Chartbook on Effective Treatment—Mental Health and Substance Abuse: Slide Presentation

Slide 1

National Healthcare Quality and Disparities Report
Chartbook on Effective Treatment

Mental Health and Substance Abuse

Slide 2

Measures

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

Slide 3

Treatment for Depression

• Treatment for depression can reduce symptoms and associated illnesses and return individuals to a productive lifestyle.
• Sequenced Treatment Alternatives to Relieve Depression (STAR*D) studied treatment:
  
  • Largest clinical trial ever of depression treatment
  • Found that 28% to 33% of participants were symptom free after the first round of medication, and nearly 70% achieved remission after 12 months (Insel & Wang, 2009).
• Compared with usual care, strategies for treating depression in primary care settings have produced positive net social benefits (Glied, et al., 2010).

• STAR*D was funded by the National Institute of Mental Health.
  
  • It involved both primary care and specialty care settings.
  • Participants included people with complex health conditions, such as multiple concurrent medical and psychiatric conditions.
• Strategies for treating depression in primary care settings include the collaborative care model.
• Glied, et al., performed cost-benefit analyses.

Slide 4

Outcomes of Treatment for Depression

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

• Anhedonia is the inability to feel pleasure.

Slide 5

Barriers to High-Quality Mental Health Care

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

Slide 6

Adults with a major depressive episode in the past year who received treatment for depression in the past year, by race/ethnicity and sex, 2008-2012

Image: Charts show adults with a major depressive episode in the past year who received treatment for depression in the past year, by race/ethnicity and sex:

Left Chart:

Right Chart:

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2008-2012.
Denominator: Adults age 18 and over with a major depressive episode in the past year.
Note: Major depressive episode is defined as a period of at least 2 weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities and had a majority of the symptoms of depression described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. Treatment for depression is defined as seeing or talking to a medical doctor or other professional or using prescription medication in the past year for depression. White and Black are non-Hispanic; Hispanic includes all races.

• Importance: The United States Preventive Services Task Force (USPSTF) recommends screening adults for depression when staff-assisted depression care supports are in place to ensure accurate diagnosis, effective treatment , and followup (USPSTF, 2015).
• Overall Rate: In 2012, 68% of adults with a major depressive episode received treatment for depression.
• Groups With Disparities:
  
  • In all years, Black adults with depression were less likely than White adults to receive treatment.
  • In every year except 2010, Hispanic adults with depression were less likely than White adults to receive treatment.
  • From 2008 to 2012, females with a major depressive episode were more likely than males to receive treatment.

Slide 7

Adolescents with a major depressive episode in the past year who received treatment for depression in the past year, by race/ethnicity and sex, 2008-2012

Image: Charts show adolescents with a major depressive episode in the past year who received treatment for depression in the past year, by race/ethnicity and sex:

Left Chart:

Right Chart:

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2008-2012.
Denominator: Adolescents ages 12-17 with a major depressive episode in the past year.
Note: Major depressive episode is defined as a period of at least 2 weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities and had a majority of the symptoms of depression described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. Treatment for depression is defined as seeing or talking to a medical doctor or other professional or using prescription medication in the past year for depression. White and Black are non-Hispanic; Hispanic includes all races.

• Importance:
  
  • Outpatient mental health treatment and psychotropic medication use in children and adolescents increased in the United States between 1996-1998 and 2010-2012. Although youths with less severe or no impairment accounted for most of the absolute increase in service use, youths with more severe impairment had the greatest relative increase in use, yet less than half accessed services in 2010-2012 (Olfson, et al., 2015).
  • The United States Preventive Services Task Force (USPSTF) recommends screening of adolescents ages 12-18 years for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and followup (USPSTF, 2015).
• Overall Rate: In 2012, 37% of adolescents with a major depressive episode received treatment for depression.
• Groups With Disparities:
  
  • In 3 of 5 years (2008, 2009, and 2010), Black adolescents with depression were less likely than White adolescents to receive treatment.
  • In 3 of 5 years (2009, 2010, and 2012), females with depression were more likely than males to receive treatment.

Slide 8

Suicide Deaths

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

Slide 9

Probability of Suicide

• Risk factors for suicide include:
  
  • Psychotic experiences (DeVylder, et al., 2015).
  • Suicidal ideation (Han, et al., 2015).
  • Positive responses to the item "Thoughts that you would be better off dead, or of hurting yourself in some way" on the Patient Health Questionnaire for depression (Simon, et al., 2013).
• Progression from ideation to suicide attempt varies by suicide plan and major depression status.
• Research needs to explore factors that affect suicide attempts and death by suicide among high-risk individuals with suicidal ideation (Han, et al., 2015).

• Individuals with psychotic experiences are about 5 times more likely to report suicidal ideation and nearly 10 times more likely to report a suicide attempt (DeVylder, et al., 2015). Assessing psychotic experiences among individuals with suicidal ideation could reduce suicide attempts.
• About 13% of suicidal ideators in a given year attempt suicide during that year. Suicidal ideation is the strongest known clinical predictor for death by suicide (Han, et al., 2015).

Slide 10

Suicide Prevention

• Suicide prevention is multifaceted, including:
  
  • Educating physicians and keeping lethal weapons away from suicidal people (Mann, et al., 2005).
  • Using cognitive-behavioral therapy (Tarrier, et al., 2008).
  • Implementing various strategies depending on risk:
    
    • Universal strategies that target entire populations.
    • Selective strategies that address at-risk populations.
    • Indicated strategies that address high-risk individuals (Nordentoft, 2011).

Note:

• Universal strategies target entire populations (e.g., public education and awareness programs).
• Selective strategies address at-risk populations (e.g., peer "natural helpers" and accessible crisis services).
• Indicated strategies address specific high-risk individuals (e.g., case management and parent support programs) (Nordentoft, 2011).

Slide 11

Suicide Prevention

• Ongoing research shows promising results for Internet-based cognitive-behavioral therapy and psychoeducation in treating individuals with conditions such as mood, eating, and sleep disorders (Thorndike, et al., 2013).
• As "mobile health" interventions become more sophisticated, they can be adapted to be culturally specific and sensitive (Burns, et al., 2013).

Slide 12

Suicide deaths per 100,000 population age 12 and over, by race/ethnicity and sex, 2008-2011

Image: Charts show Suicide deaths per 100,000 population age 12 and over, by race/ethnicity and sex:

Left Chart:

2008 Achievable Benchmark: 9 per 100,000 Population

Right Chart:

2008 Achievable Benchmark: 9 per 100,000 Population

Key: API = Asian and Pacific Islander; AI/AN = American Indian or Alaska Native.
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System—Mortality, 2008-2011.
Note: For this measure, lower rates are better. Estimates are age adjusted to the 2000 U.S. standard population. White and Black are non-Hispanic. Hispanic includes all races.

• Overall Rate: In 2011, the overall suicide death rate was 14.9 per 100,000 population age 12 and over.
• Trends: From 2008 to 2011, suicide death rates worsened for the total population, Whites, and both sexes.
• Groups With Disparities:
  
  • From 2008 to 2011, Blacks, Asians and Pacific Islanders, and American Indians and Alaska Natives had lower suicide death rates than Whites.
  • In all years, males had higher suicide death rates compared with females.
  • In all years, people living in medium metropolitan, small metropolitan, micropolitan, and noncore areas had higher suicide death rates compared with people living in large fringe metropolitan areas (data not shown). For more information on suicide death rates by geographic location, refer to the Rural Health Reform Policy Research Center 2014 Update of the Rural-Urban Chartbook, available at https://ruralhealth.und.edu/projects/health-reform-policy-research-center/pdf/2014-rural-urban-chartbook-update.pdf (3.572 MB).
• Achievable Benchmark:
  
  • The 2008 top 5 State achievable benchmark was 9 suicide deaths per 100,000 population. The top 5 States that contributed to the achievable benchmark are Connecticut, District of Columbia, Massachusetts, New Jersey, and New York.
  • APIs, Blacks, and females have achieved the benchmark.
  • The total population, AI/ANs, Whites, and males are moving away from the benchmark.

Slide 13

Treatment for Substance Abuse Disorders

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

Slide 14

Importance of Treatment

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

Slide 15

Treatment Needs

• In 2013, nearly 23 million Americans age 12 years and over needed treatment for substance abuse.
• An estimated 2.5 million people received treatment at a specialty facility, but more than 20 million people who needed this type of treatment did not receive it (SAMHSA, 2014).

• Specialty facilities include hospital (inpatient), drug or alcohol rehabilitation (inpatient or outpatient), or mental health centers.

Slide 16

People age 12 and over who needed treatment for illicit drug use or an alcohol problem and who received such treatment at a specialty facility in the last 12 months, by race/ethnicity (2002-2012) and age (2008-2012)

Image: Charts show people age 12 and over who needed treatment for illicit drug use or an alcohol problem and who received such treatment at a specialty facility in the last 12 months, by race/ethnicity and age:

Left Chart:

2011 Achievable Benchmark: 15%

Right Chart:

2011 Achievable Benchmark: 15%

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2002-2012.
Denominator: Civilian noninstitutionalized population age 12 and over who needed treatment for illicit drug use or an alcohol problem.
Note: Treatment refers to treatment at a specialty facility, such as a drug and alcohol inpatient and/or outpatient rehabilitation facility, inpatient hospital setting, or mental health center. White and Black are non-Hispanic. Hispanic includes all races.

• Overall Rate: In 2012, only 10.8% of people age 12 and over who needed treatment for illicit drug use or an alcohol problem received such treatment at a specialty facility in the last 12 months.
• Groups With Disparities: From 2002 to 2012, there were no statistically significant differences by race/ethnicity; and from 2008 to 2012, there were no statistically significant differences by age.
• Achievable Benchmark:
  
  • The 2011 top 5 State achievable benchmark was 15%. The top 5 States that contributed to the achievable benchmark are Alabama, Alaska, Delaware, Maryland, Oregon, and Utah.
  • At the current rate, the total population would need 30 years to achieve this benchmark. People ages 12-17 would take 9 years, while people ages 18-44 would take 49 years. It would take people ages 45-64 less than 1 year to achieve the benchmark. Whites could achieve the benchmark in 15 years while Blacks and Hispanics are moving away from the benchmark.

Slide 17

Completion of Substance Abuse Treatment

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

Slide 18

People age 12 and over treated for substance abuse who completed treatment course, by race/ethnicity and education 2005-2011

Image: Charts show people age 12 and over treated for substance abuse who completed treatment course, by race/ethnicity and education:

Left Chart:

2008 Achievable Benchmark: 74%

Right Chart:

2008 Achievable Benchmark: 74%

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

• Overall Rate: In 2011, 43.7% of people age 12 and over treated for substance abuse completed their treatment course.
• Groups With Disparities:
  
  • In 4 of 7 years, Blacks who were treated for substance abuse were significantly less likely than Whites to complete treatment.
  • In all years, people with less than a high school education who were treated for substance abuse were less likely than people with any college education to complete treatment.
• Achievable Benchmark:
  
  • The 2008 top 5 State achievable benchmark was 74%. The top 5 States that contributed to the achievable benchmark are Colorado, Connecticut, District of Columbia, Mississippi, and Texas.
  • No group showed progress toward the benchmark.

Slide 19

Potentially Avoidable Emergency Department Visits

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

Slide 20

Emergency department visits with a principal diagnosis related to mental health, alcohol, or substance abuse, by age and income, 2007-2011

Image: Charts show Emergency department visits with a principal diagnosis related to mental health, alcohol, or substance abuse, by age and income:

Left Chart:

Right Chart:

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

• Overall Rate: From 2007 to 2011, the overall rate of ED visits with a principal diagnosis related to mental health, alcohol, or substance abuse significantly increased from 1,527.8 to 1,766.8 per 100,000 population.
• Groups With Disparities:
  
  • In all years, individuals ages 0-17 and 65 and over were significantly less likely to have an ED visit with a principal diagnosis related to mental health, alcohol, or substance abuse than individuals ages 18-44.
  • In 2011, individuals in the highest income quartile were less likely to have an ED visit with a principal diagnosis related to mental health, alcohol, or substance abuse than individuals in all other income groups.
  • For more ED measures for mental health and substance use disorders, refer to the 2014 Care Coordination chartbook at https://archive.ahrq.gov/research/findings/nhqrdr/2014chartbooks/carecoordination/index.html.

Slide 21

References

• Ahmedani BK, Simon GE, Stewart C, et al. Health care contacts in the year before suicide death. J Gen Intern Med 2014 Jun;29(6):870–7. PMID: 24567199. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4026491/. Accessed July 17, 2015.
• Burns MN, Montague E, Mohr DC. Initial design of culturally informed behavioral intervention technologies: developing an mHealth intervention for young sexual minority men with generalized anxiety disorder and major depression. J Med Internet Res 2013;15(12):e271,1-9. http://www.ncbi.nlm.nih.gov/pubmed/24311444. Accessed February 20, 2014.
• Casey M, Perera D, Clarke D. Psychosocial treatment approaches to difficult-to-treat depression. Med J Aust 2013 Sep 16;199(6 Suppl):S52-5. PMID: 25370289.
• Center for Behavioral Health Statistics and Quality. The NSDUH Report: substance use and mental health estimates from the 2013 National Survey on Drug Use and Health: Overview of findings. Rockville, MD: Substance Abuse and Mental Health Services Administration; September 2014. http://www.samhsa.gov/data/sites/default/files/NSDUH-SR200-RecoveryMonth-2014/NSDUH-SR200-RecoveryMonth-2014.htm. Accessed June 29, 2015.
• DeVylder J, Lukens E, Link B, et al. Suicidal ideation and suicide attempts among adults with psychotic experiences. JAMA Psychiatry 2015;72(3):219-25.
• Final update summary: depression in children and adolescents: screening. U.S. Preventive Services Task Force. July 2015.. http://www.uspreventiveservicestaskforce.org/Page/Topic/recommendation-summary/depression-in-children-and-adolescents-screening?ds=1&s=Depression-screening.
• Final update summary: depression in children and adolescents: screening. United States Preventive Services Task Force. July 2015. http://www.uspreventiveservicestaskforce.org/Page/Topic/recommendation-summary/depression-in-adults-screening?ds=1&s=Depression-screening.
• Glied S, Herzog K, Frank R. Review: the net benefits of depression management in primary care. Med Care Res Rev 2010 Jun;67(3):251-74.

Slide 22

References

• Han B, Compton WM, Gfroerer J, et al. Prevalence and correlates of past 12-month suicide attempt among adults with past-year suicidal ideation in the United States. J Clin Psychiatry 2015 Mar;76(3):295-302. PMID: 25830449.
• Insel TR, Wang PS. The STAR*D trial: revealing the need for better treatments. Psychiatr Serv 2009 Nov;60(11):1466-7.
• Mann JJ, Apter A, Bertolote J, et al, Suicide prevention strategies: a systematic review. JAMA 2005 Oct 26;294(16):2064-74.
• McLellan AT, Woody GE, Metzger D, et al. Evaluating the effectiveness of addiction treatments: reasonable expectations, appropriate comparisons. Milbank Q 1996;74(1):51-85.
• Nordentoft M. Crucial elements in suicide prevention strategies. Prog Neuropsychopharmacol Biol Psychiatry 2011 Jun 1;35(4):848-53. Epub 2010 Dec 2.
• Olfson, M, Druss, B, Marcus, S. Trends in mental health care among children and adolescents. New Engl J Med 2015 May 21;372(21):2029-38. PMID: 25992747.
• Owens P, Mutter R, Stocks C. Mental health and substance abuse-related emergency department visits among adults, 2007. HCUP Statistical Brief #92. Rockville, MD: Agency for Healthcare Research and Quality; July 2010. http://hcup-us.ahrq.gov/reports/statbriefs/sb92.jsp.
• Simon GE, Rutter CM, Peterson D, et al. Does response on the PHQ-9 depression questionnaire predict subsequent suicide attempt or suicide death? Psychiatr Serv 2013; 64(12):1195-202. http://www.ncbi.nlm.nih.gov/pubmed/24036589. Accessed February 20, 2014.
• Tarrier N, Taylor K, Gooding P. Cognitive-behavioral interventions to reduce suicide behavior: a systematic review and meta-analysis. Behav Modif 2008 Jan;32(1):77-108.
• Thorndike FP, Ritterband LM, Gonder-Frederick LA, et al. A randomized controlled trial of an Internet intervention for adults with insomnia: effects on comorbid psychological and fatigue symptoms. J Clin Psychol 2013; 69(10):1078-93. http://www.ncbi.nlm.nih.gov/pubmed/24014057. Accessed July 27, 2015.