Specialty Mental Health Sector Research Articles

Twelve-month prevalence, persistence, severity, and treatment of mood and anxiety disorders in Qatar's national mental health study.

To estimate 12-month prevalence, persistence, severity, and treatment of mental disorders and socio-demographic correlates in Qatar. We conducted the first national population-based telephone survey of Arab adults between 2019 and 2022 using the Composite International Diagnostic Interview and estimated 12-month DSM-5 mood and anxiety disorders and their persistence (the proportion of lifetime cases who continue to meet 12-month criteria). The 12-month prevalence of any disorder was 21.1% (10.4% mild, 38.7% moderate, and 50.9% severe) and was associated with: younger age, female, previously married, and with persistence of any disorder. Persistence was 74.7% (64.0% mood and 75.6% anxiety) and was significantly associated with secondary education or lower. Minimally adequate treatment received among those with any 12-month mental disorder was 10.6% (74.6% in healthcare and 64.6% non-healthcare sectors). Severity and the number of disorders significantly associated with each other and with treatment received (χ2=7.24, p=0.027) including adequate treatment within the mental health specialty sector (χ2=21.42, p<0.001). Multimorbidity and sociodemographics were associated with 12-month mental disorder. Treatment adequacy in Qatar are comparable to high-income countries. Low treatment contact indicate need for population-wide mental health literacy programes in addition to more accessible and effective mental health services.

Improving Physical Health Among People With Serious Mental Illness: The Role of the Specialty Mental Health Sector.

People with serious mental illness die 10-20 years earlier, compared with the overall population, and the excess mortality is driven by undertreated physical health conditions. In the United States, there is growing interest in models integrating physical health care delivery, management, or coordination into specialty mental health programs, sometimes called "reverse integration." In November 2019, the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness convened a forum of 25 experts to discuss the current state of the evidence on integrated care models based in the specialty mental health system and to identify priorities for future research, policy, and practice. This article summarizes the group's conclusions. Key research priorities include identifying the active ingredients in multicomponent integrated care models and developing and validating integration performance metrics. Key policy and practice recommendations include developing new financing mechanisms and implementing strategies to build workforce and data capacity. Forum participants also highlighted an overarching need to address socioeconomic risks contributing to excess mortality among adults with serious mental illness.

The Epidemiology of Depressive Disorders and Service Use in China: Findings from the China Mental Health Survey

Background: In China, depressive disorders have been estimated to be the second leading cause of years lived with disability (YLDs). However, nationally representative epidemiological data for depressive disorders, in particular depressed adults’ mental health services use, are still unavailable in China. The present study is a part of the Chinese National Mental Health Survey (CMHS), 2012–15, which reported the prevalence, treatment, and associated disability of depressive disorders in the Chinese general population. Methods: The CMHS recruited a representative sample of 28140 Chinese residents (≥ 18 years) by using multistage proportional-to-population-size sampling method. Trained investigators interviewed participants with the Composite International Diagnostic Interview 3.0 to ascertain the presence of lifetime and 12-month depressive disorders according to DSM-IV criteria, including major depressive disorder (MDD), dysthymic disorder (DD), and depressive disorder not otherwise specified (DD-NOS). Participants with 12-month depressive disorders were asked whether they ever received any 12-month treatment for their emotional problems and the specific types of treatment providers. The Quick Inventory of Depressive Symptomatology and Sheehan Disability Scale (SDS) were used to evaluate the severity of and role impairments associated with 12-month depressive symptoms. Findings: The weighted lifetime and 12-month prevalence rates of any depressive disorder were 6.8% (95%CI: 5.8-7.8%) and 3.6% (95%CI: 3.0-4.2%), respectively; the corresponding figures were 3.4% (95%CI: 2.0-3.9%) and 2.1% (95%CI: 1.8-2.4%) for MDD, 1.4% (95%CI: 1.1-1.7%) and 1.0% (95%CI: 0.8-1.3%) for DD, and 3.2% (95%CI: 2.6-3.9%) and 1.4% (95%CI: 1.1-1.7%) for DD-NOS. Overall, 77.2% of persons with 12-month depressive disorders had role impairment of any SDS domain: 82.2% for MDD, 81.5% for DD, and 64.6% for DD-NOS. Depressed participants reported an average of 41.0 days out of role in the past year due to depression; the corresponding figures were 49.7 days for MDD, 54.9 days for DD, and 12.2 days for DD-NOS. In total, 88.9% of individuals with 12-month depressive disorders had clinically significant depressive symptoms: 93.7% for MDD, 91.7% for DD, and 77.5% for DD-NOS. MDD and DD had similar proportions of “severe” or “very severe” depressive symptoms (43.0% and 42.1%), which were higher than DD-NOS (13.9%). 9.5% of participants with 12-month depressive disorders were treated in any treatment sector: 3.6% in the specialty mental health (SMH), 1.5% in the general medical (GM), 0.3% in the human services (HS), and 3.3% in the complementary-alternative medical (CAM) sector. Respondents with MDD and DYS had the highest proportion of seeking treatment in SMH sector (4.7% and 3.0%) while those with DD-NOS had the highest proportion of seeking treatment in CAM sector (most treatments were Traditional Chinese Medicine) (3.3%). Only 0.5% of participants with depressive disorders were treated adequately. Rates of treatment adequacy of MDD and DYS in SMH sector were 9.2% and 2.4%, respectively. Both rates in GM sector were 0%. Interpretation: Compared to western countries, our data show a relatively low prevalence of depressive disorders in China. Nevertheless, their associated role impairments, symptom severities, and disabilities are severe. Importantly, the treatment rates are rather low, let alone adequate treatment. Nationwide programs aiming at removing barriers in availability, accessibility, and acceptability to mental healthcare are needed in China. Funding: The study was funded by the Special Research Project for Non-profit Public Service of the Chinese Ministry of Health (grant number 201202022), the National Twelfth Five-Year Plan for Science and Technology Support of the Chinese Ministry of Science and Technology (grant numbers 2012BAI01B01 & 2015BAI13B00) and the National Key R&D Program of China (grant numbers 2017YFC0907800, 2017YFC0907801). Declaration of Interests: The authors have no conflicts of interest to declare Ethical Approval: The study protocol of CMHS was approved by the Ethics Committee of the Sixth Hospital of Peking University (No.: IMH-IRB-2013-13-1).

Lifetime treatment of DSM-IV mental disorders in the Saudi National Mental Health Survey.

ObjectivesTo estimate lifetime treatment rates of mental disorders in the Saudi National Mental Health Survey (SNMHS).MethodsThe SNMHS is a face‐to‐face community epidemiological survey in a nationally representative household sample of citizens ages 15–65 in the Kingdom of Saudi Arabia (KSA) (n = 4,004). The World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) was used to produce estimates of lifetime prevalence and treatment of common DSM‐IV mental disorders.ResultsLifetime treatment ranged from 52.2% for generalized anxiety disorder to 20.3% for attention deficit/hyperactivity disorder, had a median (interquartile range) of 35.5% (30.6–39.5%) across disorders, and was 28.3% for people with any lifetime DSM‐IV/CIDI disorder. Half (49.0%) of patients received treatment in the mental health specialty sector, 35.9% in the general medical sector, 35.2% in the human services sector, and 15.7% in the complementary‐alternative medical sector. Median (interquartile range) delays in help‐seeking after disorder onset among respondents who already sought treatment were 8 (3–15) years. Odds of seeking treatment are positively related to age‐of‐onset and comorbidity.ConclusionsUnmet need for treatment of lifetime mental disorders is a major problem in KSA. Interventions to ensure prompt help‐seeking are needed to reduce the burdens and hazards of untreated mental disorders.

The Current Psychiatric Mental Health Registered Nurse Workforce.

To define and describe the current psychiatric mental health registered nursing (PMHN) workforce providing care for persons with mental health and substance use conditions, evaluate sources of data relevant to this workforce, identify additional data needs, and discuss areas for action and further investigation. This article uses currently available data, much of it unpublished, to describe the current PMHN workforce. The available data indicate that PMHNs represent the second largest group of behavioral health professionals in the United States. As is true of the overall nursing workforce, PMHNs are aging, overwhelming female, and largely Caucasian, although the PMHN workforce is becoming more diverse as younger nurses enter the field. PMHNs are largely employed in the mental health specialty sector, and specifically in institutional settings. Similar to other behavioral health professionals, a significant shortage of PMHNs exists in rural areas. Because of data limitations and difficulty accessing the best available data on the PMHN workforce, it is often overlooked or mischaracterized in published research and government reports on the behavioral health workforce. Although PMHNs are one of the largest groups in the behavioral health workforce, they are largely invisible in the psychiatric literature. Psychiatric nursing must correct misperceptions about the significance of the PMHN workforce and increase awareness of its importance among government agencies, large health care organizations, and within the broader nursing profession.

Maternal psychopathology and mental health treatment delay in adolescents from a national cohort.

To investigate whether maternal psychopathology predicts mental health service use and treatment delay in offspring with mental disorders. Weighted data collected between 2001 and 2004 from NCS-A participants (age: 13-18years; N=2939) meeting DSM-IV criteria for any lifetime mental disorder, assessed with WHO CIDI, and from their biological mothers. National representative cohort. Maternal psychopathology was assessed with self-report, adolescent mental health service use with the Service Assessment for Children and Adolescents. Maternal psychopathology predicted offspring mental health service use across various service sectors, except for school services. In the mental health specialty sector, estimates were highest for maternal affective (hazard ratio (HR)=2.17, 95 percent confidence interval (CI)=1.66-2.82) and any mental disorder (HR=2.13, 95 percent CI=1.53-2.97). For offspring use of any mental health services, estimates were highest for maternal behavior (HR=1.60, 95 percent CI=1.15-2.21) and substance use disorders (HR=1.57, 95 percent CI=1.09-2.24). Treatment delay of offspring mental health service use was predicted by maternal behavior disorders. Maternal psychopathology fostered mental health service use in offspring with mental disorders, while maternal behavior disorders might also retard treatment. Considering parental psychopathology may help improving the prevention of unmet offspring service needs.

Patterns and predictors of health service use among people with mental disorders in São Paulo metropolitan area, Brazil.

Important transformations in psychiatric healthcare (HC) delivery have been implemented in Latin America during the beginning of 21st century. However, information on current service uses patterns is scant, obstructing the estimates and proper planning of service needs for general population. The current investigation aims to describe patterns and estimates predictors of 12-month HC use by individuals with mental disorders in São Paulo metropolitan area, Brazil. Data are from São Paulo Mental Health Survey, a cross-sectional multistage representative study. Participants were face-to-face interviewed in their household, using a structured diagnostic interview, the World Mental Health Survey Initiative version of the Composite International Diagnostic Interview. A total of 5037 respondents, non-institutionalised, aged 18 years and older were interviewed. The response rate was 81.3%. We determined the percentages of individuals with 12-month DSM-IV anxiety, mood and substance disorders that received treatment in the 12 months prior to assessment in main service sectors (specialty mental health, general medicine, human services (HS), and complementary and alternative medicine). The number of visits and percentage of individuals who received treatment at minimally adequacy also was estimated. Multilevel regression controlled contextual variables that influenced the use of service and treatment adequacy. Only 10.1% of respondents used some HC service in the 12 months prior to assessment for their psychiatric problems, including 3.9% of them being treated either by a psychiatrist, 3.5% by a non-psychiatrist mental health specialist, 3.3% by a general medical (GM) provider, 1.5% by a HS provider and 1.4% by a complementary and alternative medical provider. In general, those participants who received service in the mental health specialty sector reported more visits than those in the GM sector (median 3.9 v. 1.5 visits). The cases seen in specialty sector outnumber those visiting GM treatment in terms of minimally adequate treatment (54.6 v. 23.2%). The likelihood of receiving treatment was significantly greater among individuals diagnosed with any anxiety and mood disorder, presenting more severe disorders, and with possession of HC insurance. The great majority of individuals with an active mental disorder in São Paulo were either untreated or insufficiently treated. Awareness and training programmes to GM professionals are advocated to improve recognition, care take and referral to specialty care when needed. Proper integration among HC sectors is recommended.

Telepsychiatry: Promise, Potential, and Population Health

Telepsychiatry: Promise, Potential, and Population Health

Lifetime and 12-month prevalence, severity and unmet need for treatment of common mental disorders in Japan: results from the final dataset of World Mental Health Japan Survey.

The aim of this study is to estimate the lifetime and 12-month prevalence, severity and treatment of Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV) mental disorders in Japan based on the final data set of the World Mental Health Japan Survey conducted in 2002-2006. Face-to-face household interviews of 4130 respondents who were randomly selected from Japanese-speaking residents aged 20 years or older were conducted from 2002 to 2006 in 11 community populations in Japan (overall response rate, 56%). The World Mental Health version of the World Health Organization Composite International Diagnostic Interview (WMH-CIDI), a fully structured, lay administered psychiatric diagnostic interview, was used for diagnostic assessment. Lifetime/12-month prevalence of any DSM-IV common mental disorders in Japan was estimated to be 20.3/7.6%. Rank-order of four classes of mental disorders was anxiety disorders (8.1/4.9%), substance disorders (7.4/1.0%), mood disorders (6.5/2.3%) and impulse control disorders (2.0/0.7%). The most common individual disorders were alcohol abuse/dependence (7.3/0.9%), major depressive disorder (6.1/2.2%), specific phobia (3.4/2.3%) and generalized anxiety disorder (2.6/1.3%). While the lifetime prevalence of any mental disorder was greater for males and the middle-aged, the persistence (proportion of 12-month cases among lifetime cases) of any mental disorder was greater for females and younger respondents. Among those with any 12-month disorder, 15.3% were classified as severe, 44.1% moderate and 40.6% mild. Although a strong association between severity and service use was found, only 21.9% of respondents with any 12-month disorder sought treatment within the last 12 months; only 37.0% of severe cases received medical care. The mental health specialty sector was the most common resource used in Japan. Although the prevalence of mental disorders were quite low, mental disorders were the second most prevalent cause of severe role impairment among chronic physical and mental disorders. These results suggest lower prevalence of mental disorders in Japan than that in Western countries, although the general pattern of disorders, risk factors and unmet need for treatment were similar to those in other countries. Greater lifetime prevalence for males and greater persistence for females seems a unique feature of Japan, suggesting a cultural difference in gender-related etiology and course of disorders. The treatment rate in Japan was lower than that in most other high-income countries in WMH surveys.

Location of care for patients with borderline personality disorder: Challenges and opportunities in finding a home.

Patients with borderline personality disorder (BPD) represent a population with increased care needs and high provider demand, even in the best cases of quality integrated primary care. The current article outlines the complexities of working with patients with BPD in primary care, including when the transition to the specialty mental health sector may be warranted. Core factors around transitions of care (between integrated primary care and the specialty mental health sector) have been identified. These factors included suicidal ideations, psychiatric hospitalizations/conditions, physician consultation availability, behavioral provider availability, supervision availability, finances, and patient preferences. (PsycINFO Database Record

Medication Use in US Youth With Mental Disorders

To evaluate the prevalence, demographic and clinical correlates, and specificity of classes of psychotropic medications indicated for mental disorders. Cross-sectional survey. Direct household interviews of combined household and school samples representative of the general population of adolescents in the United States. Ten thousand one hundred twenty-three adolescents aged 13 to 18 years who participated in the National Comorbidity Survey Adolescent Supplement. Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) mental disorders and neurodevelopmental disorders. Psychotropic medication use in the past 12 months. Among youth with any DSM-IV mental disorder, 14.2% reported that they had been treated with a psychotropic medication in the past 12 months. Strong associations emerged between specific disorders and classes of medications with evidence for efficacy. Antidepressants were most frequently used among those with primary mood disorders (14.1%); stimulant use was most common among those with attention-deficit/hyperactivity disorder (20.4%); and antipsychotic use was infrequent and mostly seen among those with serious developmental disorders. Less than 2.5% of adolescents without a 12-month mental disorder had been prescribed psychotropic medications, and most had evidence of psychological distress or impairment reflected in a previous mental disorder, subthreshold condition, or developmental disorder. Appropriate medication use was significantly more frequent among those in treatment in the mental health specialty sector than general medicine or other settings. These findings challenge recent concerns over widespread overmedication and misuse of psychotropic medications in US youth. In fact, these data highlight the need for greater recognition and appropriate treatment of youth with mental health disorders.

Changes in Racial-Ethnic Disparities in Use and Adequacy of Mental Health Care in the United States, 1990–2003

This study examined changes in white-black and white-Latino disparities in the use of any mental health care and minimally adequate mental health care. Using data from the 1990&#x02013;1992 National Comorbidity Survey (NCS) and the 2001&#x02013;2003 National Comorbidity Survey Replication (NCS-R), this study examined changes by race-ethnicity in use of mental health care among individuals age 18 to 54 with a 12-month mood or anxiety disorder. The sample consisted of 1,198 NCS respondents and 929 NCS-R respondents. Changes in disparities were estimated in the use of any mental health care in the general medical sector, the specialty mental health sector, and in total. Changes in disparities were also estimated in the use of minimally adequate mental health care (in total only). Disparities in the use of any mental health care increased over time, particularly between non-Latino whites and non-Latino blacks in the general medical sector and between non-Latino whites and Latinos in the specialty mental health sector. Disparities in the use of minimally adequate mental health care persisted between whites and blacks over time but were not detected between whites and Latinos in either period. The findings of greater racial-ethnic disparities in the general medical and specialty mental health sectors indicate that more targeted policies and programs are needed to increase use of mental health care in these health sectors among persons from racial-ethnic minority groups. The persistence of white-black disparities in the use of minimally adequate mental health care warrants further examination.

Falling through the cracks

Depression is the most common mental health disorder among HIV patients, affecting 20–30% of those engaged in HIV medical care.1 In addition to being a serious, costly, and potentially fatal medical condition in its own right, depression poses challenging barriers to effective medical care at multiple points along the continuum of HIV medical care engagement and treatment,2 or what has become known as the “HIV treatment cascade.”3 The HIV treatment continuum shows that for an HIV-infected individual to achieve virologic suppression, the individual must be aware of his or her diagnosis, engage in HIV medical care, remain in care, start antiretroviral therapy (ART), and adhere to ART. Thus high population-level success rates in testing, linking and retaining in care, initiating ART, and maximizing adherence are essential to maximally reduce “community viral load.”4 However, with substantial attrition at each step along the HIV treatment continuum, a recent analysis estimated that only 19% of HIV-infected individuals in the US currently have suppressed virus.2 Attrition along the steps of the HIV treatment continuum is related to many factors, but in particular is strongly predicted by depression. Mounting evidence suggests that effectively treating depression in HIV patients may have benefits for their HIV treatment retention, ART adherence, and virologic suppression, and therefore for community viral load.5,6 However, the response to depression in HIV patients suffers from its own “treatment cascade.” Depression in HIV patients, while highly prevalent, is widely unrecognized.7 When clinically recognized, the condition often goes untreated.8 When treated, providers’ adherence to best-practices guidelines about dosing, duration, and monitoring of antidepressants is low, meaning that many patients fail to receive an adequate treatment course and therefore fail to benefit from treatment.9

Who gets mental health treatment from the GP? Results from the Israel National Epidemiological Mental Health Survey

In view of the pending mental health (MH) reform, an increase in demand of MH services is expected. Primary care physicians will presumably be involved in meeting this expected increased demand. To identify the preferable route of service use of populations with MH problems based on data from the Israel National Health Survey (INHS). The sample was drawn from the INHS which assessed mental disorders as well as the existence of chronic physical diseases in the population and the use of services for MH problems (specialty and primary care). The examined variables were (i) the existence of any mood or anxiety disorder and its severity, (ii) suffering from a chronic physical disease, (iii) use of MH services and (iv) use of general health services for MH problems. Fifty-one per cent of all those treated for MH problems were treated in the MH specialty sector and 49% in the general sector. Among those who met the diagnostic Composite International Diagnostic Interview criteria of any mood or anxiety disorder, the percentages were 62% and 38%, respectively. Irrespective of diagnosis, the proportion of those using the services of the GP is significantly greater among people above the age 50 years than among younger people. People with emotional problems above the age of 50 years are more likely to prefer help for their problems from their GP regardless of the presence of any mental disorder or of a chronic medical disease.

Factors Associated With Receipt of Adequate Antidepressant Pharmacotherapy by VA Patients With Recurrent Depression

Adequate treatment of depression improves the prognosis of depressed individuals. This study identified sociodemographic, medical, psychiatric, and health care utilization factors associated with receipt of adequate antidepressant pharmacotherapy by Veterans Health Administration (VHA) patients with recurrent depression. National VHA electronic medical records were used to construct a cohort of depressed patients who were experiencing a recurrent episode of depression between 1999 and 2006. Multinomial logistic regression determined factors that were associated with no receipt of treatment and with three levels of treatment: some antidepressant pharmacotherapy, adequate acute-phase pharmacotherapy, and adequate continuation-phase pharmacotherapy. A total of 26,770 patients aged 25 to 80 years, most of whom were male (84.5%), who were experiencing a recurrent episode of depression were identified. Female patients and those with substance abuse or dependence, nicotine dependence, or panic disorder were more likely to receive adequate acute-phase or continuation-phase treatment (or both) than to receive no treatment. Nonwhite race, being unmarried, having only VA benefits, having generalized anxiety disorder, and receiving treatment outside the mental health specialty sector were associated with a lower likelihood of receiving guideline-concordant care. Factors associated with receipt of adequate treatment for recurrent depression were similar to those found in previous studies for patients with new episodes of depression. This study was one of the first to focus specifically on patients experiencing recurrent depression, rather than combining patients with new and recurrent episodes in one sample. Continued research is warranted on how to modify factors to increase receipt of adequate care.

Health Care Reform and Care at the Behavioral Health--Primary Care Interface

Health Care Reform and Care at the Behavioral Health--Primary Care Interface

Mental health service use among Canadian older adults with anxiety disorders and clinically significant anxiety symptoms

Objectives: Despite evidence of disproportionate underutilization of mental health services by older adults and by individuals with anxiety disorders, little is known specifically about service use by older adults with anxiety. This study examines the prevalence of mental health service use among older adults with anxiety disorders and clinically significant anxiety symptoms, as well as factors associated with service use. Method: The authors used data from the Canadian Community Health Survey–Mental Health and Well-Being, a nationally representative survey of community-dwelling Canadians. This study examined past-year use of mental health services in both the specialty mental health and general medical sectors by adults aged 55+ (N = 12,792). Logistic regression analyses examined predictors of service use among those with anxiety disorders (N = 279) and clinically significant anxiety symptoms (N = 880). Results: Only 20.8% of older adults with an anxiety disorder and no mood disorder used services in the past year, compared to 43.1% of those with a mood disorder and 72.7% of those with comorbid disorders. In the final logistic regression models, only need variables were significant predictors of service use among older adults with anxiety disorders and among those with significant anxiety symptoms. Conclusion: Findings indicate that anxious older adults are less likely to use mental health services than those who are depressed. While predisposing and enabling factors do not appear to impede service use, the need for help does. Anxious older adults and those they interact with may not be interpreting their anxiety symptoms as warranting services.

Women's Use of Multisector Mental Health Services in a Community-based Perinatal Depression Program

Low-income and ethnic minority women have been described as at risk for experiencing depression during and around the time of pregnancy, a finding complicated by low levels of mental health service use within this population. This study retrospectively examined data from a community-based perinatal depression project targeting low-income women in which many barriers to care were removed and a range of services could be elected from social work, specialty mental health, primary care, and peer support. The study focused on 206 women who self-referred to the project after community-based screening. In this sample, the mean age was 25.49 years, with 53% of participants identified as women of color, and 76% had income at or below 185% of the poverty level. The characteristics within this sample most strongly associated with service use varied among sectors of care. Women of color and women with elevated psychosocial risk were significantly more likely to use social work home visiting, whereas current depressive symptom level predicted specialty mental health sector treatment but not other sectors of care. Findings from this study compel future research to consider the complex factors influencing women's use of mental health services among multiple sectors of care. KEY WORDS: community-based research; depression; mental health services; service utilization; women ********** An estimated 15% or more of all women who become pregnant experience depression (Edwards et al., 2006; Evans, Heron, Francomb, Oke, & Golding, 2001). Reviews of both medical and social-behavioral research in this area have placed a needed emphasis on emerging clinical trends in identification and treatment (that is, American College of Obstetricians and Gynecologists, 2008; Bledsoe & Grote, 2006). However, elevated risk for mental health challenges for pregnant women may also collide with barriers to full use of mental health services and, thus, jeopardize the receipt of accessible, affordable, and culturally congruent care (Alegria et al., 2002; Anderson et al., 2006; Song, Sands, & Wong, 2004). Currently, there is a gap in knowledge about where and why low-income pregnant and newly parenting women with depression choose to seek mental health services when services are made available to them across sectors of care. The present study begins to address this gap by examining demographics, current symptoms, and psychosocial risk factors and their influence on service use patterns within one specific community program serving low-income, rural women during and around the time of pregnancy. This study supports Abrams and Curran's (2007) assertion that social work's research agenda for perinatal and maternal depression must be positioned to highlight the experiences of diverse groups of women within a biopsychosocial context. DOMAINS OF RISK FOR DEPRESSION A substantive body of literature illustrates demographic risk factors for perinatal and maternal depression. Elevated rates of depressive symptoms, for example, have been detected early in the postpartum period for African American and Latina women (Howell, Mora, Horowitz, & Leventhal, 2005), as have both-prevalence and continuity of elevated symptoms for African American mothers through 18 months postpartum (Beeghly et al., 2003). In addition, low socioeconomic status reportedly increases the risk for ethnic minority women (Beeghly et al., 2003; Miranda et al., 2003; Rosen, Tolman, & Warner, 2004). Life stressors and psychosocial challenges also contribute to increased risk for depression. In a recent meta-analysis, depression or anxiety during pregnancy, prior mental health history, stressful life events, and lack of adequate social support were identified as moderate to strong predictors of elevated risk for postpartum depression (Robertson, Grace, Wallington, & Stewart, 2004). Several specific forms of stress have been identified as potentially affecting the emotional well-being of women during and around pregnancy, including perinatal loss (Price, 2008), family violence and abuse (Martin et al. …

Mental Health vs Mental Disorders

IN THE CALL FOR PAPERS FOR THIS JAMA THEME ISSUE ON mental health, I noted the irony that in an issue devoted to mental health most of the articles would undoubtedly beaboutmentaldisorders,withthesimpleexplanationthat mental disorders are the problem and mental health is the goal; and that the goal for the JAMA theme issue on mental health was to“beofassistance tocliniciansandpolicymakers inhelping patients, families, and communities move in that positive direction.” Readers can now evaluate the extent to which this themeissueachieves thatgoal.A totalof182submissionswere received for consideration for the theme issue, and 6 major articles, 4 Commentaries, a Cover Story describing the circumstancessurroundingVincentVanGogh’shospitalizations,apowerful A Piece of My Mind essay, and several book reviews and Medical News & Perspectives pieces are now published in it. One area of need is that the number of persons requiring treatment for mental disorders far exceeds the capacity of the mental health specialty sector to provide that treatment. A potential solution for this problem is to expand the capacity to identify and effectively treat mental disorders in the primary care sector. An approach to providing effective evidencebased treatments for mental disorders in primary care is “collaborative care,” in which appropriately trained clinicians collaborate with primary physicians to evaluate and treat primary care patients, with mental health specialty consultation as needed. The effectiveness of this strategy for depressive disorders is now rather well established, but its use for anxiety disorders, despite their frequency in primary care, has not been well studied. The randomized controlled trial reported by Roy-Byrne et al involving an intervention called Coordinated Anxiety Learning and Management (CALM) provides a welcome assessment of a flexible and practical treatment delivery model for common anxiety disorders (panic disorder, generalized anxiety disorder, social anxiety disorder, and posttraumatic stress disorder) in the primary care setting. This trial was conducted in 17 primary care clinics in 4 US cities and found significantly better improvement in anxiety symptom ratings and also in rates of response and remission using the CALM collaborative care intervention compared with usual care. As the authors note, analyses of the cost of CALM will be important and “implementation of this model will require reimbursement mechanisms for care management that are not currently available.” Inanother randomizedcontrolled trial in this issue,Piacentini et al report the results of a behavioral treatment intervention called habit reversal training for Tourette disorder and chronic tic disorder. This study is notable not only for calling attention to an evidence-based nonpharmacologic intervention for these neuropsychiatric disorders, but also because it useda timeandattentioncontrol treatmentof supportivepsychotherapy and education as a “placebo” comparator, an improvement over many studies of psychotherapeutic interventions that use only no treatment or waiting list controls and thus do not control for the nonspecific effects of time and attention. Significantly more children receiving the behavioral treatment (53%) were rated as very much or much improved comparedwithchildrenreceiving thecontrol treatment(19%) after 10 weeks, with 87% of available responders to behavior therapy showing continued benefit 6 months after treatment. Concernsabout injuredsoldiers inIraqandAfghanistanhave recently focusedattentiononpersonswithtraumaticbrain injuries and their needs for rehabilitation. In addition to physical and cognitive impairment, psychological impairments associated with traumatic brain injuries are of concern. The occurrence of major depressive disorder (MDD) in individuals with traumatic brain injuries is one such concern. Bombardier et al report that in a cohort of 559 consecutively hospitalized adults with traumatic brain injuries (most commonly due to motor vehicle crashes), 53% met criteria for MDD at least once during the first year after their injury, with an increased risk for MDD associated with MDD at the time of injury, history ofMDDpriorto injury,youngerage,andlifetimealcoholdependence. Clearly, identification of and treatment for MDD are important issues for further research, clinical care, and rehabilitation of persons with traumatic brain injuries. In an article about the occurrence and effect of major depression in the course of another medical disorder, Hedayati et al report that the presence of a major depressive episode was associated with an increased risk of hospitalization and initiation of dialysis in patients with chronic kidney disease. Previous studies have found that depression is an independent risk factor for hospitalization and death in maintenance dialysis patients, but the new report shows that depression is associated with worse outcomes in chronic kidney disease patients not yet undergoing dialysis. Research on the efficacy and safety of treatments for depression in this patient population is clearly needed. In an analysis of an intriguing natural experiment, Costello et al report longer-term follow-up results from their 2003 JAMA report on the effects of an income supplement provided to Cherokee Indian families when a casino was opened on their reservation in 1996. The earlier report

Drawing the Line: The Cultural Cartography of Utilization Recommendations for Mental Health Problems

In the 1990s, sociologists began to rethink the failure of utilization models to explain whether and why individuals accessed formal treatment systems. This effort focused on reconceptualizing the underlying assumptions and processes that shaped utilization patterns. While we have built a better understanding of how social networks structure pathways to care and how disadvantaged sociocultural groups face substantial barriers to treatment, we have less understanding of the larger cultural context in which individuals recognize and respond to symptoms. Drawing from recent innovations in the sociology of culture, we develop the concept of "cultural mapping" to describe if and how individuals discriminate among different available sources of formal treatment. Using data from the 1996 Mental Health Module of the General Social Survey, we compare Americans' willingness to recommend providers in the general medical and specialty mental health sectors. The results indicate that, despite unrealistically high levels of endorsement, individuals do discriminate between providers based on their evaluation of the problem, underlying causes, and likely consequences. While perceived severity leads individuals to suggest any type of formal care, problems attributed to biological causes are directed to general or specialty medical providers (doctors, psychiatrists, and hospitals); those matching symptoms for schizophrenia or seen as eliciting violence are allocated to the specialty mental health sector (psychiatry, mental hospital); and those seen as being caused by stress are sent to nonmedical mental health providers (i.e., counselors). These findings help to explain inconsistencies in previous utilization studies, and they suggest the critical importance of maintaining a dialogue between medical sociology and the sociology of culture.