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The study estimated balance billing for out-of-network behavioral health claims and described subscriber characteristics associated with higher billing.Claims data (2011-2014) from a national managed behavioral health organization's employer-sponsored insurance (N=196,034 family-years with out-of-network behavioral health claims) were used to calculate inflation-adjusted annual balance billing-the submitted amount (charged by provider) minus the allowed amount (insurer agreed to pay plus patient cost-sharing) and any discounts offered by the provider. Among family-years with complete sociodemographic data (N=68,659), regressions modeled balance billing as a function of plan and provider supply, subscriber and family-year, and employer characteristics. A two-part model accounted for family-years without balance billing.Among the 50% of family-years with balance billing, mean±SD balance billing was $861±$3,500 (median, $175; 90th percentile, $1,684). Adjusted analysis found balance billing was higher ($523 higher, 95% confidence interval [CI]=$340, $705) for carve-out versus carve-in plans and for health maintenance organization (HMO) enrollees versus non-HMO enrollees ($156, 95% CI=$75, $237); for subscribers with a bachelor's degree, compared with an associate's degree or with a high school diploma or lower (between $172 [95% CI=$228, $116] and $224 [95% CI=$284, $163] higher, respectively); and for subscribers ages 45-54, compared with those ages 35-44 and 18-24 (between $57 [95% CI=$103, $10] and $290 [95% CI=$398, $183] higher, respectively). Balance billing was lower in states with more in-network providers per capita (-$8, 95% CI=-$10, -$5).Balance billing for out-of-network behavioral health claims may be burdensome. Expanded behavioral health networks may improve access.

Objectives To examine changes in carve-out financial requirements (copayments, coinsurance, use of deductibles, and out-of-pocket maxima) following the Mental Health Parity and Addiction Equity Act (MHPAEA). Data source/study setting Specialty mental health benefit design information for employer-sponsored carve-out plans from a national managed behavioral health organization's claims processing engine (2008-2013). Study design This pre-post study reports linear and logistic regression as the main analysis. Data collection/extraction methods NA. Principal findings Copayments for in-network emergency room (-$44.9, 95% CI: -78.3, -11.5; preparity mean: $56.2), outpatient services (eg, individual psychotherapy: -$7.4, 95% CI: -10.5, -4.2; preparity mean: $17.8), and out-of-network coinsurance for emergency room (-11 percentage points, 95% CI: -16.7, -5.4; preparity mean: 38.8 percent) and outpatient (eg, individual psychotherapy: -5.8 percentage points, 95% CI: -10.0, -1.6; preparity mean 41.0 percent) decreased. Probability of family OOP maxima use (29 percentage points, 95% CI: 19.3, 38.6; preparity mean: 36 percent) increased. In-network outpatient coinsurance increased (eg, individual psychotherapy: 4.5 percentage points, 95% CI: 1.1, 7.9; preparity mean: 2.7 percent), as did probability of use of family deductibles (15 percentage points, 95% CI: 6.1, 23.3; preparity mean: 38 percent). Conclusions MHPAEA was associated with increased generosity in most financial requirements observed here. However, increased use of deductibles may have reduced generosity for some patients.

BACKGROUND Relative costs of care among treatment options for opioid use disorder (OUD) are unknown. METHODS We identified a cohort of 40,885 individuals with a new diagnosis of OUD in a large national de-identified claims database covering commercially insured and Medicare Advantage enrollees. We assigned individuals to 1 of 6 mutually exclusive initial treatment pathways: (1) Inpatient Detox/Rehabilitation Treatment Center; (2) Behavioral Health Intensive, intensive outpatient or Partial Hospitalization Services; (3) Methadone or Buprenorphine; (4) Naltrexone; (5) Behavioral Health Outpatient Services, or; (6) No Treatment. We assessed total costs of care in the initial 90 day treatment period for each strategy using a differences in differences approach controlling for baseline costs. RESULTS Within 90 days of diagnosis, 94.8% of individuals received treatment, with the initial treatments being: 15.8% for Inpatient Detox/Rehabilitation Treatment Center, 4.8% for Behavioral Health Intensive, Intensive Outpatient or Partial Hospitalization Services, 12.5% for buprenorphine/methadone, 2.4% for naltrexone, and 59.3% for Behavioral Health Outpatient Services. Average unadjusted costs increased from $3250 per member per month (SD $7846) at baseline to $5047 per member per month (SD $11,856) in the 90 day follow-up period. Compared with no treatment, initial 90 day costs were lower for buprenorphine/methadone [Adjusted Difference in Differences Cost Ratio (ADIDCR) 0.65; 95% confidence interval (CI), 0.52-0.80], naltrexone (ADIDCR 0.53; 95% CI, 0.42-0.67), and behavioral health outpatient (ADIDCR 0.54; 95% CI, 0.44-0.66). Costs were higher for inpatient detox (ADIDCR 2.30; 95% CI, 1.88-2.83). CONCLUSION Improving health system capacity and insurance coverage and incentives for outpatient management of OUD may reduce health care costs.

This study explores possible associations of the Mental Health Parity and Addiction Equity Act (MHPAEA) with child access to behavioral health (BH) services (preimplementation = 2008-2009, transition = 2010, and post = 2011-2013). The study sample included children aged 4-17 years in self-insured "carve-in" plans from large employers. In "carve-ins," BH and medical care are covered through the same insurance plan. The unit of analysis is the person-month (N = 61,823,533). This study employs an interrupted time series model allowing for intercept and slope changes for the transition and postparity periods. Outcomes included total, plan and patient out-of-pocket (OOP) expenditures, and several categories of service utilization. Generalized estimating equations were used to account for clustering. There were significant increases in total and plan expenditures postparity. To illustrate, in July 2012, mean per-member-per-month total expenditures were predicted to be $5.65 without parity but $8.72 with parity. Patient OOP costs did not change significantly. Significant overall increases were seen for utilization of most outpatient services but not intermediate or inpatient services. Our findings suggest that the introduction of MHPAEA was associated with an increase in specialty BH service access for children without a commensurate increase in financial burden for families.

Among the three medications approved for the treatment of opioid use disorder, methadone has been in use for the longest period and has the most extensive evidence base of effectiveness. Yet it remains underutilized as new insurance policies favor access to buprenorphine and neglect to dismantle barriers to obtaining methadone. In the absence of wholesale regulatory change, private insurance carriers should take the lead in expanding access to this medication. We offer several solutions for private payers, including expanding coverage, removing prior authorization, addressing out-of-pocket costs, increasing provider reimbursement, and incentivizing system integration.

A major obstacle to mental health treatment for many Americans is accessibility: the United States faces a shortage of mental health providers, resulting in federally designated shortage areas. Although digital mental health treatments (DMHTs) are effective interventions for common mental disorders, they have not been widely adopted by the U.S. health care system. National and international expert stakeholders representing health care organizations, insurance companies and payers, employers, patients, researchers, policy makers, health economists, and DMHT companies and the investment community attended two Banbury Forum meetings. The Banbury Forum reviewed the evidence for DMHTs, identified the challenges to successful and sustainable implementation, investigated the factors that contributed to more successful implementation internationally, and developed the following recommendations: guided DMHTs should be offered to all patients experiencing common mental disorders, DMHT products and services should be reimbursable to support integration into the U.S. health care landscape, and an evidence standards framework should be developed to support decision makers in evaluating DMHTs.

OBJECTIVE: Adverse selection in medical insurance is well documented; however, little is known about the role of behavioral health. This study’s objective was to examine the probability of being enrolled in the lowest-deductible plan among commercially insured patients, according to psychiatric diagnosis. METHODS: This cross-sectional study used 2012–2013 benefit design and plan choice data linked to 2011–2012 behavioral health claims for a national sample of individuals (N=116,975) and different family types (couple with at least one dependent, N=59,237; single subscriber with at least one dependent, N=19,066; couple with no dependents, N=40,917) with Optum, UnitedHealth Group “carve-in” plans. Analyses included multiple logistic regressions examining whether the individual (or family) was enrolled in the plan with the lowest-deductible as functions of whether individuals (or family members) had any psychiatric diagnosis, the number of psychiatric diagnoses they had, and whether they had individual major psychiatric diagnoses. RESULTS: For individuals, having any psychiatric diagnosis was associated with an increase of about 10% in the probability of being enrolled in the lowest-deductible plan compared with having no psychiatric diagnosis (44.9% vs. 40.7%, p=0.04). Each additional psychiatric diagnosis increased this probability by three percentage points (p=0.02). A diagnosis of depression was associated with the largest increase. CONCLUSIONS: When individuals were offered the choice of a health insurance plan, having a prior psychiatric diagnosis (specifically depression) was associated with being enrolled in the lowest-deductible plans. Individuals with depression may anticipate future expenditures and select plans accordingly.

Background To assess whether implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA) was associated with: 1. Reduced differences in financial requirements (i.e., copayments and coinsurance) for substance use disorder (SUD) versus specialty mental health (MH) care and 2. Reductions in the level of cost-sharing for SUD-specific services. Methods MH and SUD copayments and coinsurance, 2008–2013, were obtained from benefits databases for carve-in and carve-out plans from Optum®. Linear regression was used to estimate the association of MHPAEA with differences between MH and SUD care financial requirements among carve-in and carve-out plans. A two-part regression model investigated whether MHPAEA was associated with changes in the use or level of financial requirements for SUD-specific services among carve-out plans. Results MHPAEA was not associated with significant changes in the difference between SUD and MH copayments or coinsurance levels among either carve-in or carve-out plans. MHPAEA was associated with decreases in the levels of inpatient (in-network: −$51.17; out-of-network: −$34.39) and outpatient (in-network: −$10.26) detox copayments, but increases in the levels of in-network outpatient detox coinsurance (6 percentage points) among all carve-out plans. Conclusion Even if SUD benefits had been historically less generous than MH benefits, SUD financial requirements were already at parity with MH financial requirements by the time MHPAEA was passed, among Optum® plans. MHPAEA’s SUD parity mandate reduced cost-sharing for detox services via copayments, but, for outpatient detox, the law simultaneously increased cost-sharing via coinsurance.

Objective:The aim of the study was to declare a call to action to improve mental health in the workplace.Methods:We convened a public health summit and assembled an Advisory Council consisting of experts in the field of occupational health and safety, workplace wellness, and public policy to offer r

Objective To document differences among racial/ethnic/gender groups in specialty behavioral health care (BH) utilization/expenditures; examine whether these differences are driven by probability vs intensity of treatment; and identify whether differences are explained by socioeconomic status (SES). Data source The cohort consists of adults continuously enrolled in Optum plans with BH benefits during 2013. Study design We modeled each outcome using linear regressions among the entire sample stratified by race/ethnicity, language and gender. Then, we estimated logistic regressions of the probability that an enrollee had any spending/use in a given service category (service penetration) and linear regressions of spending/use among the user subpopulation (treatment intensity). Lastly, all analyses were rerun with SES controls. Data collection This study links administrative data from a managed BH organization to a commercial marketing database. Principal findings We found that in many cases, racial/ethnic minorities had lower specialty BH expenditures/utilization, relative to whites, primarily driven by differences in service penetration. Among women, relative to whites, Asian non-English speakers, Asian English speakers, Hispanic non-English speakers, Hispanic English speakers, and blacks had $106, $95, $90, $48, and $61 less in total expenditures. SES explained racial/ethnic differences in treatment intensity but not service penetration. Conclusions In this population, SES was not a major driver of racial/ethnic differences in specialty BH utilization. Future studies should explore the role of other factors not studied here, such as stigma, cultural competence, and geography.

Objective Did mental health cost-sharing decrease following implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA)? Data Source Specialty mental health copayments, coinsurance, and deductibles, 2008–2013, were obtained from benefits databases for “carve-in” plans from a national commercial managed behavioral health organization. Study Design Bivariate and regression-adjusted analyses compare the probability of use and (conditional) level of cost-sharing pre- and postparity. An interaction term is added to compare differential levels of pre- and postparity cost-sharing changes for plans that were and were not already at parity pre-MHPAEA. Findings Controlling for employer/plan characteristics, MHPAEA is associated with higher intermediate care copayments ($15.9) but lower outpatient ($2.6) copayments among in-network-only plans. Among plans with in- and out-of-network benefits, MHPAEA is associated with lower inpatient ($23.2) and outpatient ($2.5) copayments, but increases in inpatient and intermediate in-network and out-of-network coinsurance (about 1 percentage point). Among the few plans not at parity pre-MHPAEA, changes in use and level of cost-sharing associated with MHPAEA were more dramatic. Conclusion Mixed evidence that MHPAEA led to more generous mental health benefits may stem from the finding that many plans were already at parity pre-MHPAEA. Future policy focus in mental health may shift to slowing growth in cost-sharing for all health services.

Since the introduction and soaring popularity of the managed behavioral healthcare (BH) "carve-out" model in the 1980s, policymakers have been concerned with their impact on access. In carve-outs, BH and medical benefits are administered separately. Earlier literature found they reduced intensity of service use while maintaining penetration rates. Recently it has become more common for employers to drop existing carve-out contracts, partly due to the Mental Health Parity and Addiction Equity Act (MHPAEA), which placed a greater administrative burden on carve-outs for parity compliance. Although prior studies focused exclusively on the impact of moving from carve-in to carve-out models, it is now more policy-relevant to understand the effects of the move from carve-out to carve-in, which may not be symmetric. Moreover, the natural experiment resulting from MHPAEA implementation may attenuate concerns about selection bias.This study examines how specialty BH care patterns change when employees and dependents are moved from a "carve-out" plan to a "carve-in" plan.Linked insurance claims, eligibility, plan and employer data from 2008-14 were obtained for three Optum( employers who dropped their carve-out contracts but retained their carve-in plans. A longitudinal "difference-in-differences" study design was used to compare changes in BH services use over time among individuals who were: (i) moved to carve-in plans when the employer dropped its carve-out contract (N=177,653); and (ii) enrolled in carve-in plans before and after the transition (N=58,658). Outcomes included total and inpatient expenditures, broken down by plan, patient, and total; outpatient visits for assessment, individual psychotherapy, family psychotherapy, and medication management; and days of structured outpatient care, day treatment, residential care, and acute inpatient care. We pooled person-year observations and estimated regressions including individual fixed effects, year dummies and interactions between indicators for post-transition period and whether transitioned from carve-out to carve-in.Relative to individuals continuously in carve-in plans, those who were transitioned experienced significant increases in inpatient utilization (beta =.02; p=.05) and patient inpatient costs (beta =2.35; p=.01) and decreases in day treatment (beta =-0.01; p=.02). Our conclusions proved robust against potential biases due to differing secular time trends and differential changes in benefits resulting from MHPAEA.The increased inpatient utilization associated with switching from carve-out to carve-in plans is consistent with previous literature. Carve-outs may use day treatment to reduce inpatient care so that increased inpatient utilization post-transition reduced demand for day treatment. Limitations include possible selection bias at the employer level; lack of data on medication and generalist use, quality, clinical endpoints and quality of life; and potential lack of generalizability.The reduction in the use of carve-out contracts by private employers associated with MHPAEA implementation likely did not have a net negative impact and may have actually increased access to care among former carve-out enrollees in need of inpatient services.Policymakers should consider and evaluate possible unintended consequences of legislation designed to improve access to care.Future work should replicate these analyses with a more representative sample.

BACKGROUND: Insurance benefit features play a role in determining access to specialty mental health care. Previous research, primarily examining the effects of copayments, coinsurance, and deductibles in a fee-for-service setting, has concluded that specialty mental health use is highly sensitive to changes in financial requirements. Less is known about the effects of other benefit features and the effects of all of these features in a managed care environment. AIMS OF THE STUDY: Determine whether increased generosity of three types of benefit features was associated with increases in specialty mental health use and expenditures in a managed care setting. Secondary analyses investigated whether these associations varied by income level. METHODS: A first-differences design used linked claims, enrollment, and benefit data for 1,242,949 non-elderly adults (aged 18–64) with employer-sponsored insurance, before (2009) and after (2011) national behavioral health parity implementation. The data were provided by a large national managed behavioral health organization. Benefit design features included combined cost sharing from copayment and coinsurance, deductibles, the presence of annual use limits, cost sharing penalties associated with services used without getting required prior-authorization, and provider network. Outcomes included visits/days, total expenditures and patient out-of-pocket expenditures for individual psychotherapy and inpatient use, with separate values for in-network and out-of-network (OON) service use. Ordinary least squares regression was performed on change scores (2011 minus 2009 values) of all outcomes to implement the first-differences study design and normalize distributions of otherwise heavily skewed (towards zero) variables. Regressions stratified by higher income (>=$75,000) and net worth (>=$100,000) and lower income/net worth were also conducted. RESULTS: For in-network individual psychotherapy, larger increases in cost sharing from copayment and coinsurance were modestly associated with larger decreases in use and total expenditures (β(visits)=−0.00008, p-value=0.030; β(totalexpenditures)=$−0.00629, p-value=0.011), and elimination of treatment limits was associated with larger increases in use (β=0.09637, p-value=0.002) and total expenditures (β=$6.57506, p-value=0.001). These results were observed among all enrollees of plans that covered in-network and out-of-network plans and among a sub-set of these enrollees who did not change plans between 2009 and 2011. Benefit features had fewer associations with inpatient care and OON services. DISCUSSION: Elimination of limits was associated with small average increases in in-network individual psychotherapy utilization and expenditures. Cost sharing sensitivities of individual psychotherapy visits to financial requirements reported here were small, and resembled previous findings based in a managed care setting, which were smaller than findings based on the fee-for-service settings. Cost sharing may not pose a practical barrier to specialty behavioral health for non-elderly adults with employer-sponsored managed care plans. However, the influence of cost sharing may vary by specific healthcare needs, something that should be explored in further research.

The study tested an intervention aimed at improving work functioning among middle-aged and older adults with depression and work limitations.A randomized clinical trial allocated an initial sample of 431 eligible employed adults (age ≥45) to a work-focused intervention (WFI) or usual care. Inclusion criteria were depression as measured by the Patient Health Questionnaire-9 (PHQ-9) and at-work limitations indicated by a productivity loss score ≥5% on the Work Limitations Questionnaire (WLQ). Study sites included 19 employers and five related organizations. Telephone-based counseling provided three integrated modalities: care coordination, cognitive-behavioral therapy strategy development, and work coaching and modification. Effectiveness (change in productivity loss scores from preintervention to four months postintervention) was tested with mixed models adjusted for confounders. Secondary outcomes included change in WLQ work performance scales, self-reported absences, and depression.Of 1,227 eligible employees (7% of screened), 431 (35%) enrolled and 380 completed the study (12% attrition). At-work productivity loss improved 44% in the WFI group versus 13% in usual care (difference in change, p.001). WFI group scores on the four WLQ scales improved 44% to 47%, significantly better than in usual care (p.001 for each scale). Absence days declined by 53% in the WFI group versus 13% in usual care (difference in change, p.001). Mean PHQ-9 depression symptom severity scores declined 51% for WFI versus 26% for usual care (difference in change, p.001).The WFI was more effective than usual care at four-month follow-up. Given increasing efforts to provide more patient-centered, value-based care, the WFI could be an important resource.

This study examined specialty behavioral health treatment patterns among employer-insured adults in same- and different-gender domestic partnerships and marriages.The study used behavioral health service claims (2008-2013) from Optum to estimate gender-stratified penetration rates of behavioral health service use by couple type and partnership status among partnered adults ages 18-64 (N=12,727,292 person-years) and levels of use among those with any use (conditional analyses). Least-squares, logistic, and zero-truncated negative binomial regression analyses adjusted for age, employer and plan characteristics, and provider supply and for sociodemographic factors in sensitivity analyses. Generalized estimating equations were used to address within-group correlation of adults clustered in employer groups.Both women and men in same-gender marriages or domestic partnerships had higher rates of behavioral health service use, particularly diagnostic evaluation, individual psychotherapy, and medication management, and those in treatment had, on average, more psychotherapy visits than those in different-gender marriages. Behavioral health treatment patterns were similar between women in same-gender domestic partnerships and same-gender marriages, but they diverged between men in same-gender domestic partnerships and same-gender marriages. Moderation analysis results indicated that adults with same-gender partners living in states with fewer legal protections for lesbian, gay, bisexual, and transgender persons were less likely than adults with same-gender partners in LGBT-friendly states to receive behavioral health treatment. Sensitivity analyses did not affect findings.Behavioral health treatment patterns varied by couple type, partnership status, and gender. Results highlight the importance of increasing service acceptability and delivering inclusive, culturally relevant behavioral health treatment for lesbian, gay, and bisexual persons.

Background The federal Mental Health Parity and Addiction Equity Act (MHPAEA) sought to eliminate historical disparities between behavioral health and medical health insurance benefits among the commercially insured. This study determines whether MHPAEA was associated with increased BH expenditures and utilization among a population with substance use disorder (SUD) diagnoses. Methods Claims and eligibility data from 5,987,776 enrollees, 2008–2013, were obtained from a national, commercial, managed behavioral health organization. An interrupted time series study design with segmented regression analysis estimated time trends of per-member-per-month (PMPM) spending and use before (2008–2009), during (2010), and after (2011−2013) MHPAEA compliance. The study sample contained individuals with drug or alcohol use disorder diagnosis during study period (N=2,716,473 member-month observations). Outcomes included: total, plan, patient out-of-pocket spending; outpatient utilization (assessment/diagnostic evaluation visits; medication management; individual, group and family psychotherapy, and structured outpatient care); intermediate care utilization (day treatment; recovery home and residential); and inpatient utilization. Results Starting at the beginning of the post-parity period, MHPAEA was associated with increased levels of PMPM total and plan spending ($25.80 [p=0.01]; $28.33 [p=0.00], respectively), as well as the number of PMPM assessment/evaluation, individual psychotherapy, and group psychotherapy visits, and inpatient days (0.01 visits [p=0.01]; 0.02 visits [p=0.01]; 0.01 visits [p=0.03]; 0.01days [p=0.01], respectively). Following these initial level changes, MHPAEA was also associated with monthly increases in PMPM total, plan, and patent out-of-pocket spending ($2.56/month [p=0.00]; $2.25/month [p=0.00]; $0.27 [p=0.03], respectively), as well as structured outpatient visits and inpatient days (0.0012 visits/month [p=0.01]; 0.0012days/month [p=0.00]). Conclusion MHPAEA was associated with modest increases in total, plan, and patient out-of-pocket spending and outpatient and inpatient utilization. These increases, while modest in magnitude, are larger in magnitude than increases detected among a sample of all enrollees (i.e. not only those with SUD diagnoses).

ObjectiveThe Mental Health Parity and Addiction Equity Act (MHPAEA) significantly changed regulations governing behavioral health benefits for large, commercially insured employers. Pre-MHPAEA, many plans covered only a specific number of behavioral health treatment days or visits; post-MHPAEA, such quantitative treatment limits (QTLs) were allowed only if they were "at parity" with medical-surgical limits. This study assessed MHPAEA's effect on the prevalence of behavioral health QTLs.MethodsAnalyses used 2008-2013 specialty behavioral health benefit design data for Optum large-group plans, both carve-outs (N=2,257 plan-years, corresponding to 1,527 plans and 40 employers) and carve-ins (N=11,644 plan-years, 3,569 plans, and 340 employers). Descriptive statistics were calculated for limits existing at parity implementation, distinguished by accumulation period (annual or lifetime), level of care (inpatient, intermediate, or outpatient), unit (days, visits, or courses), condition, and network level. Proportions of plans using specific limits during the preparity (2008-2009), transition (2010), and postparity (2011-2013) periods were compared with Fisher's exact tests.ResultsPreparity, the most common QTLs were annual visit or day limits. Accounting for overlap in limit types, 89% of regular carve-out plans, 90% of in-network-only carve-outs, and 77% of carve-in plans limited outpatient visits; 66% of regular carve-out plans, 74% of in-network-only carve-outs, and 73% of carve-ins limited inpatient or intermediate days. Postparity, QTLs almost entirely disappeared (p

Importance Although clinical trials demonstrate the superior effectiveness of medication for opioid use disorder (MOUD) compared with nonpharmacologic treatment, national data on the comparative effectiveness of real-world treatment pathways are lacking. Objective To examine associations between opioid use disorder (OUD) treatment pathways and overdose and opioid-related acute care use as proxies for OUD recurrence. Design, Setting, and Participants This retrospective comparative effectiveness research study assessed deidentified claims from the OptumLabs Data Warehouse from individuals aged 16 years or older with OUD and commercial or Medicare Advantage coverage. Opioid use disorder was identified based on 1 or more inpatient or 2 or more outpatient claims for OUD diagnosis codes within 3 months of each other; 1 or more claims for OUD plus diagnosis codes for opioid-related overdose, injection-related infection, or inpatient detoxification or residential services; or MOUD claims between January 1, 2015, and September 30, 2017. Data analysis was performed from April 1, 2018, to June 30, 2019. Exposures One of 6 mutually exclusive treatment pathways, including (1) no treatment, (2) inpatient detoxification or residential services, (3) intensive behavioral health, (4) buprenorphine or methadone, (5) naltrexone, and (6) nonintensive behavioral health. Main Outcomes and Measures Opioid-related overdose or serious acute care use during 3 and 12 months after initial treatment. Results A total of 40 885 individuals with OUD (mean [SD] age, 47.73 [17.25] years; 22 172 [54.2%] male; 30 332 [74.2%] white) were identified. For OUD treatment, 24 258 (59.3%) received nonintensive behavioral health, 6455 (15.8%) received inpatient detoxification or residential services, 5123 (12.5%) received MOUD treatment with buprenorphine or methadone, 1970 (4.8%) received intensive behavioral health, and 963 (2.4%) received MOUD treatment with naltrexone. During 3-month follow-up, 707 participants (1.7%) experienced an overdose, and 773 (1.9%) had serious opioid-related acute care use. Only treatment with buprenorphine or methadone was associated with a reduced risk of overdose during 3-month (adjusted hazard ratio [AHR], 0.24; 95% CI, 0.14-0.41) and 12-month (AHR, 0.41; 95% CI, 0.31-0.55) follow-up. Treatment with buprenorphine or methadone was also associated with reduction in serious opioid-related acute care use during 3-month (AHR, 0.68; 95% CI, 0.47-0.99) and 12-month (AHR, 0.74; 95% CI, 0.58-0.95) follow-up. Conclusions and Relevance Treatment with buprenorphine or methadone was associated with reductions in overdose and serious opioid-related acute care use compared with other treatments. Strategies to address the underuse of MOUD are needed.

This study implemented an innovative new model of delivering a Mindfulness-Based Stress Reduction (MBSR) program that replaces six of the eight traditional in-person sessions with group telephonic sessions (tMBSR) and measured the program's impact on the health and well-being of nurses employed within a large health care organization. As part of a nonrandomized pre–post intervention study, 36 nurses completed measures of health, stress, burnout, self-compassion, serenity, and empathy at three points in time. Between baseline (Time 1) and the end of the 8-week tMBSR intervention (Time 2), participants showed improvement in general health, t(37) = 2.8, p < .01, decreased stress, t(37) = 6.8, p < .001, decreased work burnout, t(37) = 4.0, p < .001, and improvement in several other areas. Improvements were sustained 4 months later (Time 3), and individuals who continued their MBSR practice after the program demonstrated better outcomes than those that did not. Findings suggest that the tMBSR program can be a low cost, feasible, and scalable intervention that shows positive impact on health and well-being, and could allow MBSR to be delivered to employees who are otherwise unable to access traditional, on-site programs.

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. Objective: The federal Mental Health Parity and Addiction Equity Act (MHPAEA) sought to eliminate historical disparities between insurance coverage for behavioral health (BH) treatment and coverage for medical treatment. Our objective was to evaluate MHPAEA's impact on BH expenditures and utilization among "carve-in" enrollees. Methods: We received specialty BH insurance claims and eligibility data from Optum, sampling 5,987,776 adults enrolled in selfinsured plans from large employers. An interrupted time series study design with segmented regression analysis estimated monthly time trends of per-member spending and use before (2008-2009), during (2010), and after (2011-2013) MHPAEA compliance (N = 179,506,951 member-month observations). Outcomes included: total, plan, patient out-of-pocket spending; outpatient utilization (assessment/diagnostic evaluation visits, medication management, individual and family psychotherapy); intermediate care utilization (structured outpatient, day treatment, residential); and inpatient utilization. Results: MHPAEA was associated with increases in monthly permember total spending, plan spending, assessment/diagnostic evaluation visits [respective immediate increases of: $1.05 (P = 0.02); $0.88 (P = 0.04); 0.00045 visits (P = 0.00)], and individual psychotherapy visits [immediate increase of 0.00578 visits (P = 0.00) and additional increases of 0.00017 visits/mo (P = 0.03)]. Conclusions: MHPAEA was associated with modest increases in total and plan spending and outpatient utilization; for example, in July 2012 predicted per-enrollee plan spending was $4.92 without MHPAEA and $6.14 with MHPAEA. Efforts should focus on understanding how other barriers to BH care unaddressed by MHPAEA may affect access/utilization. Future research should evaluate effects produced by the Affordable Care Act's inclusion of BH care as an essential health benefit and expansion of MHPAEA protections to the individual and small group markets.

© 2016 Elsevier B.V. Interrupted time series with and without controls was used to evaluate whether the federal Mental Health Parity and Addiction Equity Act (MHPAEA) and its Interim Final Rule increased the probability of specialty behavioral health treatment and levels of utilization and expenditures among patients receiving treatment. Linked insurance claims, eligibility, plan and employer data from 2008 to 2013 were used to estimate segmented regression analyses, allowing for level and slope changes during the transition (2010) and post-MHPAEA (2011–2013) periods. The sample included 1,812,541 individuals ages 27–64 (49,968,367 person-months) in 10,010 Optum “carve-out” plans. Two-part regression models with Generalized Estimating Equations were used to estimate expenditures by payer and outpatient, intermediate and inpatient service use. We found little evidence that MHPAEA increased utilization significantly, but somewhat more robust evidence that costs shifted from patients to plans. Thus the primary impact of MHPAEA among carve-out enrollees may have been a reduction in patient financial burden.

Substantial empirical support exists for alcohol screening and brief intervention (SBI) in medical, but not nonmedical settings. A pre- and postdesign is used to examine the effects of an alcohol SBI program implemented telephonically by Employee Assistance Program (EAP) specialists at OptumHealth Behavioral Solutions. Identification rates of risky alcohol use were significantly higher for the Post-SBI Time Period compared to the Pre-SBI Time Period (7.5% vs. 20.1%, p

Comorbid medical and behavioral conditions are associated with greater functional disability, increased morbidity and suicide-related mortality, and greater total healthcare use and costs.1,2 Mental and substance use disorders are twice as likely to occur among the chronically ill, with depression being the most common comorbid condition among medical patients (approximate prevalence of 25%).3 Although there is evidence of bidirectionality of medical and mental health conditions,4 research on their comorbidity has focused primarily on prevalence rates of

This study examined the use of outcome reports sent to clinicians by a managed behavioral healthcare organization to monitor patient progress and its relation to treatment outcome. Results showed that clinicians who reported using outcome information had patients who also reported greater improvement at 6 months from baseline. Improvement per session was greatest among patients whose clinicians reported reading the outcome report and using outcome measures in their clinical practice. Using baseline and ongoing measures to assess patient improvement can provide clinicians with feedback during treatment, which may lead to better clinical outcomes and enable quality management systems in managed care to flag high-risk cases and identify failure of adequate improvement.

Medical and pharmacy utilization patterns were examined among 782 depressed patients seen by independent clinicians through a Managed Behavioral Health Organization using behavioral, medical and pharmacy claims spanning 2 years. Two-thirds received psychiatric care in the medical and mental health sector concurrently, 43% had comorbid medical disorders, 61% received psychotropic medications, and 54% were on antidepressants. Fewer depressed medically comorbid patients used medical services while in mental health treatment than before or after treatment, while the per patient costs remained the same. For those with chronic conditions, medical utilization and costs remained the same. A quarter of depressed patients received mental health treatment before seeing a mental health specialist, and a quarter remained in treatment in the medical sector after treatment in the mental health sector. Despite increases in mental health services access made available through managed behavioral health organizations, patients continue receiving mental health treatment in the medical sector.

Background Although published guidelines recommend the continuation of treatment for depression until full remission of symptoms and restoration of functioning, little is known about how often remission is achieved in usual practice and the precipitants of treatment termination when treatment outcome has not been optimal. Method A naturalistic study design examined 1859 patients receiving treatment for DSM-III-R major depression between 1995 and 1997 in the national provider network of a managed behavioral health organization (MBHO). Symptom and impairment ratings by clinicians were used to group patients into full remission, partial remission, and no response. Claims data were used to characterize treatment and identify comorbid medical conditions. Results According to clinician ratings, approximately 27% to 39% of patients achieved full remission. Medical and substance use comorbidity and hospital admission were more common in those with a partial response to treatment. Only half of patients without a treatment response received a trial of medication during their treatment. Patient choice was the most common reason for termination of treatment, although nearly 40% of clinicians concurred with patients' decisions even when symptoms had not improved. Conclusion Although rates of full remission were comparable to those in clinical trials of antidepressants, results suggest that clinicians may fail to recommend continuation and maintenance treatment consistent with best practice guidelines and that unsuccessful treatment often does not include antidepressant medication.

This study tests whether a managed behavioral health care organization can influence adherence to practice guidelines for the treatment of major depression in a randomized trial of guideline dissemination. Guidelines were disseminated to mental health clinicians (N = 443) under one of three conditions: (1) a general mailing of guidelines to clinicians, (2) a mailing in which guidelines were targeted to a patient starting treatment with the clinician, and (3) no mailing of guidelines. The results showed no effects of guideline dissemination as measured by self-report of patients and clinicians and through episode characteristics derived from claims data, despite sentinel effects. Results also showed high rates of clinician-reported guideline adherence that were not detected in the claims data, indicating significant undertreatment of depression. Results suggest that mental health systems must look to other dissemination strategies to improve adherence to standards of care and raise the performance of independent practicing clinicians.

To test the effectiveness of a work-focused intervention (WFI) on the work outcomes of employed adults with dysthymia.This subgroup analysis from a randomized controlled trial compares an initial sample of 167 employees (age: ≥45 years), screened for dysthymia using the PC-SAD without current major depressive disorder randomized to WFI (n=85) or usual care (UC) (n=82). Study sites included 19 employers and five additional organizations. Telephone-based WFI counseling (eight, twice monthly 50-min sessions) provided work coaching and modification, care coordination and cognitive behavioral therapy. Adjusted mixed effects models compared the WFI vs. UC group preintervention to 4-month postintervention change in at-work limitations measured by the Work Limitations Questionnaire. Secondary outcome analysis compared the change in self-reported absences and depression symptom severity (Patient Health Questionnaire PHQ-9 scores).Work productivity loss scores improved 43.0% in the WFI group vs. 4.8% in UC (difference in change: P.001). Absence days declined by 58.3% in WFI vs. 0.0% in UC (difference in change: P=.09). Mean PHQ-9 depression symptom severity declined 44.2% in WFI vs. 5.3% in UC (difference in change: P.001).At 4 months, the WFI was more effective than UC on two of the three outcomes. It could be an important mental and functional health improvement resource for the employed dysthymic population.

Brief and culturally compatible measures of depression are necessary, yet most depression scales are translated without regard for cultural biases. In this study, 292 medical outpatients completed an English or a Spanish-translated and back-translated version of the Beck Depression Inventory (BDI). The BDI items were analyzed for bias between Spanish and English-speaking patients to determine the equivalence of the scale. A Differential Item Function (DIF) using a Mantel Haenszel Approach for Ordered Response Categories was used to analyze how likely subjects in the two ethnic groups were to endorse each response category. The results suggest that regardless of level of depression, Latinos are more likely to endorse items reflecting tearfulness and punishment, and less likely to endorse inability to work. Cultural interpretations and recommendations for use of the BDI are discussed. © 2001 John Wiley & Sons, Inc. J Clin Psychol 57: 355–365, 2001.

This study examined the impact of case management on hospital service use, hospital costs, homelessness, substance abuse, and psychosocial problems in frequent users of a public urban emergency department (ED). Subjects were 53 patients who used the ED five times or more in 12 months. Utilization, cost, and psychosocial variables were compared 12 months before and after the intervention. The median number of ED visits decreased from 15 to 9 (P < .01), median ED costs decreased from $4,124 to $2,195 (P < .01) and median medical inpatient costs decreased from $8,330 to $2,786 (P < .01). Homelessness decreased by -57% (P < .01), alcohol use by -22% (P = .05) and drug use by -26% (P = .05). Linkage to primary care increased 74% (P < .01). Fifty-four percent of medically indigent subjects obtained Medicaid (P < .01). There was a net cost savings, with each dollar invested in the program yielding a $1.44 reduction in hospital costs. Thus, case management appears to be a cost-effective means of decreasing acute hospital service use and psychosocial problems among frequent ED users.

Women seen in public gynecology settings are at very high risk of developing psychiatric disorders. Because low-income and ethnic minority women seen in such settings underutilize mental health services, it is important to better understand treatment preferences and obstacles among this high-risk patient population. Public women's clinic patients (N = 105) who reported psychological or emotional distress were asked about their interest in medication, psychotherapy, and psychoeducational classes, as well as perceived obstacles to using these services. The vast majority were interested in receiving some form of mental health treatment, with the most interest shown for individual therapy and general psychoeducational classes about health and stress. Less interest was expressed in group therapy and medication. Women anticipated more instrumental barriers to using services, such as lack of money, transportation, and childcare, than stigma-related barriers, such as fear of embarrassment or rejection. However, Latinas, women with less education, and those with a current mood or anxiety disorder were more likely to anticipate stigma-related barriers to treatment than other women. Implications of these findings for referral and treatment of mental health problems among public women's clinic patients are discussed.

Objective: We examined the mental health needs of poor young women seen in public-sector gynecologic settings. Study Design: Participants were 205 ethnically diverse women, mean age 29 years, seen by gynecologists at San Francisco General Hospital, all either uninsured or receiving public medical assistance. An interview with an instrument designed to diagnose mood, anxiety, alcohol, and eating disorders in medical patients, the Prime-MD, was used to assess current mental disorders. Any history of sexual or other physical assault was recorded. Receipt of primary case was scored for comprehensiveness. Results: The rates of current psychiatric disorders were extremely high; 21.5% had current major depression. The prevalence of anxiety disorders was also elevated among these women. Many had a history of sexual trauma, and 28% had been the victims of unwanted intercourse. Finally, many reported behaviors that pose serious health risks. For example, 32% smoked and 2% used illicit drugs. Fewer than half had access to comprehensive primary medical care. Conclusions: Young, poor women who seek care in public-sector gynecologic clinics would benefit from comprehensive medical care addressing their psychosocial needs.

OBJECTIVE: The objectives of this study were to examine rates and predictors of psychotropic use and multiclass polypharmacy among commercially insured children with autism spectrum disorders (ASD). METHODS: This retrospective observational study used administrative medical and pharmacy claims data linked with health plan enrollment and sociodemographic information from 2001 to 2009. Children with ASD were identified by using a validated ASD case algorithm. Psychotropic polypharmacy was defined as concurrent medication fills across ≥2 classes for at least 30 days. Multinomial logistic regression was used to model 5 categories of psychotropic use and multiclass polypharmacy. RESULTS: Among 33 565 children with ASD, 64% had a filled prescription for at least 1 psychotropic medication, 35% had evidence of psychotropic polypharmacy (≥2 classes), and 15% used medications from ≥3 classes concurrently. Among children with polypharmacy, the median length of polypharmacy was 346 days. Older children, those who had a psychiatrist visit, and those with evidence of co-occurring conditions (seizures, attention-deficit disorders, anxiety, bipolar disorder, or depression) had higher odds of psychotropic use and/or polypharmacy. CONCLUSIONS: Despite minimal evidence of the effectiveness or appropriateness of multidrug treatment of ASD, psychotropic medications are commonly used, singly and in combination, for ASD and its co-occurring conditions. Our results indicate the need to develop standards of care around the prescription of psychotropic medications to children with ASD.

We compared risk of injury among children with autism spectrum disorder (ASD) to those without ASD, adjusting for demographic and clinical characteristics.We used claims data from 2001 to 2009 from a commercial health plan in the United States. A validated ASD case identification algorithm identified 33,565 children (ages 0-20 years) with ASD and 138,876 children without. Counting process models tested the association between ASD status and injury episodes with separate regressions run for children during different age periods.Unadjusted results demonstrated that children with ASD had a 12% greater injury risk than children without ASD (hazard ratio [HR] = 1.119; P.001). After including demographic variables, the HR was 1.03 (P.05); after controlling for co-occurring conditions, such as seizures, depression, etc, HR decreased to 0.889 (P.001). For the age period analysis, HR values were as follows: for 0 to 2 years, HR 1.141; 3 to 5 years, HR 1.282; 6 to 10 years, HR not significant; and 11 to 20 years, HR 0.634 (P.05 for all significant results).Children with ASD have more injuries than children without ASD. After controlling for demographic factors and co-occurring conditions, children with ASD are at lower risk of injury, suggesting that co-occurring conditions or the ways these conditions interact with ASD is related to injuries. Clinicians should understand that injury risk in children with ASD may be driven by co-occurring conditions. Treating these conditions could thus decrease injury risk as well as have other benefits. Injury prevention interventions are especially warranted for younger children with ASD and those with seizures, depression, visual impairment, or attention-deficit disorders.

Low-income minority women are underrepresented in mental health service settings, yet they are clearly at risk for psychiatric disorders. We staff a clinic specialized in the treatment of depression in economically disadvantaged medical patients. We will share our experience treating disadvantaged and ethnic minority women and will discuss the ingredients necessary to provide quality therapy for these women. We will begin by discussing how poor and minority women access treatment, and the strategies we have used to keep these women in treatment. Then we will consider how services can be made sensitive to the special needs of disadvantaged women, including particular techniques we have found useful in their treatment. Finally, we will discuss common therapeutic issues for these women, as well as successful strategies for helping with the common issues.

Objectives: To evaluate the effect of the Medicare benzodiazepine coverage exclusion on psychotropic use of benzodiazepine users. Design: Pre�post design with concurrent control group. Setting: General community. Participants: Intervention and comparison cohorts of individuals drawn from the same insurer who were prescribed benzodiazepines through the end of 2005. Intervention participants (n = 19,339) were elderly adults from a large, national Medicare Advantage plan subject to benzodiazepine exclusion as a result of the Medicare Modernization Act (MMA). Comparison participants (n = 3,488) were near-elderly individuals enrolled in a managed care plan not subject to the MMA benzodiazepine exclusion. Measurements: Any psychotropic drug use and expenditures. Results: In the intervention cohort, benzodiazepine use and expenditures significantly declined from 100% and $134 in 2005 to 74.8% and $59, respectively, in 2007. Nonbenzodiazepine psychotropic drug use and expenditures significantly increased from 35.8% and $163 in 2005 to 39.5% and $207, respectively, in 2007. In the comparison cohort, benzodiazepine use and expenditures also significantly declined from 100% and $173 in 2005 to 57.5% and $105, respectively, in 2007, but nonbenzodiazepine psychotropic drug use and expenditures significantly declined from 55.4% and $647 in 2005 to 45.1% and $572, respectively, in 2007. Changes in antidepressant and anxiolytic use were the primary cause of changes in nonbenzodiazepine psychotropic drugs in both cohorts. Conclusion: Use of benzodiazepines continued in elderly adults despite negative financial incentives, possibly because of the low costs of such medications. Although some substitution occurred with antidepressants and anxiolytics, the magnitude of this increase did not fully offset the reduction in benzodiazepine use.

While telephone care management has shown promise as a cost-effective approach to manage patients with depression, there is little evidence on the effectiveness of this method for Medicaid beneficiaries in managed care. This study examines a 1-year telephone care management intervention designed to help this low-income, hard-to-reach population enter and remain engaged with treatment.A randomized controlled trial of 499 Rhode Island Medicaid managed care beneficiaries with depression (all parents, average age of 35, and 90% women). Care managers conducted telephonic outreach with the intervention group to establish a relationship, initiate treatment, make referrals for in-person psychotherapy and/or medication treatment, and monitor treatment progress. The control group received usual care and was given a referral list of providers participating in the Medicaid program.Primary outcomes were the use of health services and depression severity at 6 and 18 months. Administrative claims provided information on medical and mental health services use. Surveys of sample members provided information on depression severity. Analysis controlling for sociodemographic characteristics was done to assess the effectiveness of providing care management.Care managers contacted 91% of those assigned to the intervention group. The intervention was effective in enrolling participants into mental health services (42% in intervention group vs 31% in control; P = .05), but did not successfully reduce average depression severity.The intervention's lack of success in reducing depression severity for Medicaid beneficiaries suggests the need for more intensive interventions that strengthen telephone care management and potentially include in-person components as well.

This descriptive study used stakeholder input to prioritize evidence-based strategies for improving depression care and to select incentives for mental health clinicians to adopt those strategies, and to conduct a feasibility test of an incentive-based program in a managed behavioral healthcare organization (MBHO). In two rounds of interviews and a stakeholder meeting, MBHO administrators and clinicians selected increasing combination treatment (antidepressant plus psychotherapy) rates as the program goal; and paying a bonus for case reviews, clinician feedback, and clinician education as incentives. We assessed program feasibility with case review and clinician surveys from a large independent practice association that contracts with the MBHO. Findings suggest that providing incentives for mental health clinicians is feasible and the incentive program did increase awareness. However, adoption may be challenging because of administrative barriers and limited clinical data available to MBHOs.

tinuous quality improvement teams (7) have also been shown to be more influential in changing physicians’ behavior than education alone. However, given that most mental health specialists are unaffiliated, provide care in private offices, and belong to numerous open managed care networks, it would be unrealistic to rely on the use of academic detailing and continuous quality improvement in large decentralized delivery systems. Few studies of effective dissemination of guidelines as a strategy for influencing psychiatrists’ clinical practice have been published, and there have been no studies of nonphysician mental health practitioners. Managed behavioral health organizations (MBHOs) provided coverage to 176 million people (8) in 1999. They are thus in a unique position in the mental health services system to study clinicians’ behavior in realworld settings. Studying dissemination of guidelines in an MBHO provides access to a large population of patients throughout the United States who are treated by a representative sample of independent clinicians who have different backgrounds and clinical experience. We sought to determine whether clinicians read guidelines disseminated by MBHOs and, if so, whether they find such guidelines helpful.

This study described the association of general medical and psychiatric comorbidities with receipt of guideline-concordant depression care.Pharmacy, medical, and behavioral claims and enrollment data from OptumHealth in 2003-2006 were linked for 1,835 adults with a new depression diagnosis or a new antidepressant fill. Multiple logistic regression was used to estimate the association of comorbidities with receipt of guideline-concordant pharmacotherapy, guideline-concordant psychotherapy, and any guideline-concordant therapy.Eleven percent of patients received guideline-concordant psychotherapy; 23%, guideline-concordant pharmacotherapy; and 33%, any guideline-concordant therapy. Having a psychiatric but no medical comorbidity was associated with higher rates of guideline-concordant psychotherapy and overall guideline concordance; conversely, having a general medical but no psychiatric comorbidity was associated with lower rates of guideline-concordant psychotherapy. Comorbidities were associated with the probability of receiving any guideline-concordant therapy, but they were not associated with improved guideline concordance among patients already receiving therapy.Patients with general medical comorbidities may not receive psychotherapy referrals, perhaps because of well-established relationships with their primary care providers.

Although mental health policy initiatives have called for quality improvement in depression care, practical tools to describe the quality of psychotherapy for depression are not available. We developed a clinician-report measure of adherence to three types of psychotherapy for depression—cognitive behavioral therapy, interpersonal therapy, and psychodynamic therapy. A total of 727 clinicians from a large, national managed behavioral health care organization responded to a mail survey. The measure demonstrated good psychometric properties, including appropriate item-scale correlations, internal consistency reliability, and a three-factor structure. Our results suggest that this questionnaire may be a promising approach to describing psychotherapy for depression in usual care.

Evidence-based psychotherapies to treat depression are available, yet it remains unknown the extent to which these practices are used in routine care for depression. Using survey and administrative data, we sought to describe usual care psychotherapy for depression for adult patients receiving care through a large, managed behavioral health care organization. Data from 420 patients receiving psychotherapy for depression and 159 of their therapists provide evidence that some practitioners are using evidence-based psychotherapy techniques for depression, but also demonstrate the need for improved tools to monitor and improve quality of psychotherapy in usual care.

Context Although outreach and enhanced treatment interventions improve depression outcomes, uptake has been poor in part because purchasers lack information on their return on investment. Objective To estimate the costs and benefits of enhanced depression care for workers from the societal and employer-purchaser perspectives. Design Cost-effectiveness and cost-benefit analyses using state-transition Markov models. Simulated movements between health states were based on probabilities drawn from the clinical literature. Participants Hypothetical cohort of 40-year-old workers. Intervention Enhanced depression care consisting of a depression screen and care management for those depressed vs usual care. Main Outcome Measures Our base-case cost-effectiveness analysis was from the societal perspective; costs and quality-adjusted life-years were used to compute the incremental cost-effectiveness of the intervention relative to usual care. A secondary cost-benefit analysis from the employer's perspective tracked monetary costs and monetary benefits accruing to employers during a 5-year time horizon. Results From the societal perspective, screening and depression care management for workers result in an incremental cost-effectiveness ratio of $19 976 per quality-adjusted life-year relative to usual care. These results are consistent with recent primary care effectiveness trials and within the range for medical interventions usually covered by employer-sponsored insurance. From the employer's perspective, enhanced depression care yields a net cumulative benefit of $2895 after 5 years. In 1-way and probabilistic sensitivity analyses, these findings were robust to a variety of assumptions. Conclusion If these results can be replicated in effectiveness trials directly assessing effects on work outcomes, they suggest that enhanced treatment quality programs for depression are cost-beneficial to purchasers.

In a collaborative effort between a managed behavioral health organization, a health maintenance organization, and a state employer, this pilot study tested the value of mailing a depression education flyer to primary care patients who were recently prescribed antidepressant medications and an informational letter to their physician. The intervention, designed to improve use of behavioral healthcare services and antidepressant medication adherence, had a moderate impact on consistency of antidepressant medication use and on use of psychotherapy in combination with antidepressant medications. Additionally, intervention patients on combination treatment were more likely to stay on antidepressant medications into the continuation phase of treatment.

Because young women seen in public care gynecology clinics are at very high risk for depression, it is important to find ways to increase detection of depression in this patient population. This study examined rates and predictors of self-recognition of depression in a sample of 95 depressed public care women's clinic patients. We found that fewer than half of the women (44%) identified their problems as depression, suggesting that the majority of women were not likely to receive treatment for their problems. Predictors of self-recognition included being told by a doctor in the past that they were depressed, endorsing medical/psychiatric causes of mental illness, and use of the coping strategies of facing a problem, alcohol or drug use, and prayer. These findings indicate the need for gynecology settings to (1) provide education about depression to women, (2) encourage them to discuss emotional problems with their physicians, and (3) provide increased education and training to physicians and staff about depression detection and assessment.