Manual Improving Treatment Compliance: Counseling & Systems Strategies for Substance Abuse & Dual Disorders

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For example, a new primary care program for veterans designed to expand access to specialty mental health failed to do so Rosenheck, , despite the success of similarly designed gateway programs for other populations. Tailoring programs to the needs of distinct populations, including minority groups, is essential, given that they are less likely to access mental health treatment than are whites US DHHS, Its promise has been to improve access to health care by lowering its cost, reducing inappropriate utilization, relying on clinical practice guidelines to standardize care, promoting organizational linkages, and by emphasizing prevention and primary care.

The impact of managed care on mental health services has been profound in terms of costs: there is strong evidence that managed care has lowered the cost of mental health services US DHHS, The study cited above by the Hay Group indicated that during the growth of managed care, there was a 50 percent reduction in the mental health portion of total health care costs paid by employer-based insurance. Whether these cost reductions have lowered access to, and quality of, mental health services for people who need them is a critical topic for research, but one for which answers have been elusive.

Research has been stymied by the dramatic pace of change in the health care marketplace, the difficulty of obtaining proprietary claims data, and the lack of information systems tracking mental health quality or outcome measures Fraser, ; US DHHS, Most concerns center on potentially poorer quality and outcomes of care from limited access to mental health specialists, reduced length of inpatient care, and reductions in intensity of outpatient mental health services Mechanic, ; Mechanic, The impact of managed care expressly on detection or treatment of suicide has been largely unstudied.

The limited body of relevant research has focused on depression treatment, spotlighting problems in quality of care and outcomes. The first major studies of prepaid managed care versus traditional fee-for-service care found generally no overall differences in outcome, but poorer outcomes for patients with the most severe mental illness Lurie et al. Later studies, focusing exclusively on primary care, found that less than 50 percent of depressed patients in staff-model health maintenance organizations received antidepressant medication that met practice guidelines Katon et al.

One of few managed care studies to have addressed suicide, at least tangentially, was of outpatients with depression receiving care from seven managed care organizations of varying organizational structures Wells et al. Using patient questionnaires, the study found that about 48—60 percent of patients with depressive disorder received some sort of mental health care. Only 35—42 percent of depressed. Two findings of the study are particularly relevant to suicide prevention: 1 patients with suicidal ideation did not receive higher rates of treatment than did patients without suicidal ideation using measures of process and quality ; 2 patients with both depression and alcohol abuse—which places them at higher risk of suicide—were not given more specialty referrals, as recommended by treatment guidelines see later section on Substance Abuse.

A largely unstudied question is whether reductions in intensity of outpatient services, or in length of stay in inpatient care, contribute to suicide risk.

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Reduction in care was defined by the study as one or more of the following: reduced appointment frequency, lowered doses of medication, less supervised location e. While this study was not of managed care per se , it raises questions about cost containment strategies used by managed care to reduce intensity or frequency of services for people at risk of suicide.

In related findings, initial results from a study of all hospital discharges in Pennsylvania found a 25 percent reduction in length of stay during a 3-year period for inpatient treatment of depression. Preliminary results suggest that the reduction in length of stay was accompanied by an increase in readmission rates, a finding that the study investigators interpreted as suggesting that caution should be used when implementing practice guidelines for length of stay personal communication, J.

Quality improvement guidelines have been demonstrated to be successful at improving productivity and outcomes of depression in managed care, according to a randomized controlled trial Wells et al. The overwhelming majority of suicide victims have a diagnosable mental disorder—most commonly a mood or substance use disorder Chapter 3. Yet, as indicated earlier, most suicide victims do not have their disorder diagnosed or adequately treated at the time of suicide.

This section explores the multiple barriers to treatment posed by clinicians in primary care, emergency care, and specialty care.


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Primary care has become a critical setting for detection of depression and alcohol use disorders US Preventive Services Task Force, because of their high prevalence Murphy, Primary care refers to family physicians, obstetrician-gynecologists, nurse practitioners, general internists, or pediatricians. The detection and treatment of depression by primary care physicians is of great relevance to suicidology. Depression evaluation presents the first opportunity for primary care physicians to ask about suicidal ideation, which is one of several symptoms of major depressive disorder APA, , and a major risk factor for completed suicide Harris and Barraclough, Treatment of depression in primary care is associated with reduced rates of completed suicide, according to an uncontrolled ecological study on the Swedish island of Gotland see discussion in Chapters 7 and 8 , Rutz et al.

The effects of depression treatment in primary care on suicidal behavior are being studied in a controlled clinical trial in the United States. Preliminary results indicate reduced rates of hopelessness, suicidal ideation, and related symptoms of depression in older primary care patients personal communication, C. Reynolds, G.

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Alexopoulos, and I. Katz, University of Pittsburgh School of Medicine, In primary care, routine screening for depression is not currently recommended for all asymptomatic adults; however, routine screening for depression is recommended if the physician suspects depression or if the patient carries depression risk factors Beck et al. Preventive Services Task Force, New recommendations from the U. Preventive Task Force , Annals of Internal Medicine now call for screening for depression in the primary care setting.

Medical Association council, considerable evidence indicates that a diagnostic interview for depression is comparable in sensitivity and specificity to many radiologic and laboratory tests commonly used in medicine Preboth, During depression screening, guidelines explicitly recommend asking patients about suicidal intent and past suicide attempts. When a suicidal patient is identified, primary care physicians should refer them to specialty care and consider hospitalization Beck et al. The role of primary care is likely to expand, however, as a result of recent health care trends and high level public health concern about suicide prevention.

The expanding role of primary care in detection and treatment of depression stems from at least four major factors. The first is awareness of how frequently depression is encountered in primary care. Depression is one of the most common of all mental and somatic diagnoses Von Korff et al.

About 6—10 percent of people attending primary care settings have major depression Katon and Schulberg, The second is that many people with depression prefer to be treated in primary care or resist referral to specialty care Cooper-Patrick et al. Seventy-five percent of those seeking help for depression do so through their primary care physician rather than through a mental health professional Goldman et al. One reason may be that they perceive primary care as less stigmatizing than specialty mental health care.

The third factor is the advent of new classes of antidepressant medications that are less toxic when taken in overdose, thus making medication management less complex for non-specialists Hirschfeld and Russell, ; US DHHS, The fourth factor is the trend in cost containment. Managed care generally encourages the receipt of mental health services in primary, rather than specialty, care because of lower costs Mechanic, It is thus not surprising that about half of all people with depression and other mental disorders—either by preference or by financing—receive their mental health treatment in primary care US DHHS, Primary care physicians handle nearly half of all anti-depressant-related office visits Pincus et al.

Only about 30—50 percent of adults with diagnosable depression are accurately diagnosed by primary care physicians Higgins, ; Katon et al.


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Even more startling to suicide prevention are findings about the infrequency of suicide questioning during routine depression evaluation. Only 58 percent of a random sample of primary. When broken down by specialty, the study found 65 percent of family physicians, 52 percent of general internists, and 48 percent of obstetrician-gynecologists assessed suicide by direct questions. Through regression analyses, the study found that family physicians and general internists were significantly more likely to make direct assessments for suicide than were obstetrician-gynecologists Williams et al.

Reasons for physician reticence in asking about suicide are discussed in a later section. Since the vast majority of primary care physicians prefer to treat depression with medication Williams et al. Although detection and treatment in primary care are improving, major professional efforts have been undertaken to highlight and respond to the problem Beck et al. What are the reasons for inadequate detection and treatment of depression by primary care physicians? The most frequently cited barriers relate to lack of knowledge and time.

One recent survey of randomly selected primary care physicians found them to report widespread lack of knowledge about diagnostic criteria and treatment of depression. Overall, about one-third reported knowledge of formal diagnostic criteria and treatment, yet there was great variation between primary care specialties. Obstetrician—gynecologists reported the least knowledge, whereas family physicians reported the most knowledge Williams et al.

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Inadequate time and competing demands created by other health problems— under the cost pressures of managed care—have been identified as barriers in several studies Borowsky et al. The mean duration of a visit to a primary care physician is The time constraints on the primary care physician become immediately apparent, sparking concerns that primary care clinicians are ill-equipped for their enhanced role in detection of depression Kane, ; Katon et al.

Under-detection and under-treatment of depression are clearly associated with patient distress and disability Hirschfeld et al. Substance use disorders are second to mood disorders as the most common risk factor for suicide Chapter 3.

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Substance abuse is an especially important risk factor for suicide in young adults Chapter 3. Furthermore, substance abuse and mood disorders frequently co-occur, with 51 percent of suicide attempters having both Suominen et al. Treatment of co-morbid alcoholism and depression with selective serotonin reuptake inhibitors SSRI reduces suicidality Cornelius et al.

Thus, detection and treatment of substance abuse and depression in primary care is important for suicide prevention Murphy, ; PHS, For the primary care setting, numerous professional groups recommend routine detection of problem drinking in all patients, as well as brief counseling for non-dependent problem drinkers summarized in US Preventive Services Task Force, Nevertheless, problem drinking often goes undetected in primary care. In recent surveys, about 40 percent of primary care physicians do not perform routine screening for substance abuse Bradley et al.

The most commonly cited reasons are lack of time and fear of spoiling the relationship with the patient Arborelius and Damstrom-Thakker, For detection of drug abuse in primary care, professional guidelines diverge from those for problem drinking: they generally do not recommend screening all primary care patients for drug abuse. However, clinicians are recommended to be alert to signs and symptoms and to refer drug-abusing patients to specialized treatment US Preventive Services Task Force, Standardized screening questionnaires are thought to be too insensitive to identify potential drug abusing patients.

A later section deals with the treatment of substance abuse, with or without a co-occurring mental disorder, because it is reserved for specialty care US Preventive Services Task Force, It is well established that a large proportion of suicide victims are not detected in primary care in the days before suicide.

A systematic review of published studies found that, in the week before death, contact with primary care was made for 16—20 percent of completed suicides. These findings are widely interpreted as suggesting that patients are motivated to seek help but are reluctant to bring up suicide as the reason during an office visit Hirschfeld and Russell, ; Michel, Yet people with suicidal thoughts usually tell their physicians if they are asked Delong and Robins, Communication of suicidal intent is an interactive process.

During the final contact with primary care, there is a striking breakdown in communication: physicians often do not ask about suicidal intent or ideation, and patients often do not spontaneously report it. Suicide risk was commented upon in the medical record in only one case. Yet the physicians deemed that 64 percent of the patients had psychological concerns as the principal reason for the visit.

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The figures are somewhat higher in a study from Finland in which 19 percent of suicide completers with depression communicated their intent to medical providers Isometsa et al. Despite limitations of using case notes to infer what occurred during the final visit, these studies—as well as clinical experience—point to a major barrier in communication: patients are reluctant to communicate their suicidal intent, and primary care physicians are reluctant to ask Hirschfeld and Russell, There is also indirect research support for this statement.


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The suicide. The study did not indicate whether the general practitioner asked patients about suicide. Furthermore, the vast majority of patients in primary care—both suicidal and nonsuicidal—hold the view that physicians should inquire about emotional health issues on a regular basis or at yearly checkups Zimmerman et al. Another reason for physician reticence comes from the lack of acute predictors for suicide assessment.

Most studies have found low sensitivity and specificity of suicide prediction Goldney, ; see Chapter 7 ; Pokorny, In a prospective study, long-term risk factors for suicide were unable to provide the means for acute prediction of suicide Fawcett et al. Considering the rarity of suicide in primary care—one suicide every 3—5 years—physicians have little incentive to take active steps to become skilled in suicide assessment or treatment Michel, Nor do professional guidelines recommend routine screening of asymptomatic patients.

Many professional organizations do not have guidelines on suicide assessment. This plan encourages development of guidelines for primary care settings.