Mental Health: Research Findings

Mental Health: Research Findings
Program Brief
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Mental disorders were one of the five most costly conditions in the United States in 2006, affecting numerous adults and children. Family abuse and substance abuse also remain serious problems. The Agency for Healthcare Research and Quality (AHRQ) supports a diverse array of mental health research projects that examine these and other issues.

This Program Brief presents findings from AHRQ intramural and extramural research projects on mental health, which were published between 2007 and 2009.

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Contents
Introduction
Abuse (Intimate Partner and Family Violence)
Access to/Cost of Care
Addiction/Substance Abuse
Cognitive Impairment/Psychosis
Depression
Disparities
Health Information Technology
Pharmaceuticals
Other Findings
More Information

Introduction
About one in four adults in the United States suffers from a mental disorder in a given year, with about 6 percent suffering from a serious mental illness. These problems typically take a toll on overall health. For example, patients diagnosed with a serious mental disorder die 25 years earlier than the general population. Related behavioral issues such as substance abuse or domestic violence also remain persistent problems. For example, nearly one-third of U.S. adults suffer from some type of mental illness or substance abuse. In addition, an estimated 1.3 million women are physically abused by their intimate partners each year and about 1 million abused children are identified each year. Care costs for these problems are significant. Mental disorders were one of the five most costly conditions in the United States in 2006, with care expenditures rising from $35.2 billion in 1996 to 57.5 billion in 2006. Treatment settings are also changing. For example, a growing number of children and adults are being diagnosed and treated for mental illness by primary care clinicians. Also, use of telepsychiatry and new medications are extending the reach and type of treatment available.

The Agency for Healthcare Research and Quality (AHRQ) supports a diverse array of mental health research projects that examine these and other issues. Topics of recently funded projects range from mental comorbidity and chronic illness, feedback systems to improve evidence-based therapies for children with mental disorders, and the impact of atypical antipsychotic use on elderly health care use to electronic personal health records for mental health consumers and assessment and intervention for elder self-neglect.

The Agency continues to expand funding for research to improve mental health care through health information technology (IT) and primary care delivery. AHRQ has also developed a new focus on the complex patient – the patient with multiple chronic illnesses, who also often battles substance abuse, depression, and other mental health problems.

This program brief presents findings from a cross-section of AHRQ-supported extramural and intramural research projects on mental health, which were published between 2007 and 2009. An asterisk at the end of a summary indicates that reprints of an intramural study or copies of other publications are available from AHRQ. See the last page of this program brief to find out how to get more detailed information about AHRQ’s research programs and funding opportunities.



Abuse (Intimate Partner and Family Violence)
An estimated 1.3 million women are physically abused by their intimate partners each year. Also, about one in every four women seeking care in emergency rooms has injuries resulting from domestic violence. More than one in four men have also been victims of intimate partner violence during their lifetime. About 1 million abused children are identified in the U.S. each year, with 1,500 dying of abuse and neglect each year. What’s more, an estimated 551,000 older adults are victims of family abuse or neglect. The physical and psychological fallout from intimate partner and family violence are reflected in the high use of health care services by the abused, as well as high rates of depression, substance abuse, suicide, and poor pregnancy outcomes among women, and behavior problems, developmental delay, and school failure among abused children.

Domestic violence victims have higher health care use and costs than other women, even long after the abuse has ended.
Women who suffer from intimate partner violence (IPV) typically have more headaches, chronic pain, gastrointestinal and gynecologic problems, depression and anxiety, and injuries than other women. They also have significantly higher health care use and costs than other women. Forty-six percent of 3,333 women aged 18 to 64 years enrolled in a large HMO in Washington State and northern Idaho reported IPV in their lifetime. Although health care use decreased over time after the IPV stopped, it was still 20 percent higher 5 years after the abuse ceased compared with women who had never been abused. After adjusting for several factors, use of health care by women with IPV was about 50 percent higher than women with no history of IPV for emergency department visits, twofold higher for mental health visits, and sixfold higher for use of alcohol or drug services. Abused women also had 14 to 21 percent more primary and specialty care visits and pharmacy use than women with no history of IPV. Adjusted annual total health care costs were 19 percent higher in women with a history of IPV (amounting to $439 annually) compared with women without IPV. Rivara, Anderson, Fishman, et al., American Journal of Preventive Medicine 32(2):89-96, 2007 (AHRQ grant HS10909).

Women who suffer abuse use mental health care services more than women who have never been abused, regardless of when the abuse occurred.
Researchers surveyed 3,333 women aged 18 to 64 in the Pacific Northwest and found that mental health service use was highest when the physical or nonphysical (verbal threats or controlling behavior) abuse was ongoing. Whether women suffered abuse recently (within 5 years) or 5 years ago or longer, they still accessed mental health services at higher rates than women who were never abused. Compared with women who never experienced abuse, women who were physically abused used more emergency, outpatient, pharmacy, and specialty services (perhaps for injuries resulting from the abuse). Women suffering ongoing physical and nonphysical abuse had total annual health care costs that were 42 percent and 33 percent higher, respectively, than women who never suffered abuse. Bonomi, Anderson, Rivara, and Thompson, "Health care utilization and costs associated with physical and nonphysical-only intimate partner violence," Health Services Research 44(3), pp. 1-16, 2009 (AHRQ grant HS10909).

Women who were sexually or physically abused are more likely to seek medical care and legal assistance than women who report only psychological abuse.
The duration and severity of domestic abuse that women endure serve as a predictor of whether they will seek medical and legal help. Women who were psychologically abused were more inclined to obtain legal than medical services. Sexually abused women were 1.3 times as likely to seek medical care as women who were psychologically abused. The longer the abuse continued, the more likely the woman was to obtain legal help. For example, compared with women who were abused for 0 to 2 years, women who were physically abused for 3 to 10 years were 1.4 times more likely to seek legal services. Those who suffered physical abuse for more than 10 years were 1.9 times as likely to get legal help. The findings were based on telephone interviews with 1,509 women from one health plan, who said they had experienced physical, sexual, or psychological abuse since reaching age 18. Duterte, Bonomi, Kernic, et al., "Correlates of medical and legal help seeking among women reporting intimate partner violence," Journal of Women’s Health 17(1):85-88, 2008 (AHRQ Grant HS10909).

Health care costs are significantly greater for women who were physically or sexually abused as children than for women who left childhood unscathed.
Health care costs for women with a history of physical and sexual abuse averaged $3,203 annually, while costs for women who were not abused averaged $2,413, a nearly $800 difference. Women who endured both types of abuse also used more mental health, hospital outpatient, emergency department, primary care, specialty care, and pharmacy services than the nonabused group. Thirty four percent of women said they were abused as children. These women were more likely to have smoked, used recreational drugs in the past year, shown symptoms of depression, and have a higher body mass index than women who had not suffered abuse as children. The researchers interviewed 3,333 women by telephone who received care from one health plan over a 10-year period (1992-2002). Bonomi, Anderson, Rivara, et al., "Health care utilization and costs associated with childhood abuse," Journal of General Internal Medicine 23(3):249-299, 2008 (AHRQ grant HS10909)

Children of women who are or have been abused by their partners seek more mental and other health care than children of nonabused mothers.
Health care use and costs were greater for children of mothers with a history of IPV and were significantly greater for mental health services, primary care visits and costs, and laboratory costs. Even after IPV was reported to have ended, children of abused mothers were three times more likely to use mental health services and had 16 percent higher primary care costs than did children of nonabused mothers, although their overall costs were no higher. Even children whose mothers’ abuse ended before the children were born used significantly more mental health, primary care, specialty care, and pharmacy services and had 24 percent higher care costs than children whose mothers had not been abused. Researchers compared health care use and costs of 760 children of mothers with no history of IPV with 631 children of mothers with a history of IPV over an 11-year period (1992- 2003). Rivara, Anderson, Fishman, et al., "Intimate partner violence and health care costs and utilization for children living in the home," Pediatrics 120:1270-1277, 2007 (AHRQ grant HS10909).

More than 200 abused children under age 5 died in U.S. hospitals in 2005.
Of 6,700 children hospitalized for physical abuse or neglect in 2005, more than 200 died and all fatalities were under age 5, according to a new report from AHRQ. Children less than 5 years old comprised 80 percent of all those under 18 years of age who were admitted that year for abuse or neglect. Hospital care for children who suffered physical, sexual, emotional abuse, or neglect cost almost $100 million. The average stay for an abused and/or neglected child cost $14,800—75 percent more than the average pediatric admission. More than one-third of children hospitalized for physical abuse had head injuries, 26 percent had bruises, 21 percent had bleeding behind the eye, 20 percent had epileptic convulsions, and 18 percent had broken legs or feet. Children from the poorest communities accounted for nearly 36 percent of hospitalizations for abuse or neglect, regardless of age. Medicaid was billed for 71 percent of these stays. For more information, see Hospital Stays Related to Child Maltreatment, 2005, HCUP Statistical Brief #49 (http://www.hcup-us.ahrq.gov/reports/statbriefs/sb49.jsp).

Intimate partner abuse has no age limit.
More than one-fourth of 70 elderly women surveyed, who were enrolled in a West Coast care delivery system, reported being physically or psychologically abused by intimate partners during their adult life. Half the women were 65 to 74 years of age and half were age 75 and older. About 18 percent of the women said that they suffered sexual abuse or physical abuse, and 22 percent were victims of nonphysical abuse, including being threatened, called names, or having their behavior controlled by an intimate partner. The duration of abuse ranged from 3 years for forced sexual contact to 10 years of being put down, called names, or having their behavior controlled. About 60 percent of the victims of physical violence and 71 percent of the women who were subjected to psychological abuse and threats rated the abuse as severe. Only 3 percent of the women said that they had been asked by a health care provider about physical or sexual violence by an intimate partner since age 18. Bonomi, Anderson, Reid, et al., "Intimate partner violence in older women," Gerontologist 47(1):34-41, 2007 (AHRQ grant HS10909).

Locating homeless services in dilapidated, crime-ridden areas may contribute to the violence against homeless women.
Homeless women living near skid row in Los Angeles (LA) were 1.5 times more likely to be physically assaulted than homeless women living in other areas of LA. Safer locations for shelters and other assistance programs could reduce violence against homeless women. However, surrounding higher income communities have opposed efforts to relocate programs outside of the skid row district of LA, note the researchers. They interviewed 974 homeless women visiting 64 shelters and 38 meal programs serving homeless women in 8 regions of LA County. For every one standard deviation increase in proximity to skid row, there was an estimated 48 percent increase in a woman’s chance of being assaulted. Heslin, Robinson, Baker, and Gelberg, "Community characteristics and violence against homeless women in Los Angeles County," Journal of Health Care for the Poor and Underserved 18: 203- 218, 2007 (AHRQ grants HS08323 and HS14022).

Nearly half of pregnant Latina women report intimate partner abuse.
Nearly 44 percent of 210 pregnant Latina women studied for 1 year reported intimate partner abuse. This is a problem, because women who are abused while they are pregnant are more likely to attempt homicide, have unplanned pregnancies, forego prenatal care until the second trimester, and suffer complications during birth. The researchers assessed the women for IPV, strength, adverse social behavior, post-traumatic stress disorder (PTSD), and depression. Social support was lower for the 92 abused women, who also reported higher levels of social undermining by their partner and stress. As expected, women who were exposed to abuse were more likely to be depressed (41.3 percent) or have PTSD (16.3 percent) than their nonabused counterparts (18.6 and 7.6 percent, respectively). Rodriguez, Heilemann, Fielder et al., "Intimate partner violence, depression, and PTSD among pregnant Latina women, "Annals of Family Medicine 6(1):44-52, 2008 (AHRQ grant HS11104).

Married women who are abused are more at risk for delivering babies with low birth weights than women who never experience violence.
A study in Boston found that women who were exposed to violence either before or during their pregnancies were not at increased risk of delivering early or having babies born with low birth weights compared with women who never experienced violence. However, married women who suffered violence were more at risk for delivering babies with low birth weights than women who never experienced violence. Determining the relationship between a mother’s experience with violence and its effect on her pregnancy may provide the medical community with strategies to prevent poor pregnancy outcomes, suggest the Massachusetts researchers. They used data from 1,555 women who enrolled in Boston’s Healthy Baby Program, which provides services to pregnant women living in areas with high rates of infant deaths. Fried, Cabral, Amaro, and Aschengrau, "Lifetime and during pregnancy experience of violence and the risk of low birth weight and preterm birth," Journal of Midwifery and Women’s Health 53(6):522-528, 2008 (AHRQ grant HS 08008).

More than in one in four men have been victims of intimate partner violence during their lifetime.
More than one in four men (29 percent) have been victims of intimate partner violence (IPV) during their lifetime, 10 percent in the past 5 years, and nearly 5 percent in the past year. Men aged 18 to 55 were twice as likely to be recently abused than men aged 55 and older (14.2 vs. 5.3), even though overall rates of physical (ranging from hitting, slapping, and shoving to choking or worse) and nonphysical IPV (threats, anger, and or controlling behavior) were similar. Nearly one-third (32 percent) of men reported mildly violent IPV, and 39 percent reported moderately or extremely violent IPV. Compared with men who never suffered IPV, older men who had experienced IPV suffered from nearly three times more depressive symptoms and had low mental health scores on a standard scale. These findings were based on interviews with 420 English speaking adult men enrolled in a large health care system and surveys that assessed types of IPV, overall health, and mental health. Reid, Bonomi, Rivara, et al., "Intimate partner violence among men: Prevalence, chronicity, and health effects," American Journal of Preventive Medicine 34 (6):478-485, 2008 (AHRQ grant HS10909).



Access to/Cost of Care
Access to mental health care is an ongoing problem for people in rural/frontier areas of the country as well as many other groups. For example, 4 percent of young adults reported foregoing mental health care in the past year, despite self-reported mental health needs. Commonly cited reasons ranged from inability to pay, belief that the problem would go away, and lack of time. Cost of mental health care is also a burden. For example, individuals nationwide spent an average of 10 percent of their family’s annual income out of pocket for mental health/substance abuse treatment. Also, mental disorders were one of the five most costly conditions in the United States in 2006, with expenditures at $57.5 billion.

Mental disorders were one of the five most costly conditions for children in 2006.
The five most costly children’s conditions in 2006 were mental disorders, asthma, trauma-related disorders (fractures and other injuries), acute bronchitis, and infectious diseases, according to the latest data from AHRQ.Treating mental disorders in children, such as depression, cost the most at $8.9 billion compared with $8 billion for asthma and $6.1 billion for trauma-related disorders.Mean expenditures per child with expenses were highest for mental disorders at $1,931. Medicaid paid for more than one-third of the expenditures for mental disorders (35.2 percent), with private insurance paying the largest percentage of expenditures. Out-of-pocket payments were highest for mental disorders at 21.3 percent. These data are taken from the Medical Expenditure Panel Survey (MEPS), a detailed source of information on U.S.health services use, cost, and sources of payment. For more information, see MEPS Statistical Brief #242, The Five Most Costly Children’s Conditions, 2006: Estimates for the U.S. Civilian Noninstitutionalized Children, Ages 0 to 17, at http://www.meps.ahrq.gov/mepsweb/data_files/publications/st242/stat242.pdf.

Mental disorders led the list of the five most costly conditions overall in 2006.
Mental disorders, heart conditions, cancer, trauma-related disorders, and asthma ranked highest in terms of direct medical spending in 1996 and 2006, according to the latest data from AHRQ. The number of people accounting for expenses for mental disorders nearly doubled from 19.3 million to 36.2 million during that period. Of the five conditions, out-of-pocket payments were highest for the treatment of mental disorders in both 1996 and 2006 (23.1 and 25 percent, respectively). These data are taken from the Medical Expenditure Panel Survey (MEPS), a detailed source of information on U.S. health services use, cost, and sources of payment. For more information, see MEPS Statistical Brief #248, The Five Most Costly Conditions, 1996 and 2006: Estimates for the U.S. Civilian Noninstitutionalized Population, at http://www.meps.ahrq.gov/mepsweb/data_files/publications/st248/stat248.pdf.

People with psychotic disorders and bipolar disorder are 45 percent and 26 percent less likely, respectively, to have a primary care doctor than those without mental disorders.
Researchers compared access and barriers to medical care among 156,475 adults reporting psychotic and mood disorders or no mental disorders, who completed the National Health Interview Survey (NHIS) and NHIS-Disability Component for 1994 and 1995. People with psychotic disorders, bipolar disorder, or major depressive disorder had 2.5 to 7 times greater odds of any barriers to care, ranging from delaying medical care because of costs to being unable to get needed medical care or a needed prescription medication. However, those with major depression were as likely to report having a regular source of care as those who did not report psychiatric disorders. Bradford, Kim, Braxton, and others, "Access to medical care among persons with psychotic and major affective disorders," Psychiatric Services 59(8), pp. 847-852, 2008 (AHRQ grant HS13353).

Young adults’ mental health problems are compounded by the number of barriers they face when accessing medical care.
Four percent of young adults reported foregoing mental health care in the past year, despite self-reported mental health needs. Commonly cited reasons ranged from inability to pay, belief that the problem would go away, and lack of time. Among individuals suffering from depressive symptoms, young adults reported significantly lower rates of counseling use than adolescents. Female gender, high maternal education, school attendance, and receipt of routine physical exams were significantly predictive of counseling use among young adults. Young black adults were significantly less likely to receive counseling than their white counterparts. These findings were based on analysis of data from a sample of 10,817 participants in the National Longitudinal Study of Adolescent Health in 1995 and follow-up data 7 years later. Yu, Adams, Burns, et al., "Use of mental health counseling as adolescents become young adults," Journal of Adolescent Health 43:268-276, 2008 (AHRQ grant HS00086).

A quality improvement (QI) program that improves access to psychotherapy (QI-therapy) and antidepressant medication (QI-meds) is cost-effective for managing depression in primary care patients.
The researchers examined the cost effectiveness of managing care of 746 primary care patients with 12-month depressive disorder and 502 patients with current depressive symptoms but no disorder (sub-threshold depression). The patients were randomly assigned to enhanced usual care or to QI-Meds or QI-Therapy for 6 to 12 months.

The cost of the QI program was $2,028 per quality-adjusted life year (QALY) for those with sub-threshold depression and $53,716 per QALY for those with depressive disorder. This is similar to the cost effectiveness of many widely used medical therapies. The researchers calculated that the costs of the intervention per se - as distinct from intervention effects on use of services and medication - were $86 per patient in the QI-Meds group and $79 per patient in the QI-Therapy group. Wells, Schoenbaum, Duan, et al., "Cost effectiveness of quality improvement programs for patients with subthreshold depression or depressive disorder," Psychiatric Services 58(10):1269-1278, 2007 (AHRQ grant HS08349).

Southerners bear a higher financial burden for mental health/substance abuse treatment.
About 11 percent of people using outpatient mental health and substance abuse (MH/SA) treatment in the South used more than 5 percent of their family’s annual income to cover their out-of-pocket treatment costs from 2001 to 2005. Southerners paid the highest percentage of treatment costs out of their own pockets because they were most likely to use prescription medications for their treatment and they paid the greatest share (39 percent) of the costs of these medications. For other regions of the country, between 8 and 10 percent of MH/SA treatment recipients spent more than 5 percent of their family’s annual income, and 10 percent did nationwide. Patient out-of-pocket costs included fees for psychiatrists, psychologists, social workers, and other specialty providers; MH treatment provided by primary care physicians; and medications. Prescription medications accounted for almost two-thirds of out-of-pocket spending for outpatient MH treatment. Zuvekas and Meyerhoefer, "State variations in the out-of-pocket spending burden for outpatient mental health treatment," Health Affairs 28(3):713-722, 2009 (AHRQ Publication No. 09-R056).*

Managed behavioral health care organizations have reduced the costs of specialty mental health and substance abuse treatment by shifting to outpatient services.
There remains concern that managed behavioral health care organizations (MBHOs) may shift mental health treatment to primary care and prescription drugs (use of drugs instead of psychotherapy) in order to reach contractual cost-savings goals. However, this study of a single MBHO found no evidence to suggest that it shifted treatment costs in this way. Researchers analyzed claims data from 1991-1995 from an insurer that introduced an MBHO in 1992 to control treatment costs. The use of any psychotropic medication rose 64 percent over the 4- year period among enrollees of the large employer group that had parity for physical and mental health care and by 87 percent in the smaller groups without parity. Often these medications were prescribed in primary care settings. Introduction of the MBHO was not significantly associated with the use of any psychotropic medication alone, and for newer antidepressants, it was associated with a 2.4 percentage point decrease in medication use alone in the large group. Zuvekas, Rupp, and Norquist, "Cost shifting under managed behavioral health care," Psychiatric Services 58(1):100-108, 2007 (AHRQ Publication No. 07-R036).*

Hospital cost and stay duration for the elderly with non-dementia psychiatric illnesses varies by care settings.
General hospitals, psychiatric units, long-stay hospitals, and skilled nursing facilities (SNFs) are the inpatient settings where non-dementia psychiatric illnesses (NDPI), such as depression, bipolar disorders, and substance abuse, are treated. Medicare’s cost-cutting reimbursement strategies and caps on stay lengths in addition to treatment advances have affected how the elderly receive care for NDPI. Analysis of Centers for Medicare & Medicaid Services data from 1992 to 2002 found that mean inpatient length of stay for NDPI illnesses fell from nearly 14.9 days in 1992 to just 12.1 days in 2002. Similarly, mean Medicare expenditures per stay declined from $8,461 to $6,207. Each of the four types of facilities treating these patients was impacted differently during the 10-year period. For example, the portion of NDPI stays that were in general hospitals fell from 34.5 percent to 27.4 percent, and the portion in long-stay hospitals fell from 19.5 percent to 11.3 percent. However, mean Medicare-covered SNF days per NDPI stay remained stable, while mean Medicare-covered costs rose from $4,153 to $6,375. Hoover, Akincigil, Prince, et al., "Medicare inpatient treatment for elderly non-dementia psychiatric illnesses 1992-2002; length of stay and expenditures by facility type," Administration and Policy in Mental Health 35(4): 231-240, 2008 (AHRQ grant HS16097).

States vary greatly in nursing home admissions for people with mental illnesses.
State variation in services for people with mental illnesses and how they are admitted to nursing homes may result in longer-than-average stays for those individuals. Researchers analyzed 2005 data from the Centers for Medicare and Medicaid Services. They found that States varied widely in nursing home admission rates for people suffering from mental illness. For example, nursing homes in Wyoming, Nevada, Arkansas, and South Dakota had the lowest rates for admitting individuals with schizophrenia and bipolar disorder, while Connecticut, Ohio, and Massachusetts had the highest rates. What’s more, in 2004 nearly 46 percent of people with mental illnesses admitted to nursing homes in the United States remained in the facility 90 days after admission compared with 24 percent of people who did not have a mental illness. The way Medicaid pays nursing homes may be one reason for State variations in admissions for people with mental illnesses. For instance, Medicaid pays nursing homes higher rates for people with mental illnesses who have minimal physical problems. Thus, these higher rates may give nursing homes an incentive to admit these patients. Variation could also be a result of some States being able to offer home and community-based services or State psychiatric hospitals in lieu of nursing home care. Grabowski, Aschbrenner, Feng, and Mor, "Mental illness in nursing homes: Variations across States," Health Affairs 28(3), pp. 689-700, 2009 (AHRQ grant T32 HS00011).

Changes in cost to patients reduce new use of antidepressants among the elderly, but have less impact on continued use.
In January 2002, the British Columbia Government switched from paying the full cost of prescriptions for seniors to requiring a copay of $25 Canadian ($10 for low-income seniors). In May 2003, the program began requiring patients to pay a 25 percent coinsurance once an income-based deductible was met. The level of antidepressant initiation increased from 4.3 starts per 1,000 seniors per month in 1997 to 5.0 starts per 1,000 in December 2001. Implementation of the copay policy in January 2002 reduced the antidepressant therapy start level by 0.38 per 1,000 seniors per month without changing the rate of increase over time. Introduction of coinsurance in May 2003 reduced the rate of increase per month by 0.03 per 1,000 seniors. Wang, Patrick, Dormuth et al, "The impact of cost sharing on antidepressant use among older adults in British Columbia," Psychiatric Services 59(4):377–383, 2008 (AHRQ grant HS10881).