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Porous PDMS elastomers were synthesized using emulsion templated thiol–ene “click” reactions to obtain materials with tunable storage moduli at a single porosity value that achieve low sound speed values of ∼40 m s−1.

Porous elastomers possessing gradient morphology or chemistry are needed for new applications including biomaterial interfaces, additive manufacturing, and separation membranes. However, elastomers possessing a porosity gradient are often difficult to prepare requiring slow multistep synthesis techniques. In this work, layered porosity polydimethylsiloxane (PDMS)-based polymerized high internal phase emulsions (polyHIPEs) with defined interfaces have been synthesized using one-step reactions. The total porosity, pore size, and surface area of the prepared polyHIPEs are controlled by varying the volume of aqueous dispersed phase in the emulsion. Analysis of SEM images and pore size calculations of layered porosity polyHIPEs proved the emulsion patterning method did not disrupt emulsion morphology and a clear porosity interface was maintained. Total porosity values dictate the storage moduli of the polyHIPEs, where highly porous materials possess the lowest observed moduli of ~70–90 kPa. Tensile testing shows that the interface between two layers is mechanically robust and does not split during elongation at break experiments. This work provides a simple technique to prepare layered porosity PDMS-based polyHIPEs having up to five tunable porosity layers with strong interfaces between the layers.

Objective:Practice-based collaborative care is a complex evidence-based practice that is difficult to implement in smaller primary care practices that lack on-site mental health staff. Telemedicine-based collaborative care virtually co-locates and integrates mental health providers into primary care settings. The objective of this multisite randomized pragmatic comparative effectiveness trial was to compare the outcomes of patients assigned to practice-based and telemedicine-based collaborative care.Method:From 2007 to 2009, patients at federally qualified health centers serving medically underserved populations were screened for depression, and 364 patients who screened positive were enrolled and followed for 18 months. Those assigned to practice-based collaborative care received evidence-based care from an on-site primary care provider and a nurse care manager. Those assigned to telemedicine-based collaborative care received evidence-based care from an on-site primary care provider and an off-site team:...

In a randomized trial of two interventions on employer health benefit decision-making, 156 employers in the evidence-based (EB) condition attended a two hour presentation reviewing scientific evidence demonstrating depression products that increase high quality treatment of depression in the workforce provide the employer a return on investment. One-hundred sixty-nine employers participating in the usual care (UC) condition attended a similar length presentation reviewing scientific evidence supporting healthcare effectiveness data and information set (HEDIS) monitoring. This study described the decision-making process in 264 (81.2%) employers completing 12 month follow-up. The EB intervention did not increase the proportion of employers who discussed depression products with others in the company (29.2% versus 32.1%, p &gt, 0.10), but it did significantly influence the content of the discussions that occurred. Discussion in EB companies promoted the capacity of a depression product to realize a return on investment (18.4% versus 4.7%, p = 0.05) and to improve productivity (47.4% versus 25.6%, p = 0.06) more often than discussions in UC companies. Almost half of EB and UC employers reported that return on investment has a large impact on health benefit decision-making. These results demonstrate the difficulty of influencing employer decisions about health benefits using group presentations.

This study investigated whether outpatient visits to psychiatrists and primary care physicians (family physicians, general internists, or general practitioners) by individuals with schizophrenia differed in antipsychotic medication management and subsequent hospitalization by age, gender, race-ethnicity, insurance, rurality, and region.Data for the study were from office visit forms completed between 1999 and 2007 by physicians in the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. A total of 3,359 outpatient visits by individuals with a diagnosis of schizophrenia were identified. The research team used four logistic regression models to test the relationship of sociodemographic variables to antipsychotic medication management during the visit and to hospitalization after the visit. The four models controlled for available clinical covariates with or without physician specialty in the entire cohort and in the cohort of visits in which patients had no active psychotic symptoms.In at least three of the four models, the research team observed that visits by non-Hispanic black patients had significantly (p.05) greater odds of involving antipsychotic medication management than visits by non-Hispanic whites (range of odds ratios [ORs] 1.66 to 1.88) and of resulting in hospitalization (range of ORs, 3.52 to 6.95). In all four models, visits by patients who lacked insurance were significantly less likely to result in hospitalization than visits by patients who had private insurance (OR=.001 in all models).These findings provide the first national evidence of potential treatment disparities for schizophrenia. Further research is needed to definitively identify disparities and to understand their causes and consequences.

Despite increasing consensus about the value of depression disease management programs, the field has not identified which stakeholders should absorb the relatively small additional costs associated with these programs. This paper investigates whether two proposed stakeholders (health plans and employer purchasers) economically benefit from depression care management (reduced outpatient utilization and work costs, respectively) in two delivery systems (rural and urban). This study examined the main and differential effects of depression care management on outpatient utilization and work costs over 24 months in a preplanned secondary analysis of 479 depressed patients from rural and urban primary care practices in a randomized controlled trial. Over 24 months, the intervention did not significantly reduce outpatient utilization costs in the entire cohort (−$191, 95% confidence interval (CI) = −$2,083 to $1,647), but it did decrease work costs (−$1,970, 95% CI = −$3,934 to −$92). While not statistically significant, rural–urban differences in work costs were in the same direction, while rural–urban differences in utilization costs differed in direction. These findings provide preliminary evidence that employers who elect to cover depression care management costs should receive comparable economic benefits in the rural and urban employees they insure. Given the limited sample size, further research may be needed to determine whether health plans who elect to cover depression care management costs will receive comparable economic benefits in the rural and urban enrollees they insure.

We hypothesized that somatizing patients managed by primary care physicians (PCP) would improve with a relationship-based intervention.We randomized 30 adults with medically unexplained symptoms to treatment or usual care. Four PCPs were trained to intervene with cognitive-behavioral, pharmacological, and patient-centered management and deployed the intervention with seven scheduled visits over 12 months. Outcomes obtained at baseline and 12 months were: Mental component summary (MCS), the primary endpoint, and measures of physical and psychological symptoms and of satisfaction with the PCP.Patients averaged 52.5 years; 83.3% were female; 79.6% were black. Using a difference of differences approach, we found that the intervention produced a large effect size (ES) (0.82; CI: 0.08 to 1.57) for the MCS in the predicted direction, similar to the ES for physical (-0.80; CI: -1.55 to -0.04) and psychological (-1.06; CI: -1.83 to -0.28) improvement and for increased satisfaction with the PCP (0.94; CI: 0.15 to 1.74). Using ANCOVA in a sensitivity analysis, we found that the ES fell slightly (0.59), while other measures were unchanged.Moderate-large effect sizes support the hypothesis that PCPs can effectively treat somatization. This points to the importance of performing a full RCT.

Efforts to improve primary care depression treatment have assessed strategies across heterogeneous groups of patients, but few have examined clinician-level influences on depression treatment.To examine clinician characteristics that affect depression treatment in primary care settings, using multilevel ordinal regression modeling to disentangle patient- from clinician-level effects.Secondary analysis from the Quality Improvement in Depression Study dataset.The participants were 1,023 primary care patients with depression who reported on treatment in the 6-month follow-up and whose clinicians (n = 158) had at least 4 patients in the study.Primary outcome variable was depression treatment intensity, derived from assessment of concordance with AHCPR depression treatment guidelines based on patient-reported data on their treatment. Primary independent variable was clinical practice burden for treating depression, derived from patient- and clinician-reported composite measures tested for significant association with clinician-reported practice burden.Clinicians who treat patients with more chronic medical comorbidities perceive less burden from treating depressed patients in their practice (Spearman's rho = -.30, p.05). Clinicians who treat patients with more chronic medical comorbidities also provide greater intensity of depression treatment (adjusted OR = 1.44, p = .02), even after adjusting for the effects of patient-level chronic medical comorbidities (adjusted OR = 0.95, p = .45).Clinicians who provide more chronic care also provide greater depression treatment intensity, suggesting that clinicians who care for complex patients can integrate depression care into their practice. Targeting interventions to these clinicians to enhance their ability to provide guideline-concordant depression care is a worthwhile endeavor and deserves further investigation.

In the Institute of Medicine (IOM) (2003)Unequal Treatment report, “discrimination” refers to a health care provider's treatment of patients with similar health care needs differently due to the patient's race or ethnicity. Investigators have studied three types of discrimination—affective bias, cognitive stereotyping, and statistical discrimination (Hilton and von Hippel 1996; Fiske 1998; Dovidio 1999; Balsa and McGuire 2003; IOM 2003; Escarce 2005; Fennell 2005), noting that each type of discrimination has distinct implications for appropriate remedial actions (Balsa and McGuire 2003). Statistical discrimination appears to be a potent (if more difficult to observe) source of discrimination in health care use (Balsa, McGuire, and Meredith 2005; Lutfey and Ketcham 2005; Werner 2005). In statistical discrimination, providers apply correct information about a group to reduce their clinical uncertainty about an individual patient. While discrimination stemming from affective bias and cognitive stereotyping is generally expected to reduce treatment of minorities in comparison with whites, statistical discrimination may or may not exacerbate race/ethnicity gaps in treatment (Balsa and McGuire 2001). Statistical discrimination can be in the minority patient's best interest if physicians use reliable group differences in the absence of reliable data about the individual. Nonetheless, if physician must rely less on individual level information, treatment for minority patients is less likely to be matched well to their individual needs. When poor communication exacerbates clinical uncertainty, providers give undue weight to group-based generalizations, taking the form of diminished responsiveness to the circumstances of an individual patient. Prior research has documented worse communication between white providers and minority patients compared with white patients (see, for example, Cooper-Patrick et al. 1999). Because providers primarily rely on patient report to judge the severity of depression, effective communication is particularly important for the physician to allocate severity-appropriate treatment resources for this condition. The objective of this paper is to test the hypothesis that providers employ statistical discrimination in treating depressed patients over time. Specifically, we assess whether treatment intensity changes as depression severity changes comparably over 2 years for minority and white patients.

This study measured geographic variation in depression hospitalizations and identified community-level risk factors. Depression hospitalizations were identified from the Statewide Inpatient Database. The dependent variable was specified as the indirectly standardized hospitalization rate. County-level data for 14 states were collected from federal agencies. The Bayesian spatial regression model included socio-demographic, economic, and health system characteristics as independent variables. There were 8.5 depression hospitalizations per 1,000 residents. 8.8% of counties had hospitalization rates 33% greater than the standardized rate. Significant risk factors included unemployment, poverty, physician supply, and hospital bed supply. Significant protective factors included rurality, economic dependence, and housing stress.

Context: Federally qualified health centers across the country are adopting depression disease management programs following federally mandated training; however, little is known about the relative effectiveness of depression disease management in rural versus urban patient populations. Purpose: To explore whether a depression disease management program has a comparable impact on clinical outcomes over 2 years in patients treated in rural and urban primary care practices and whether the impact is mediated by receiving evidence-based care (antidepressant medication and specialty care counseling). Methods: A preplanned secondary analysis was conducted in a consecutively sampled cohort of 479 depressed primary care patients recruited from 12 practices in 10 states across the country participating in the Quality Enhancement for Strategic Teaming study. Findings: Depression disease management improved the mental health status of urban patients over 18 months but not rural patients. Effects were not mediated by antidepressant medication or specialty care counseling in urban or rural patients. Conclusions: Depression disease management appears to improve clinical outcomes in urban but not rural patients. Because these programs compete for scarce resources, health care organizations interested in delivering depression disease management to rural populations need to advocate for programs whose clinical effectiveness has been demonstrated for rural residents.

The impact of depression on the workplace has been widely observed in studies examining absenteeism and reduced productivity during days at work. However, there is little scientific evidence about whether depression interventions are cost-beneficial to employers.We construct a cost-benefit analysis of depression treatment under different workplace assumptions better reflecting the nature of employment.Data from a randomized controlled trial in which employed primary care patients with depression were treated in practices randomly assigned to an enhanced treatment intervention or usual care were used to construct a cost-benefit model from an employer perspective under different assumptions regarding employment.A national sample of 198 workers employed in a range of positions by companies was studied.Benefits included self-reported productivity and absenteeism; costs included intervention and treatment costs. Net benefit was calculated under different scenarios and return on investment (ROI) is derived.Enhanced depression treatment resulted in an average net benefit to the employer of Dollars 30 per participating worker in Year 1 of the intervention and Dollars 257 per participating worker in Year 2, for an estimated ROI during the 2-year period of 302%. ROI increased in firms that rely on team production, hire more costly substitute labor, or realize penalties for output shortfalls. ROI decreased in firms that have a large fraction of employees with dependent coverage and experience high turnover rates. Results also are sensitive to how subjectively reported productivity is valued.Many employers will receive a potentially significant ROI from depression treatment models that improve absenteeism and productivity at work.

National working groups identify the need for return on investment research conducted from the purchaser perspective; however, the field has not developed standardized methods for measuring the basic components of return on investment, including costing out the value of work productivity loss due to illness. Recent literature is divided on whether the most commonly used method underestimates or overestimates this loss. The goal of this manuscript is to characterize between and within variation in the cost of work productivity loss from illness estimated by the most commonly used method and its two refinements. One senior health benefit specialist from each of 325 companies employing 100+ workers completed a cross-sectional survey describing their company size, industry and policies/practices regarding work loss which allowed the research team to derive the variables needed to estimate work productivity loss from illness using three methods. Compensation estimates were derived by multiplying lost work hours from presenteeism and absenteeism by wage/fringe. Disruption correction adjusted this estimate to account for co-worker disruption, while friction correction accounted for labor substitution. The analysis compared bootstrapped means and medians between and within these three methods. The average company realized an annual $617 (SD = $75) per capita loss from depression by compensation methods and a $649 (SD = $78) loss by disruption correction, compared to a $316 (SD = $58) loss by friction correction (p

Little is known about how psychiatric disorders affect health care costs in Medicaid programs. The prevalence of psychiatric disorders and costs of care for members of a Medicaid health maintenance organization (HMO) who had psychiatric disorders were examined.A cross-sectional, observational analysis of adult Medicaid beneficiaries over a 12-month period was conducted by using data from a health plan that has both an HMO and a behavioral health carve-out. Claims data were analyzed for 6,500 adults who were eligible for services in both plans and who received medical or behavioral health services during calendar year 2000.Thirty-nine percent of the 6,500 adults had a psychiatric diagnosis. Of this subset, 67.2 percent had received no specialty mental health care in the previous year. The presence of any psychiatric diagnosis significantly increased total health care costs by a factor of 2.24 ($6,995 compared with $3,121 for persons with no psychiatric diagnosis) and costs to the medical plan by a factor of 1.77 ($4,690 compared with $2,649). For beneficiaries with bipolar or psychotic diagnoses, higher health plan costs were due predominately to increases in pharmacy and specialty mental health costs. In contrast, higher costs for beneficiaries with depression, anxiety, or substance use diagnoses were attributable to greater use of general medical services.An analysis of claims data showed that adult Medicaid beneficiaries have exceptionally high rates of comorbid psychiatric conditions, which were associated with significantly higher medical and pharmaceutical costs. The high cost of these beneficiaries to the medical plan has policy implications in terms of the importance of addressing mental health issues in Medicaid general medical populations.

Although employers commonly review administrative database indicators to assess depression treatment quality, they do not know whether these indicators predict relevant outcomes like absenteeism. In 230 employed patients in five health plans, we tested how administrative database-derived indicators for antidepressant medication and psychotherapy provided during the first 6 months of a new depression treatment episode predicted patient-reported absenteeism change over 12 months. The medication indicator was not significantly associated with absenteeism change over 12 months (p= .64); however, the psychotherapy indicator was significantly associated with an average 26.1% improvement in absenteeism over 12 months (p< .05). If subsequent studies confirm the results we report, quality monitoring initiatives interested in employer-relevant indicators of depression treatment quality should examine administrative database indicators of psychotherapy.

Background: Employers recently requested a valid metric of depression treatment quality. Such an indicator needs to measure the proportion of the population in need who receive high-quality care, and to predict clinical improvement. Methods: We constructed an administrative database indicator derived from HEDIS criteria for antidepressant medication management, and tested it in 230 employed patients in five health plans. Results: Indicator rates were 7.0% in the population in need. Conformance to indicator criteria in this population was associated with 23.0% improvement in depression severity over 1 year (p = .02). Conclusions: Administrative database indicators that predict clinical improvement are a very rare accomplishment. Existing depression indicators may need to be calculated for the population in need to provide a valid metric for employer purchasers.

A B S T R AC T OBJECTIVE:To identify the clinical and economic implications of depression in the workplace and review how integrated care models can improve overall patient outcomes. SUMMARY:Depression is a significant financial burden to the employer due to lost days of work and decreased productivity. Employers are demanding return on the investment for their increasing health care expenditures. The cost of depression to employers may be contained by delivering care using integrated models that leverage primary care provider treatment with care management and mental health consultation. CONCLUSION:There is a need to reduce silos in the organization and financing of mental health care to prevent cost shifting that provides no benefit to patients, payers or providers. Poor mental health care will likely lead to a rise in absenteeism and presenteeism.

Objective: To test whether an intervention to improve primary care depression management significantly improves productivity at work and absenteeism over 2 years. Setting and Subjects: Twelve community primary care practices recruiting depressed primary care patients identified in a previsit screening. Research Design: Practices were stratified by depression treatment patterns before randomization to enhanced or usual care. After delivering brief training, enhanced care clinicians provided improved depression management over 24 months. The research team evaluated productivity and absenteeism at baseline, 6, 12, 18, and 24 months in 326 patients who reported full-or part-time work at one or more completed waves. Results: Employed patients in the enhanced care condition reported 6.1% greater productivity and 22.8% less absenteeism over 2 years. Consistent with its impact on depression severity and emotional role functioning, intervention effects were more observable in consistently employed subjects where the intervention improved productivity by 8.2% over 2 years at an estimated annual value of $1982 per depressed full-time equivalent and reduced absenteeism by 28.4% or 12.3 days over 2 years at an estimated annual value of $619 per depressed full-time equivalent. Conclusions: This trial, which is the first to our knowledge to demonstrate that improving the quality of care for any chronic disease has positive consequences for productivity and absenteeism, encourages formal cost-benefit research to assess the potential return-on-investment employers of stable workforces can realize from using their purchasing power to encourage better depression treatment for their employees.

OBJECTIVE: To investigate the effects of exclusively physical presentation of depression on 1) depression management and outcomes under usual care conditions, and 2) the impact of an intervention to improve management and outcomes. DESIGN AND SETTING: Secondary analysis of a depression intervention trial in 12 community-based primary care practices. PARTICIPANTS: Two hundred adults beginning a new treatment episode for depression. MEASUREMENTS: Presenting complaint and physician depression query at index visit; antidepressant use, completion of adequate antidepressant trial, change in depressive symptoms, and physical and emotional role functioning at 6 months. MAIN RESULTS: Sixty-six percent of depressed patients presented exclusively with physical symptoms. Under usual care conditions, psychological presenters were more likely than physicial presenters to complete an adequate trial of anti-depressant treatment but experienced equivalent improvements in depressive severity and role functioning. In patients presenting exclusively with physicial symptoms, the intervention significantly improved physician query (40.8% vs 18.0%; P=.06), receipt of any antidepressant (63.0% vs 20.1%; P=.001), and an adequate antidepressant trial (34.9% vs 5.9%; P=.004), but did not significantly improve depression severity or role functioning. In patients presenting with psychological symptoms, the intervention significantly improved receipt of any antidepressant (79.9% vs 38.0%; P=.01) and an adequate antidepressant trial (46.0% vs 23.8%; P=.004), and also improved depression severity and physical and emotional role functioning. CONCLUSIONS: Our results suggest that there is a differential intervention effect by presentation style at the index visit. Thus, current interventions should be targeted at psychological presenters and new approaches should be developed for physical presenters.

This paper describes the impact of a care recommendation (CR) letter intervention on patients with multisomatoform disorder (MSD) and analysis of patient factors that affect the response to the intervention.One hundred eighty-eight patients from 3 family practices, identified through screening of 2,902 consecutive patients, were classified using somatization diagnoses based on the number of unexplained physical symptoms from a standardized mental health interview. In a controlled, single-crossover trial, patients were randomized to have their primary care physician receive the CR letter either immediately following enrollment or 12 months after enrollment. The CR letter notified the physician of the patient's somatization status and provided recommendations for the patient's care. Patients were followed for 24 months with assessments of functional status at baseline, 12, and 24 months.Longitudinal analysis revealed a 12-month intervention effect for patients with multisomatoform disorder (MSD) of 5.5 points (P.001) on the physical functioning (PCS) scale of the SF-36. Analysis of scores on the MCS scale of the SF-36 found no significant effect on mental functioning. The intervention was more effective for patients with 1 or more comorbid chronic physical diseases (P = .01).The CR letter has a favorable impact on physical impairment of primary care patients with MSD, especially for patients with comorbid chronic physical disease. Multisomatoform disorder appears to be a useful diagnostic classification for managing and studying somatization in primary care patients.

Background. Ethnic minority patients are less likely than white patients to receive guideline-concordant care for depression. It is uncertain whether racial and ethnic differences exist in patient beliefs, attitudes, and preferences for treatment. Methods. A telephone survey was conducted of 829 adult patients (659 non-Hispanic whites, 97 African Americans, 73 Hispanics) recruited from primary care offices across the United States who reported 1 week or more of depressed mood or loss of interest within the past month and who met criteria for Major Depressive Episode in the past year. Within this cohort, we examined differences among African Americans, Hispanics, and whites in acceptability of antidepressant medication and acceptability of individual counseling. Results. African Americans (adjusted OR, 0.30; 95% CI 0.19–0.48) and Hispanics (adjusted OR, 0.44; 95% CI, 0.26–0.76) had lower odds than white persons of finding antidepressant medications acceptable. African Americans had somewhat lower odds (adjusted OR, 0.63; 95% CI, 0.35–1.12), and Hispanics had higher odds (adjusted OR, 3.26; 95% CI, 1.08–9.89) of finding counseling acceptable than white persons. Some negative beliefs regarding treatment were more prevalent among ethnic minorities; however adjustment for these beliefs did not explain differences in acceptability of treatment for depression. Conclusions. African Americans are less likely than white persons to find antidepressant medication acceptable. Hispanics are less likely to find antidepressant medication acceptable, and more likely to find counseling acceptable than white persons. Racial and ethnic differences in beliefs about treatment modalities were found, but did not explain differences in the acceptability of depression treatment. Clinicians should consider patients’ cultural and social context when negotiating treatment decisions for depression. Future research should identify other attitudinal barriers to depression care among ethnic minority patients.

Background and Objectives. To assess the differential impact of an ongoing primary care depression intervention on uninsured and insured patients’ outcomes 12, 18, and 24 months following baseline. Research Design. Quasi-experimental longitudinal study of insured and uninsured patients with depression receiving treatment from 12 practices randomized to enhanced (intervention) and usual care study conditions. Subjects. In 1996 to 1997, 383 nonelderly patients with depression (290 insured, 93 uninsured) were enrolled and followed for 24 months. Measures. Mental-health-related-quality-of-life (MHQOL) was assessed at each follow-up using the SF-36 Mental Component Summary scale. Presence of major depressive episode was assessed at 24-month follow-up with the Composite International Diagnostic Interview. Results. Uninsured enhanced-care patients had significantly better MHQOL outcomes at 24 months than uninsured usual care patients (40.6 vs. 32.7, respectively;P = 0.01). The intervention had no significant impact on insured patients’ MHQOL outcomes at any follow-up interval. Among patients receiving usual care, the uninsured compared with the insured had significantly poorer MHQOL outcomes (32.7 vs. 40.7, respectively;P = 0.002) and significantly increased probability of experiencing a major depressive episode (40.6% vs. 19.8%, respectively;P = 0.04) at 24 months. No such disparities were observed between uninsured and insured patients receiving enhanced care. Conclusions. The ongoing intervention significantly improved quality-of-life outcomes in uninsured patients at 24 months. If the intervention’s impact on MHQOL can be confirmed and proved cost-effective in larger uninsured patient populations, clinicians serving the uninsured may want to consider implementing the study’s intervention.

This review synthesizes empirical research in rural mental health services to identify current research priorities to improve the mental health of rural Americans. Using a conceptual framework of the multiple determinants of use, quality, and outcomes, the authors address (1) how key constructs are operationalized, (2) their theoretical influence on the care process, (3) reported differences for nonmetropolitan and metropolitan individuals or within nonmetropolitan individuals, (4) salient issues rural advocates have raised, and (5) key research questions. While the authors recognize that rurality is a useful political umbrella to organize advocacy efforts, they propose that investigators no longer employ any of the multiple definitions of the term in the literature as even intrarural comparisons have not provided compelling evidence about the underlying causes of observed outcomes differences. Until these underlying causes have been identified, it is difficult to determine which components of the nonmetropolitan service system need to be improved.

This study used qualitative and quantitative methods to examine the reasons primary care physicians and nurses offered for their inability to initiate guideline-concordant acute-phase care for patients with current major depression.Two hundred thirty-nine patients with 5 or more symptoms of depression seeing 12 physicians in 6 primary care practices were randomized to the intervention arm of a trial of the effectiveness of depression treatment. Sixty-six (27.6%) patients identified as failing to meet criteria for guideline-concordant treatment 8 weeks following the index visit were the focus of this analysis.The research team interviewed the 12 physicians and 6 nurse care managers to explore the major reasons depressed patients fail to receive guideline-concordant acute-phase care. This information was used to develop a checklist of barriers to depression care. The 12 physicians then completed the checklist for each of the 64 patients for whom he or she was the primary care provider. Physicians chose which barriers they felt applied to each patient and weighted the importance of the barrier by assigning a total of 100 points for each patient. Cluster analysis of barrier scores identified naturally occurring groups of patients with common barrier profiles.The cluster analysis produced a 5-cluster solution with profiles characterized by patient resistance (19 patients, 30.6%), patient noncompliance with visits (15 patients, 24.2%), physician judgment overruled the guideline (12 patients, 19.3%), patient psychosocial burden (8 patients, 12.9%), and health care system problems (8 patients, 12.9%). The physicians assigned 4,707 (75.9%) of the 6,200 weighting points to patient-centered barriers. Physician-centered barriers accounted for 927 (15.0%) and system barriers accounted for 566 (9.1%) of weighting points. Twenty-eight percent of the patients not initiating guideline-concordant acute-stage care went on to receive additional care and met criteria for remission at 6 months, with no statistical difference across the 5 patient clusters.Current interventions fail to address barriers to initiating guideline-concordant acute-stage care faced by more than a quarter of depressed primary care patients. Physicians feel that barriers arise most frequently from factors centered with the patients, their psychosocial circumstances, and their attitudes and beliefs about depression and its care. Physicians less frequently make judgments that overrule the guidelines, but do so when patients have complex illness patterns. Further descriptive and experimental studies are needed to confirm and further examine barriers to depression care. Because few untreated patients improve without acute-stage care, additional work is also needed to develop new intervention components that address these barriers.

Background Employers can purchase high quality depression products that provide the type, intensity and duration of depression care management shown to improve work outcomes sufficiently for many employers to achieve a return on investment. The purpose of this randomized controlled trial was to test an intervention to encourage employers to purchase a high quality depression product for their workforce. Methods Twenty nine organizations recruited senior health benefit professional members representing public or private employers who had not yet purchased a depression product for all 100+ workers in their company. The research team used randomization blocked by company size to assign eligible employers to: (1) a presentation encouraging employers to purchase a high quality depression product accompanied by a scientifically-derived return on investment estimate, or (2) a presentation encouraging employers to work with their most subscribed health plan to improve depression treatment quality indicators. Two hundred ninety three employers (82.3% of 356) completed baseline data immediately before learning that 140 employers had been randomized to the evidence-based (EB) depression product presentation and 153 had been randomized to the usual care (UC) depression treatment quality indicator presentation. Analysis of 250 (85.3% of 293) employers who completed web-based interviews at 12 and/or 24 months was conducted to determine presentation impact on depression product appraisal and purchasing behavior. Results The intervention had no impact on depression product appraisal in 232 subjects (F = 2.36, p = .07) or depression product purchasing (chisquare = 1.82, p = .44) in 250 subjects. Depression product appraisal increased in companies with greater health benefit generosity whose benefit professionals were male. Depression product purchasing behavior increased in small companies compared to large companies, companies who knew a vendor that sold depression products at baseline, companies with greater health benefit risk taking, and companies with less politicalization of health care benefit decision making. Conclusions Policy makers need to build innovative bridges to the employer community to convince them to purchase evidence-based benefits, even when benefits offer potential financial savings. Trial registration Clinical Trials Registration Number: NCT01013220.

Objective: This study examined the test-retest reliability of a new instrument, the Services Assessment for Children and Adolescents (SACA), for children’s use of mental health services. Methods: A cross-sectional survey was undertaken at two sites. The St. Louis site used a volunteer sample recruited from mental health clinics and local schools. The Ventura County, California, site used a double-blind, community-based sample seeded with cases of service-using children. Participating families completed the SACA and were retested within four to 14 days. The reliability of service use items was calculated with use of the kappa statistic. Results: The SACA– Parent Version had excellent test-retest reliability for both lifetime service use and previous 12-month use. The SACA also had good to excellent reliability when administered to children aged 11 and older for lifetime and 12-month use. Reliability figures for children aged nine and ten years were considerably lower for lifetime and 12-month use. The younger children’s responses suggested that they were confused about some questions. Conclusions: This study demonstrates that parents and older children can reliably report use of mental health services by using the SACA. The SACA can be used to collect currently unavailable information about use of mental health services. (Psychiatric Services 52:1088–1094, 2001)

Objective To validate the prototype Adolescent Treatment Outcomes Module (ATOM), examine its sensitivity to clinical change, and determine its feasibility for administration in routine clinical settings. Method A sample of 67 adolescents, aged 11 through 18, was selected from new patients at two inpatient and two outpatient mental health programs. Adolescents and parents completed the ATOM and validating instruments at intake, 1 week postintake, and again at 6 months. Results Nine self-report symptoms predicted positive diagnoses of oppositional defiant, conduct, anxiety, and depressive disorders on the basis of structured diagnoses, with sensitivities of 0.7 to 0.8. Test-retest correlations for outcome scales were largely excellent (>0.70). Scales that measured functioning at home, in school, and in the community were moderately correlated in the expected direction with global functioning. Decreases in symptom severity and functional impairment were generally associated with decreases in validating instruments. Administration time averaged 25 minutes for adolescents and 28 minutes for parents. Conclusions Both parents and adolescents readily completed the ATOM. Module scales demonstrated excellent reliability and good to fair concurrent validity. The ATOM was able to detect change and its absence.

Researchers have tested a range of interventions to improve primary care management of major depression to address the poor outcomes these patients often achieve.1–6 The most successful of these interventions have utilized mental health professionals as part of multi-faceted interventions to provide extended consultation on medication management7–9 or to provide psychotherapy in the primary care setting.10,11 While impressive, these models may be difficult to disseminate widely since only one third of primary care physicians work in practices with onsite mental health professionals.12 In addition, few practices without onsite mental health professionals have reimbursement arrangements to support collaborative care. More transportable interventions have trained primary care nurses/extenders to monitor medication response13,14 or to provide brief psychotherapy.15,16 Building on these latter studies, we tested the Quality Enhancement by Strategic Teaming (QuEST) intervention. The QuEST intervention redefined roles across the primary care team to improve the detection and management of major depression without the assistance of an onsite mental health professional. Incorporating strengths from effectiveness studies, we tested the intervention with primary care professionals in community practices caring for patients meeting criteria for major depression, the population described in the Agency for Health Care Policy and Research (AHCPR) Guidelines.17,18 The primary objective of the study was to evaluate the effect of the QuEST intervention on the process and outcomes of care provided to this heterogeneous group of primary care patients with major depression. We anticipated the intervention would be more effective in improving outcomes among patients beginning a new treatment episode, because patients who remained depressed after treatment might be more treatment-resistant. Neither the AHCPR Guidelines nor the QuEST intervention provided evidence-based recommendations for treatment-resistant patients since efficacy trials are only now beginning to define the treatment these patients need. Because patient treatment preferences have a significant impact on the quality of care depressed primary care patients receive,19 we also anticipated that the intervention's effect on outcomes would be more observable in the patients who reported at baseline that antidepressant medication was an acceptable treatment for their problem.

This longitudinal, nonexperimental study examined whether depression treatment provided in concordance with guidelines developed by the Agency for Healthcare Research and Quality (AHRQ) is associated with improved clinical outcomes.The medical, insurance, and pharmacy records of a community-based sample of 435 subjects who screened positive for current major depression were abstracted to ascertain whether depression treatment was received and whether it was provided in accordance with AHRQ guidelines. Regression analyses estimated the impact of guideline-concordant treatment on the change in depression severity and on mental and physical health over a six-month period. An instrumental variables analysis was used to check the sensitivity of the results to selection bias.A total of 106 subjects were treated for depression by 105 different primary care and specialty providers. Sixty percent of the sample had current major depression, and about 40 percent had subthreshold depression. Only 29 percent of the patients received guideline-concordant treatment. For patients with major depression, guideline-concordant care was significantly and substantially associated with improved depression severity but not with improvements in overall mental or physical health. The instrumental variables analysis indicated that the standard regression analysis underestimated the treatment effect by 21 percent. For those with subthreshold depression, guideline-concordant care was not associated with improved outcomes.This community-based, nonexperimental study found a positive relationship between the quality of care for depression and clinical outcomes for patients with major depression in routine practice settings.

Objective and design To evaluate a cohort of patients with major depression to examine the effect of competing demands on depression care during multiple visits over 6 months. Participants and setting Ninety-two patients with 5 or more symptoms of depression and no recent depression treatment were evaluated by 12 primary care physicians in 6 practices in the usual-care arm of an effectiveness trial of the Agency for Health Care Policy and Research Depression Guidelines. Main outcome measure Treatment was considered to be initiated if the patient reported starting a guideline-concordant antidepressant medication or making a visit for specialty counseling. Treatment completion was defined as either a 3-month course of guideline-concordant antidepressant use or completion of 8 or more specialty counseling visits. Results Among the 92 patients reporting no recent treatment at study enrollment, 57% reported starting and 17% reported completing a course of guideline-concordant antidepressant medication and or specialty counseling at the 6-month interview. The severity of physical problems among patients with high enthusiasm for depression treatment decreased the odds that patients would initiate depression therapy. Severity of physical problems had no observable effect on completing depression therapy in the group of patients who initiated treatment. Conclusions Physical problems compete with depression for attention over multiple visits in untreated patients who are enthusiastic about getting care for their emotional problems. Interventions are needed for this high-risk group, because depression treatment could potentially enhance patients' treatment of their physical problems. Arch Fam Med. 2000;9:1059-1064

To determine the criteria other than cost large employers use in selecting and monitoring behavioral health benefits, this study interviewed 31 of 44 (70.4%) randomly selected corporations employing at least 5,000 workers. While more than 60% of employers considered administrative efficiency and provider access to be very influential in their selection of behavioral health benefits, only 12.9% (95% confidence interval 0.7%-25.1%) considered clinical outcomes. Employers who considered clinical outcomes in their purchasing decision reported significantly greater satisfaction with the quality and cost of their behavioral health benefits. Following selection, 38.7% of corporations used employee complaints to monitor quality problems in their behavioral health benefits; 3.2% used clinical outcomes. If society expects employers to purchase behavioral health care on the basis of quality as well as cost, more employers need better indicators of quality.

Objective To examine whether competing demands explain the appearance of inadequate primary care depression treatment observed at a single visit. Design A cross-sectional patient survey. Participants and setting Two hundred forty patients with 5 or more symptoms of depression seeing 12 physicians in 6 primary care practices, representing 77.4% of the depressed patients identified through 2-stage screening of more than 11,000 primary care attenders. Main outcome measures In patients with elevated depressive symptoms, discussing depression as a possible diagnosis in untreated patients, and changing depression management in treated patients. Results Physicians and patients discussed depression in 46 (47.9%) of 96 untreated patients; physicians changed depression treatment recommendations in 87 (60.4%) of 144 treated patients with current symptoms. Chronic physical comorbidity decreased the odds that physicians and untreated patients discussed depression as a possible diagnosis (odds ratio = 0.66, P = .01). New problems decreased the odds that treatment recommendations would be changed in treated patients who remained depressed (odds ratio = 0.39, P = .05). Physicians and untreated patients were more likely to discuss depression as a possible diagnosis if patients reported antidepressant medication was acceptable (odds ratio = 4.57, P = .01) and less likely to discuss depression if patients reported specialty care counseling was acceptable (odds ratio = 0.33, P = .05). Conclusions The attention depression gets during a given medical visit is less associated with the severity of the patient's depressive symptoms than with the number or recency of other problems the patient has. If competing demands provide ongoing barriers to depression treatment, interventions will be needed to assure that patients with chronic physical problems receive high-quality mental health care in the primary care setting.

The purpose of this study was to identify a community sample of rural and urban at-risk drinkers, to compare them in terms of sociodemographics, access measures and severity of illness, and to study them prospectively to identify rural/urban differences in use of 12-month alcoholism treatment services.A brief telephone screening interview of over 12,000 respondents in six southern states identified a sample of at-risk drinkers. A baseline interview was administered to 733 individuals (67% men, 50% rural residents) that obtained information on substance use and psychiatric disorders, psychosocial factors, social support, four dimensions of access to alcoholism treatment services and prior alcoholism service use. Interviews at 6 and 12 months obtained self-reports of subsequent receipt of alcoholism treatment services.We identified modest differences between rural and urban at-risk drinkers. The rural sample was significantly less well-educated and reported significantly less affordability, accessibility and acceptability of some treatment services (p.05). Rural at-risk drinkers also appeared to possess significantly greater illness characteristics, including more lifetime DSM-IV criteria for alcohol use disorders, more frequent recent alcohol disorders and more chronic medical problems (p.05). The longitudinal sample comprised 579 participants, of whom 7% reported receiving some form of alcoholism treatment services in the year after the initial interview. In bivariate analysis, rural drinkers in the sample reported greater use of help for their drinking, more use of psychiatrists and more use of inpatient, outpatient and ER treatment settings than did their urban counterparts. However, significant independent predictors of 12-month alcoholism treatment use in multiple logistic regression were female gender (OR = 0.3), greater social support (OR = 2.2) and illness or severity characteristics including recent diagnosis of alcohol dependence (OR = 3.3), social consequences of drinking (OR = 1.7), concurrent medical problems (OR = 2.1) and prior treatment experience (OR = 4.4).We found modest differences among rural and urban at-risk drinkers and some evidence of greater barriers to treatment and greater illness severity among rural inhabitants. Further research is needed to know whether community interventions with social networks and other interventions to improve social support may help bring at-risk drinkers into treatment in both urban and rural settings as well as provide other support for sobriety.

We introduce the inverse hyperbolic sine transformation to health services research. The IHS transformation is unique because it is applicable in regressions where the dependent variable to be transformed may be positive, zero, or negative. In contrast, the most frequently used Box-Cox family of transformations is applicable only when the dependent variable is non-negative (or strictly positive in the special case of log transformation). We apply the IHS transformation to examine the economic benefits of mental health treatment for individuals with depression, where over half of the observations of the dependent variable are negative or zero.

Objective: This research compared alternative measures of geographic access to health care providers using different levels of spatial aggregation (county, zipcode and street) and different methods of calculating the cost of space (Euclidean distance, road distance and travel time).

Although treatment for major depression has been shown to reduce the costs of lost earnings resulting from lost work days, research has not demonstrated whether the reduction fully offsets the costs of treatment for the disorder.A statewide cohort of community residents with recent major depression, dysthymia, or substantial depressive symptoms was recruited and interviewed at baseline and at six-month and 12-month follow-ups. The cost of lost earnings was measured by lost work days multiplied by subjects' wage rates. Cost of treatment for depression was approximated using charges abstracted from provider and insurance records. Net economic cost, defined as the sum of changes in lost earnings and depression treatment costs, was examined in multiple regression analyses.After the analyses controlled for sociodemographic characteristics, baseline severity of depression, and comorbidity, no statistically significant effect of depression treatment on net economic cost was found. This finding suggests that the cost of depression treatment was fully offset by savings from reduction in lost work days. Results from sensitivity analyses in multiple alternative scenarios support the same conclusion.The finding of a full offset of depression treatment cost is conservative because other benefits, such as reduced pain and suffering and increased productivity while at work, were not included in the analyses. Employers who bear the cost from lost work days should encourage their employees with depressive disorders to seek treatment, even if it means paying for the entire treatment cost. Self-employed individuals with depression also will benefit even if they pay for the treatment costs themselves.

OBJECTIVES For depression, this research measures the impact of travel time on visit frequency and the probability of receiving treatment in concordance with AHCPR guidelines. METHODS The medical, insurance, and pharmacy records of a community-based sample of 435 subjects with current depression were abstracted to identify those treated for depression, to determine the number of depression visits made over a 6-month period, and to ascertain whether treatment was provided in concordance with AHCPR guidelines. A Geographic Information System was used to calculate the travel time from each patient to their preferred provider. Poisson and logistic regression analyses were used to estimate the impact of travel time on visit frequency and guideline-concordance, controlling for patient casemix. RESULTS In the community-based sample, 106 subjects were treated for depression by 105 different preferred providers. About one-third (30.7%) were treated by a mental health specialist. One average, patients made 2.8 depression visits over the 6-month period. One-third (28.9%) of the patients received guideline-concordant treatment for depression. The average number of visits for those receiving guideline-concordant care was significantly greater than for those not receiving guideline-concordant care (P < 0.01). Travel time to the preferred provider was significantly associated with making fewer visits (P < 0.0001) and having a lower likelihood of receiving guideline-concordant care (P < 0.05). DISCUSSION For depression, both pharmacotherapy and psychotherapy treatment regimens require frequent provider contact to be effective. This study suggests that travel barriers may prevent rural patients from making a sufficient number of visits to receive effective guideline-concordant treatment.

This study examined the relationship between costs of treating physical problems and costs of treating depression, for 322 rural residents with depression. Multiple regressions were used to control for sociodemographics, depression severity, and physical and mental health comorbidities at baseline. The results indicated a $1.42 (n = 322) reduction in the costs of treating physical problems for a $1.00 increase in the costs of treating depression. The reduction was $2.61 (p < 0.05) among those receiving depression treatment (n = 125). These findings suggest a net savings from depression treatment, in addition to other benefits such as improved symptoms and functioning and increased productivity.

Background Because primary care physicians (PCPs) are the initial health care contact for most patients with depression, they are in a unique position to provide early detection and integrated care for persons with depression and coexisting medical illness. Despite this opportunity, care for depression is often suboptimal. Objective To better understand how to design interventions to improve care, we examine PCPs' approach to recognition and management and the effects of physician specialty and degree of capitation on barriers to care for 3 common depressive disorders. Methods A 53-item questionnaire was mailed to 3375 randomly selected subjects, divided equally among family physicians, general internists, and obstetrician-gynecologists. The questionnaire assessed reported diagnosis and treatment practices for each subject's most recent patient recognized to have major or minor depression or dysthymia and barriers to the recognition and treatment of depression. Eligible physicians were PCPs who worked at least half-time seeing outpatients for longitudinal care. Results Of 2316 physicians with known eligibility, 1350 (58.3%) returned the questionnaire. Respondents were family physicians (n = 621), general internists (n = 474), and obstetrician-gynecologists (n = 255). The PCPs report recognition and evaluation practices related to their most recent case as follows: recognition by routine questioning or screening for depression (9%), diagnosis based on formal criteria (33.7%), direct questioning about suicide (58%), and assessment for substance abuse (68.1%) or medical causes of depression (84.1%). Reported treatment practices were watchful waiting only (6.1%), PCP counseling for more than 5 minutes (39.7%), antidepressant medication prescription (72.5%), and mental health referral (38.4%). Diagnostic evaluation and treatment approaches varied significantly by specialty but not by the type of depression or degree of capitation. Physician barriers differed by specialty more than by degree of capitation. In contrast, organizational barriers, such as time for an adequate history and the affordability of mental health professionals, differed by degree of capitation more than by physician specialty. Patient barriers were common but did not vary by physician specialty or degree of capitation. Conclusions A substantial proportion of PCPs report diagnostic and treatment approaches that are consistent with high-quality care. Differences in approach were associated more with specialty than with type of depressive disorder or degree of capitation. Quality improvement efforts need to (1) be tailored for different physician specialties, (2) emphasize the importance of differentiating major depression from other depressive disorders and tailoring the treatment approach accordingly, and (3) address organizational barriers to best practice and knowledge gaps about depression treatment.

OBJECTIVE: To compare primary care providers’ depression-related knowledge, attitudes, and practices and to understand how these reports vary for providers in staff or group-model managed care organizations (MCOs) compared with network-model MCOs including independent practice associations and preferred provider organizations. DESIGN: Survey of primary care providers’ depression-related practices in 1996. SETTING AND PARTICIPANTS: We surveyed 410 providers, from 80 outpatient clinics, in 11 MCOs participating in four studies designed to improve the quality of depression care in primary care. MEASUREMENTS AND MAIN RESULTS: We measured knowledge based on depression guidelines, attitudes (beliefs about burden, skill, and barriers) related to depression, and reported behavior. Providers in both types of MCO are equally knowledgeable about treating depression (better knowledge of pharmacologic than psychotherapeutic treatments) and perceive equivalent skills in treating depression. However, compared with network-model providers, staff/group-model providers have stronger beliefs that treating depression is burdensome to their practice. While more staff/group-model providers reported time limitations as a barrier to optimal depression treatment, more network-model providers reported limited access to mental health specialty referral as a barrier. Accordingly, these staff/group-model providers are more likely to treat patients with major depression through referral (51% vs 38%) or to assess but not treat (17% vs 7%), and network-model providers are more likely to prescribe antidepressants (57% vs 6%) as first-line treatment. CONCLUSIONS: Whereas the providers from staff/group-model MCOs had greater access to and relied more on referral, the providers from network-model organizations were more likely to treat depression themselves. Given varying attitudes and behaviors, improving primary care for the treatment of depression will require unique strategies beyond enhancing technical knowledge for the two types of MCOs.

Policy analysts have long been concerned that the reduced availability of mental health professionals in rural areas prohibits rural individuals from getting the care they need for serious psychiatric conditions like bipolar disorder. Through a community-based telephone survey, the researchers recruited 54 subjects with bipolar disorder who were currently experiencing depressive episodes. Forty-six (85.1%) of them were reinterviewed one year after the first survey. Multivariate models indicate that while rural subjects were just as likely to receive nonacute services for mental health problems as their urban counterparts, the rural residents had 22.1 times the odds (95% confidence interval 2.5 to 198.3, P=0.006) of receiving such services exclusively from a general medical provider. Rural subjects had 5.8 times the odds (95% confidence interval 0.8 to 40.7, P=0.07) of using hospital or emergency room services and 4 times the odds (95% confidence interval 0.8 to 20.5, P=0.10) of experiencing a manic episode during the year following baseline. While rural individuals with bipolar disorder have a comparable likelihood of receiving care for their mental health problems, they utilize more acute services and experience worse outcomes. Further research is warranted to deter-mine what causes these differences before developing cost-effective ways to improve the care delivered to individuals with this serious illness.

OBJECTIVE: Health policy makers lack accurate information about per capita spending for the treatment of major depression, the distribution of those expenditures, and the proportion of the health care dollar consumed by depression treatment. METHOD: The authors recruited and followed a community cohort of individuals with major depression; the 298 subjects were either enrolled in fee-for-service insurance plans or self-insured. Charges for all health care services received during the year following baseline were abstracted from medical and insurance records. RESULTS: Over the course of 1 year, 48.1% of the subjects received depression treatment. The per capita total expenditure for inpatient and outpatient depression treatment averaged $631, with a median of $152, for the treated subjects. Just 4.9% of the treated subjects consumed 45.0% of the outpatient expenditures. Depression treatment consumed only 8 cents of every health care dollar spent on the patients treated for depression. CONCLUSIONS: Studies ...

OBJECTIVES: Because there are fewer per capita providers trained to deliver mental health services in rural areas, the authors hypothesized that depressed rural individuals would receive less outpatient treatment and report higher rates of hospital admittance and suicide attempts than their urban counterparts. METHODS: The authors recruited 74% of eligible participants (n = 470) from a 1992 telephone survey and followed up 95% of subjects for 1 year. The authors collected data from subjects on psychiatric problems and service use and from insurers/providers on treatment and expenditures. RESULTS: Although there were no rural-urban differences in the rate, type, or quality of outpatient depression treatment, rural subjects made significantly fewer specialty care visits for depression. Depressed rural individuals had 3.05 times the odds of being admitted to the hospital for physical problems (P = 0.02) and 3.06 times the odds of being admitted for mental health problems (P = 0.08) during the year. Elevated rates of hospital admittance disappear in models controlling for number of specialty care depression visits in the previous month. Rural subjects reported significantly more suicide attempts during the period of 1 year (P = 0.05). CONCLUSIONS: Additional work is warranted to determine how to alter barriers to outpatient specialty care if the rural health care delivery system is to provide cost-effective depression care. Language: en

Objectives.Using a community-based sample of currently depressed subjects, this research modeled the joint decision to seek depression treatment and choice of provider sector (primary care or specialty mental health). The objective was to identify those subject-specific casemix factors and those

To investigate how practice guidelines or recommendations can be applied in the assessment of quality of care, 72 subjects beginning specialty treatment for panic disorder were enrolled. The Panic Outcomes Module assessed symptoms, health status, and treatment at baseline and after 8 weeks. Ustng published guidelines, the authors developed specific criteria to rate whethersubjects' reports reflected appropriate treatment, including antipanic medication or three or more subse quent visits that involved antipanic behavioral therapy elements. Scxty-nine subjects (96%) completed the Panic Outcomes Module at both baseline andfollow-up. Improvement in symptoms and health status was not different between subjects receiving appropriate and inappropriate care.