decision to use an SSRI-based pharmacotherapy need not consider carefully the patient's personal characteristics. Shifting depressed patients' pharmacotherapy away from TCAs to SSRIs has the effect of improving outcomes by lowering the incidence of discontinuation of pharmacotherapy while leaving largely unchanged the likelihood of having high overall health care charges. Targeted use of concurrent psychotherapy may be additionally cost-effective. Implications for Health Policies: The interaction of various components of depression care can alter the cost-effectiveness of antidepressant therapy. Our results demonstrate a role for the non-specialty provider in initiating care and support increased use of SSRIs as first-line therapy for depression as a way of providing cost-effective care that is consistent with APA guidelines for continuous antidepressant treatment. Implications for Further Research: Further research that improves our understanding of how decisions regarding provider choice, concurrent psychotherapy, and drug choice are made will improve our understanding of the effects treatment choices on the cost-effectiveness of depression care. We have suggested that targeted concurrent psychotherapy may prove to be cost-effective; research to determine groups most likely to benefit from the additional treatment would further enable clinicians and healthcare policy makers to form a consensus regarding a model for treating depression. Copyright © 2000 John Wiley & Sons, Ltd.

BACKGROUND: Most research on the civilian labor market experiences of veterans has focused on the extent to which the skills and experience acquired in the military are rewarded in the civilian employment sector. While studies have been mindful of the need to analyze this question in a multivariate framework, controlling for other factors that might independently affect labor market outcomes, they have met this goal with limited success. As a result, an important element of the employment and wage determination process - psychiatric health - has been absent from this literature. AIMS OF THE STUDY: Using a nationally representative survey of Vietnam-era veterans, this study analyzes the contribution of psychiatric health toward explaining differences in the post-service civilian wages, hours worked, and employment probabilities among male veterans. METHODS: The analysis is based on data from the National Survey of the Vietnam Generation, a survey, completed in the late 1980s, of persons who were on active duty during the years of the Vietnam War, 1964-1975. Three outcome variables are studied - the hourly wage rate, usual hours worked per week, and a 0-1 indicator for whether the respondent is currently working. Lifetime diagnoses of four categories of mental disorders - major depression, anxiety disorders, substance abuse/dependence, and combat-related posttraumatic stress disorder (PTSD) - were constructed from the US NIMH Diagnostic Interview Schedule, administered by the survey. The employment probability equation was estimated using probit; the hourly earnings and hours worked equations via ordinary least squares conditioned on being employed. RESULTS: The study finds that PTSD significantly lowered the likelihood of working and, for those veterans who were working, their hourly wages. On average, a veteran with a lifetime diagnosis of PTSD was 8.5 percentage points less likely to be currently working than was a veteran who did not meet diagnostic criteria. Among those who were employed, veterans with PTSD earned, on average, $2.38 less per hour ($3.61 in 1999 U.S. dollars). Anxiety disorders and major depression had nearly as large an effect on employment rates, as did PTSD. Major depression was also found to have lowered hourly wages by an average of $6.77 per hour ($10.17 in 1999 US dollars). However, psychiatric health did not affect typical hours worked per week. DISCUSSION: This study contributes new information to several literatures. Previous research on the extent to which PTSD interferes with readjustment to civilian life has focused on quality-of-life outcomes such as overall well-being, physical health, and homelessness. Previous research on mental health and earnings has focused on annual earnings. This study makes hourly wage comparisons, a closer measure of productivity differences since they represent differences in pay for the same input of time. Finally, this study demonstrates that the effects of psychiatric health are as important as the influence of non-health characteristics that are thought to signal earnings potential in the civilian labor market (education and experience). These findings, however, may not apply generally. The importance of PTSD may be specific to veterans of the Vietnam War and may not pertain to persons suffering non-combat-related PTSD. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE AND HEALTH POLICY FORMULATION: The magnitude of our estimates implies potentially large benefits from developing effective treatments for PTSD and from insuring access to these treatments. IMPLICATIONS FOR FURTHER RESEARCH: Future research should examine the relationship between work and PTSD in the general population and should explore the indirect effects of mental health, such as its effects on the post-service educational attainment and occupational choices of veterans.

BACKGROUND: There are over 17 000 nursing homes in the United States. Within these, special care units (SCUs) provide a separate residential and/or activity locus for residents, and are expected to provide more staff time and more specialized staff assignments. This paper addresses a fundamental issue relating to the nature, quality and quantity of resident care inputs: what impacts of SCUs are associated with added service inputs, and thus with personnel costs, recognizing that personnel account for the majority of costs associated with nursing home care? AIMS OF THE STUDY: The aim of this aspect of the study was to determine the extent to which additions of staff would result in a diminution of deviant behaviors among residents of special care and of traditional care units. METHOD: The data were collected from a random sample of ten downstate nursing homes located in New York State. Using rigorous sampling procedures, random samples of 40 residents were drawn from each of the facilities, equally divided between special care unit and traditional care unit residents. Thus, the sampling design involved two levels of clustering: subjects were clustered within units and units were clustered within facilities. The observational behaviour measure was taken from the INCARE (institutional version of the Comprehensive Assessment and Referral Evaluation). The behavioral observation measure contains 23 items such as "disruptive of others", "picks/pulls clothing", "repetitive movements", "repetitive questioning"and "wandering". Each item is rated as to frequency of occurrence; ratings are collected on three occasions, and averaged. Outcome and covariate data (e.g., behavior and cognition) were collected by trained research staff who visited each site for three to four weeks of intensive data collection, accomplished through direct resident interviews, staff interviews and questionnaires and chart data abstraction. The clinical staff time data were collected using the InfoAide system, whereby each care provider used a portable barcode scanner to record the type of care given, the recipient and the duration of care. A random effects model using the SAS mixed procedure was applied to the data; adhering to this model, some effects were fixed and some random. The random effects were comprised of the subject (intercept or subject starting point at baseline) and the unit; used here was restricted maximum likelihood (REML) with the EM algorithm. RESULTS: There was a significant reduction of behavior disorder associated with more provision of aide time in SCUs as contrasted with non-SCUs. The greater the service provided, the greater the slope, i.e., the greater the reduction. That is, while SCU residents showed improvements in behavior accompanying increases in aide time, no such change was observed among non-SCU residents. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The significant effect of SCU + time + aide-minutes indicates that more aide time on SCUs was associated with improvement in behavior. It appears that the important ingredient in relation to the reduction of behavior disorder is not membership in an SCU per se, but the provision of more aide time within SCUs. Those SCUs that provide more aide time have a better behavior outcome. Thus, these findings point to additional paths for exploration, i.e., future research needs to focus on elements of SCUs such as the available amounts of program and staff resources rather than on SCU status alone.

The Journal of Mental Health Policy and EconomicsVolume 3, Issue 3 p. 119-120 Editorial Editorial First published: 30 April 2001 https://doi.org/10.1002/mhp.98AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume3, Issue3September 2000Pages 119-120 RelatedInformation