Ruth S. Shim

Prevalence, Treatment, and Control of Depressive Symptoms in the United States: Results from the National Health and Nutrition Examination Survey (NHANES), 2005–2008

Background:Depression remains a major public health problem that is most often evaluated and treated in primary care settings. The objective of this study was to examine the prevalence, treatment, and control of depressive symptoms in a national data sample using a common primary care screening tool for depression. Methods:We analyzed a sample of adults (n = 4836) from 2005 to 2008 National Health and Nutrition Examination Survey data. Depressive symptoms were assessed using the Patient Health Questionnaire (PHQ-9) to determine the overall prevalence, rates of treatment, and antidepressant control of mild, moderate, moderately severe, and severe depressive symptoms. Results:Of the sample, 20.1% reported significant depressive symptoms (PHQ-9) score, ≥5), the majority of whom had mild depressive symptoms (PHQ-9) score, 5–9). Even among individuals with severe depressive symptoms, a large percentage (36.9%) received no treatment from a mental health professional or with antidepressant medication. Of those taking antidepressants, 26.4% reported mild depressive symptoms and 18.8% had moderate, moderately severe, or severe depressive symptoms. Conclusions:Despite greater awareness and treatment of depression in primary care settings, the prevalence of depressive symptoms remains high, treatment levels remain low, and control of depressive symptoms are suboptimal. Primary care providers need to continue to focus their efforts on diagnosing and effectively treating this important disease.

Mental Comorbidity and Quality of Diabetes Care Under Medicaid: A 50-State Analysis

Background:Patients with comorbid medical and mental conditions are at risk for poor quality of care. With the anticipated expansion of Medicaid under health reform, it is particularly important to develop national estimates of the magnitude and correlates of quality deficits related to mental comorbidity among Medicaid enrollees. Methods:For all 657,628 fee-for-service Medicaid enrollees with diabetes during 2003 to 2004, the study compared Healthcare Effectiveness Data and Information Set (HEDIS) diabetes performance measures (hemoglobin A1C, eye examinations, low density lipoproteins screening, and treatment for nephropathy) and admissions for ambulatory care-sensitive conditions (ACSCs) between persons with and without mental comorbidity. Nested hierarchical models included individual, county, and state-level measures. Results:A total of 17.8% of the diabetic sample had a comorbid mental condition. In adjusted models, presence of a mental condition was associated with a 0.83 (0.82–0.85) odds of obtaining 2 or more HEDIS indicators, and a 1.32 (1.29–1.34) increase in odds of one or more ACSC hospitalization. Among those with diabetes and mental comorbidities, living in a county with a shortage of primary care physicians was associated with reduced performance on HEDIS measures; living in a state with higher Medicaid reimbursement fees and department of mental health expenses per client were associated both with higher quality on HEDIS measures and lower (better) rates of ACSC hospitalizations. Conclusions:Among persons with diabetes treated in the Medicaid system, mental comorbidity is an important risk factor for both underuse and overuse of medical care. Modifiable county and state-level factors may mitigate these quality deficits.

Opioid Addiction and Abuse in Primary Care Practice: A Comparison of Methadone and Buprenorphine as Treatment Options

Opioid abuse and addiction have increased in frequency in the United States over the past 20 years. In 2009, an estimated 5.3 million persons used opioid medications nonmedically within the past month, 200000 used heroin, and approximately 9.6% of African Americans used an illicit drug. Racial and ethnic minorities experience disparities in availability and access to mental health care, including substance use disorders. Primary care practitioners are often called upon to differentiate between appropriate, medically indicated opioid use in pain management vs inappropriate abuse or addiction. Racial and ethnic minority populations tend to favor primary care treatment settings over specialty mental health settings. Recent therapeutic advances allow patients requiring specialized treatment for opioid abuse and addiction to be managed in primary care settings. The Drug Addiction Treatment Act of 2000 enables qualified physicians with readily available short-term training to treat opioid-dependent patients with buprenorphine in an office-based setting, potentially making primary care physicians active partners in the diagnosis and treatment of opioid use disorders. Methadone and buprenorphine are effective opioid replacement agents for maintenance and/or detoxification of opioid-addicted individuals. However, restrictive federal regulations and stigmatization of opioid addiction and treatment have limited the availability of methadone. The opioid partial agonist-antagonist buprenorphine/naloxone combination has proven an effective alternative. This article reviews the literature on differences between buprenorphine and methadone regarding availability, efficacy, safety, side-effects, and dosing, identifying resources for enhancing the effectiveness of medication-assisted recovery through coordination with behavioral/psychological counseling, embedded in the context of recovery-oriented systems of care.

Primary Care, Behavioral Health, and Public Health: Partners in Reducing Mental Health Stigma

The authors reflect on the role that collaboration between the primary care, behavioral health and public health sectors can play in reducing mental health stigma. They suggest that stigma against mental illness and substance abuse disorders contributes to poor health outcomes and is a major public health problem. They argue that a collaboration between primary care, behavioral health and public health is essential to achieve less stigmatized, more optimal health outcomes for all.

Racial Disparities in Economic and Clinical Outcomes of Pregnancy Among Medicaid Recipients

To explore racial-ethnic disparities in adverse pregnancy outcomes among Medicaid recipients, and to estimate excess Medicaid costs associated with the disparities. Cross-sectional study of adverse pregnancy outcomes and Medicaid payments using data from Medicaid Analytic eXtract files on all Medicaid enrollees in fourteen southern states. Compared to other racial and ethnic groups, African American women tended to be younger, more likely to have a Cesarean section, to stay longer in the hospital and to incur higher Medicaid costs. African-American women were also more likely to experience preeclampsia, placental abruption, preterm birth, small birth size for gestational age, and fetal death/stillbirth. Eliminating racial disparities in adverse pregnancy outcomes (not counting infant costs), could generate Medicaid cost savings of

The Relationship Between Obesity and Depression Among Adolescents

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The Social Determinants of Mental Health: An Overview and Call to Action

214 million per year in these 14 states. Despite having the same insurance coverage and meeting the same poverty guidelines for Medicaid eligibility, African American women have a higher rate of adverse pregnancy outcomes than White or Hispanic women. Racial disparities in adverse pregnancy outcomes not only represent potentially preventable human suffering, but also avoidable economic costs. There is a significant financial return-on-investment opportunity tied to eliminating racial disparities in birth outcomes. With the Affordable Care Act expansion of Medicaid coverage for the year 2014, Medicaid could be powerful public health tool for improving pregnancy outcomes.

Telepsychiatry Services for Korean Immigrants

Obesity and depression are two major public health problems among adolescents. Both obesity and depression are very prevalent and associated with numerous health complications, including hypertension, coronary heart disease, and increased mortality.1 Because they both carry a risk for cardiovascular disease, a possible association between depression and obesity has been assumed and studied.2 Several evidence-based studies have shown that obese teens have a higher incidence of mental health problems such as depression, anxiety, and poor self-esteem than nonobese teens.3 A reasonable conclusion is that obesity should predict depression, but the findings are not clear.4 In reality, few studies have found that obesity predicted depression over time, thus it has been proposed that instead of looking at the basic main effects of obesity predicting depression, it might be more practical to examine the specific processes or experiences by which obesity might lead to depression among adolescents so that specific interventions can be targeted.5 This article summarizes data on the role of mediating and moderating variables associated with obesity and depression among adolescents. This literature review also examines the thoughts and experiences of obese adolescents that facilitate the development of depressive symptoms.

Health Care Reform and Integrated Care: A Golden Opportunity for Preventive Psychiatry

Mental disorders are among the most prevalent, chronic, and disabling health conditions; they touch the lives of all Americans in some way.1 Although these disorders clearly have biological correlates, they are also substantially influenced by modifiable social, economic, and environmental conditions that affect not only individuals, but whole communities, neighborhoods, and populations. Historically, many theories have been postulated to help explain the origins of disease. During the 19th century, miasma theory attributed the causes of disease epidemics to “bad air” and led to a focus on public health interventions to improve living conditions of populations as a means of effectively limiting the incidence and prevalence of disease.2 This theory, although later supplanted by the germ theory of disease, was one of the earliest conceptualizations supporting the role of social factors in causing and sustaining illnesses. Furthermore, miasma theory led to important public health interventions, such as urban sanitation Ruth Shim, MD, MPH, is Associate Professor, Department of Psychiatry and Behavioral Sciences; Associate Director, National Center for Primary Care, Morehouse School of Medicine. Carol Koplan, MD, is Adjunct Assistant Professor, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University. Frederick J.P. Langheim, MD, PhD, is Joint Director, Consultation and Liaison Psychiatry, St. Mary’s Hospital; Staff Psychiatrist, Dean Health System; Clinical Adjunct Assistant Professor, University of Wisconsin, Madison. Marc W. Manseau, MD, MPH, is Public Psychiatry Fellow, Department of Psychiatry, Columbia University Medical Center, New York State Psychiatric Institute. Rebecca A. Powers, MD, MPH, is Adjunct Clinical Associate Professor of Psychiatry, Stanford University School of Medicine. Michael T. Compton, MD, MPH, is Chairman, Department of Psychiatry, Lenox Hill Hospital; Professor, Department of Psychiatry, Hofstra North Shore – LIJ School of Medicine at Hofstra University. Address correspondence to: Ruth Shim, MD, MPH, National Center for Primary Care, Morehouse School of Medicine, 720 Westview Drive, Atlanta, GA 30310; email: rshim@msm. edu. Disclosure: The authors have no relevant financial relationships to disclose. doi: 10.3928/00485713-20140108-04 The Social Determinants of Mental Health: An Overview and Call to Action

Health care avoidance among people with serious psychological distress: analyses of 2007 Health Information National Trends Survey.

Asian Americans often face cultural and language barriers when obtaining mental health treatment. With the small number of Asian mental health providers, it is difficult to ensure the linguistic and ethnic matching of providers and patients. Telepsychiatry holds great promise to address the unique needs of Asian Americans. We developed a project to establish telepsychiatry services that connect Korean mental health patients in Georgia with a linguistically and culturally competent psychiatrist in California and assessed the level of acceptability of psychiatric treatment via real-time teleconferencing among these patients. Upon the completion of the program, 16 patients (5 men, 11 women) completed a questionnaire that measured their acceptability of the telepsychiatry service. The findings indicate a high level of acceptance of the program among Korean patients. The quantitative and qualitative data show that they especially appreciated the cultural sensitivity of the consultation and the comfortable interaction with the provider. However, challenges such as technical issues of teleconferencing may negatively affect the quality of the clinical interaction. Our study expands the knowledge base regarding the acceptability of such services to a population that experiences disparities in mental health care. Future research should extend telepsychiatry services to other Asian population groups that experience lower access to mental health services.