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Compendium of Research Related to Mental Health

Program Note 6


Each year, about 20 percent of Americans have a mental disorder, resulting in high human costs as well as high direct and indirect costs. The Agency for Healthcare Research and Quality (AHRQ) has a broad portfolio of mental health research, some focused specifically on mental health and some with a strong mental health component.

This compendium is an overview of the research and activities conducted or funded by AHRQ. In addition to briefly describing the material, the compendium gives information on how to access the material.

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Contents

Introduction
Extramural Research
   Addiction/Substance Abuse
   Alzheimer's Disease/Cognitive Impairment
   Anxiety Disorders
   Depression
   Pharmaceuticals
   Quality
   Schizophrenia
   Stress
   Tools
   Trauma
   Violence
   Other
Intramural Research
   Access
   Cost
   Institutional Care
   Measurement
   Parity
   Utilization
   Other
Evidence-Based Practice Reports
   Attention-Deficit/Hyperactivity
   Depression
   Alcohol Dependence
Clinical Guidelines
   Treating Tobacco Use and Dependence
   Depression in Primary Care
   Early Identification of Alzheimer's and Related Dementias
National Guideline Clearinghouse
User Liaison Program
   Depression: Implications for State and Local Health Care Programs
   Improving the Outcomes of State Health and Human Service Initiatives
   Reducing Violence: Issues, Options, and Opportunities for State Governments
Other Activities
   U.S. Preventive Services Task Force
   Foundation for Accountability Abstracts
   HIV Cost and Services Utilization Study
   AHRQ Domestic Violence Scholar in Residence

Introduction

During the course of a year, about one in five American adults (or 20 percent) has a mental disorder, according to current epidemiological estimates.1 The direct costs of mental health services in 1996 were $69.0 billion, with an additional $17.7 billion spent on Alzheimer's disease and $12.6 billion on substance abuse treatment.2 The indirect costs of mental disorders in the United States in 1990 were estimated at $78.6 billion.3 The World Health Organization, in the landmark Global Burden of Disease Study, found that mental illness is the second leading cause of disability and premature mortality and that mental disorders collectively account for more than 15 percent of the overall burden of disease from all causes.4

Because of these startling statistics, there has been a greater focus on mental health issues, starting with the White House Conference on Mental Health in 1999 and the first U.S. Department of Health and Human Services Secretarial Initiative on Mental Health. In late 1999, the first ever Mental Health: A Report of the Surgeon General was published.2

Besides a renewed focus, the last decade has witnessed a great deal of change in the field of mental health. Managed care and other changes in the health delivery system have led to a shift away from specialty care for mental health and toward treatment by primary care providers. Pharmaceuticals have provided a whole new range of treatments that can work very effectively, especially when combined with psychosocial interventions. Last but not least, consumers and families have emerged as powerful and knowledgeable participants in the process of care.

The Agency for Healthcare Research and Quality (AHRQ) conducts an array of health services research that provides evidence-based information on health care outcomes; quality; and cost, utilization, and access. AHRQ's research provides this information to help clinicians, policymakers, and patients make more informed decisions and improve the quality and outcome of health care services.

AHRQ has a broad portfolio of mental health research and other related activities, ranging from intramural studies to grants, contracts, and workshops. Some of the research has focused expressly on mental health, while other endeavors, such as conferences and training symposia, are more general in scope but have a strong mental health component. For example, a symposium on making health services research more accessible to people and groups outside the research community focused on substance abuse and other aspects of mental health. Additionally, many of AHRQ's studies on other diseases use a mental disorder as a measure for determining the effectiveness of a specific treatment or intervention. For example, a study on arthritis might include depression as a measure of a patient's health status. Because so many of these studies exist, they are not included here, even though they may reveal depression-related findings.

This compendium provides an overview of the research and activities that AHRQ has conducted and funded. It was organized so it can be useful to people approaching AHRQ research from different perspectives.

  • The research is first divided into broad sections such as extramural research grants/contracts, intramural research, and meetings sponsored by AHRQ's User Liaison Program.
  • The broader sections are categorized into subject-matter areas. Extramural research is categorized by type of disorder or problem (such as depression or violence) or by a cross-cutting topic (such as pharmaceuticals or quality). Intramural research is categorized by such health services research topics as access, cost, and utilization.
  • Many of the entries give the information you need to access the research, such as the AHRQ publication number or information you can use to locate journal articles.
  • Brief descriptions of findings are included if available. It was not feasible to include all the findings from some studies, such as the Depression Patient Outcomes Research Team (PORT), which has generated many publications to date. In addition, many projects will continue to release new findings after the publication of this compendium.

AHRQ has a history of name changes. It began as the National Center for Health Services Research. In 1989, it became the Agency for Health Care Policy and Research; in 1999, it was reauthorized as the Agency for Healthcare Research and Quality. With each name change, research foci have changed somewhat but the tradition of health services research has remained the same. In general, this compendium covers research conducted from 1989, when the Agency was created, to the present.

The research results may be available in print as articles, conference proceedings, or AHRQ reports. They may be available on the Web or be available as audio tapes. They may be released as the result of projects undertaken in cooperation with other organizations, such as the U.S. Preventive Services Task Force. AHRQ publications and other products (anything with an AHRQ or AHCPR number given) are available through the AHRQ Publications Clearinghouse, usually for free. You can:

Callers outside the United States should dial (703) 437-2078. For TDD service, dial 888-586-6340.

Whenever you request something from the AHRQ Publications Clearinghouse, please include the AHRQ number in your request.

References

1 Regier DA, Narrow WE, Rae DS, et al. The de facto US mental and addictive disorders service system. Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry 1993 Feb;50(2):85-94.

2 U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health; 1999.

3 Rice DP, Miller LS. The economic burden of schizophrenia: conceptual and methodological issues and cost estimates. In: Moscarelli M, Rupp A, Sartorious N, editors. Handbook of Mental Health Economics and Health Policy. Vol. 1: Schizophrenia. New York: John Wiley and Sons; 1996. p. 321-24.

4 Murray CJL, Lopez AD, editors. The Global Burden of Disease. A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Cambridge, MA: Harvard School of Public Health; 1996.

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Extramural Research

The AHRQ-sponsored research in this section is generally organized by type of disorder. Some projects in this section, such as symposia or training grants, do not have an apparent mental health focus but yielded significant findings in the area of mental health.

Each grant entry shows the principal investigator (PI), an overview of the grant, and any findings that are available. If a printed report or other product of the grant is available, it is listed along with the information you need to locate it.

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Addiction/Substance Abuse

PI: Peter P. Budetti, M.D., J.D., Northwestern University
Grant No.: T32 HS00078
Grant Period: 7/1/98-6/30/03
Title: Predoctoral and Postdoctoral Training Program

Description: This is an interdisciplinary predoctoral and postdoctoral health services research training program under the auspices of the Institute for Health Services Research and Policy Studies at Northwestern University, Evanston and Chicago, Illinois. The predoctoral training program provides interdisciplinary training, although students are matriculated in discipline-specific departments (e.g., clinical psychology, economics, sociology, organizational behavior, management). Generally, students receive AHRQ support for 2 years. The postdoctoral training program focuses on the research development of both clinical and research doctorates. Participants are required to take six courses in research methods and health policy, plus two electives. This AHRQ/National Research Service Award fellowship program is integrated with parallel fellowship programs, one of which is supported by the National Institute on Disability and Rehabilitation Research and another of which focuses on mental health services and policy.

Findings: Young people who are in residential treatment for serious emotional or behavioral problems are among the most needy in the child welfare system. Those who also abuse drugs or alcohol are more likely than the others to escape from the residence, commit suicide, or be placed in an institution such as a hospital or detention center. Young people entering residential treatment programs should be screened for type and severity of substance use problems, and services should be individualized to ensure close supervision and monitoring of their high-risk behaviors. This specialized approach could facilitate their discharge into foster homes or as adopted children rather than moving them to another institution.

These researchers retrospectively analyzed medical chart data on 564 children and adolescents in residential treatment and State custody in Florida and Illinois who had serious emotional or behavioral disturbances. They evaluated differences in clinical characteristics and compared placement outcomes between young people with and without coexisting substance use disorders.

Overall, 26 percent of boys and 37 percent of girls had substance use problems in addition to serious emotional or behavioral disturbances. Youngsters with dual diagnoses were significantly more likely than those with only one diagnosis to be at risk for suicide (57 vs. 35 percent of girls, 45 vs. 32 percent of boys), elopement (77 vs. 41 percent of girls, 67 vs. 35 percent of boys), and crime or delinquency (63 vs. 31 percent of girls, 82 vs. 42 percent of boys). Among girls, those with substance use problems were more likely than those without these problems to be discharged to institutions (56 vs. 15 percent), and fewer girls with substance use problems were placed in the community (44 vs. 85 percent). There were no differences in placement between boys with and without substance use problems.

PI: Margaret A. Compton, M.S., New York University (Dissertation Grant)
Grant No.: R03 HS06964
Grant Period: 8/1/91-12/31/92
Title: Perception, Drug Preference, and Pain in Drug Users

Description: The objective of this study was to develop a better understanding of substance abusers' experience of pain so that nurses can better assess and manage these patients' discomfort. The specific aim of the study was to learn if patients' pain experience is related to their perceptual style, which is also expected to be manifest in their preferred drug of use. The survey sampled 60 substance abusers in treatment and 60 recovering substance abusers.

Findings: Decreased pain tolerance was found in current drug users. Drug type makes a significant difference in level of tolerance, with opioid abusers having less tolerance than cocaine abusers.

PI: Lillian Gelberg, M.D., M.S.P.H., University of California, Los Angeles
Grant No.: R01 HS06696
Grant Period: 7/1/91-6/30/95
Title: Physical Health and Medical Care in a Homeless Cohort

Description: The goal of this study was to assess the influences on the normal course of status of physical health, health care utilization, and compliance with recommendations for treatment in a population of homeless adults. Factors influencing utilization of medical treatment, and therefore of particular emphasis in the research, included mental illness and substance abuse.

Findings: Most of the homeless adults living in Los Angeles suffer from mental illness, alcoholism, or drug addiction. These homeless individuals can be motivated to seek medical care for conditions they consider serious, despite mental illness or substance abuse problems. The researchers pointed out that residential history, mental health, substance abuse, history of victimization, and competing needs affect the use of health services and clinical outcomes. The researchers believe that social isolation may be a more important barrier to access to care than chronic psychiatric problems or substance use among the homeless. The study also suggests that multiservice health-related programs, including drug and alcohol treatment, be made available to the homeless for greater convenience in access to care.

PI: Julia Hidalgo, Sc.D., Maryland State Department of Health and Mental Hygiene
Grant No.: R03 HS06185
Grant Period: 1/1/89-12/31/89
Title: Cost of Treatment of Intravenous Drug Users with AIDS

Description: In this study, the investigator profiled social-demographic and clinical characteristics of intravenous drug users (IVDUs) with AIDS, focusing on variations in the use of health, addiction, and mental health services and the fiscal impact on hospitals, Medicaid, and other public programs of treatment for IVDUs with AIDS. The researchers utilized the Maryland Human Immunodeficiency Virus Information System (HIVIS), a database that includes statewide pharmacy records, clinical trials information, health insurance claims data, AIDS Registry information, and data from death certificates and health care records. They also analyzed payment records from the Michigan Medicaid program, generated from 1985 to 1989 by 783 persons, to determine Medicaid payments for services related to HIV.

Findings: The survival time of patients with AIDS who were treated with the drug zidovudine (AZT) has more than doubled. The median survival climbed to 450 days, compared with 310 days among those diagnosed between 1987 and 1989. AIDS patients diagnosed between 1987 and 1989 who received AZT had a mean survival rate of 770 days, while those diagnosed within the same time period who did not receive the drug had a mean survival rate of 190 days. Of the AIDS patients diagnosed during or after April 1987, a 2-year survival time was more frequent among homosexual men, persons younger than 45 years of age, non-Hispanic whites, and AIDS patients presenting with Kaposi's sarcoma or Pneumocystis carinii pneumonia as opposed to other opportunistic infections. According to Michigan Medicaid program data, the average monthly Medicaid payment in 1989 dollars for HIV services was $1,302.57. Services unrelated to HIV infection accounted for 12.5 percent of the total amount, and 2.5 percent was undetermined. The average monthly expenditure for men was roughly twice that for women. Payments for HIV-related treatments rose with age to about 40 years and declined slightly among older adults, with the highest payments for those 19-35 years of age.

PI: Alison M. Hughes, University of Arizona (Small Conference Grant)
Grant No.: R13 HS06991
Grant Period: 6/1/91-5/31/93
Title: Southwest Border Rural Health Research Conference

Description: The purpose of this conference was to bring researchers and policymakers together to review research results and their policy implications, to recommend steps for action, and to identify additional research directions regarding the status of health care research along the United States-Mexico border. Substance abuse was a topic of interest at the time in border development and therefore was included in the conference.

Findings: No products or findings are available at this time.

PI: Ellen M. Hutchins, Sc.D., Johns Hopkins University (Dissertation Grant)
Grant No.: R03 HS08040
Grant Period: 9/30/93-9/29/94
Title: Risk Factors for Prenatal Drug Use and Treatment Success

Description: The purpose of this research was to determine the association between seven psychosocial risk factors and the propensity for drug use during pregnancy and completion of a drug treatment program. The psychosocial risk factors are family history of alcohol and/or drug problems, history of childhood sexual abuse, presence of a male partner who introduced subject to drug use, depression, transiency, lack of social support, and frequency of alcohol/drug use by male partner. For the study on drug use during pregnancy, 237 women were recruited from a large, inner-city prenatal clinic in Detroit and were categorized as users or nonusers. The research on treatment success studied pregnant addicted women in Baltimore and categorized them as completers or noncompleters of a drug treatment program.

Findings: All variables, with the exception of a history of childhood sexual abuse, were found to be significant with regard to drug use during pregnancy. The dissertation thesis includes information on prevalence rates of psychosocial risk factors for both drug-using and non-drug-using populations, allowing comparisons to be drawn between the two groups.

PI: Jonathan Klein, M.D., M.P.H., University of Rochester
Grant No.: R01 HS08192
Grant Period: 9/30/96-9/29/99
Title: Effective Organization of Adolescent Health Services

Description: The goal of this project was to understand how the organization of adolescent health services affects adolescents' access to care. The research was based on the Environment-Systems-Services-Outcomes model for adolescent health service evaluation. The project set out to identify barriers and facilitators to the delivery of services to adolescents, and how factors such as confidentiality, cost, and comprehensiveness influence adolescents' access to and potential use of preventive health care and other services.

Findings: Many physicians ask their adolescent patients about their use of tobacco products, but far fewer physicians pursue the subject with these youngsters, despite guidelines that recommend specific steps that are effective in helping many adults to quit smoking. Among these are smoking prevention guidelines sponsored by the U.S. Public Health Service (PHS). Physicians reported asking 91 percent of adolescents about their smoking habits, and they discussed the health risks of tobacco with 77 percent. However, the physicians asked only 41 percent of adolescents about smoking among their friends (which increases the likelihood they will smoke), and only 32 percent were asked if they used smokeless tobacco. Doctors assessed the motivation to quit of 81 percent of smokers, but they set quit dates for only 34 percent and scheduled followup visits for only 28 percent of smokers.

Pediatricians asked more patients about peer influences than did family physicians. However, family physicians more often asked about smokeless tobacco use, assessed motivation to quit, provided smoking cessation handouts, helped set quit dates, and scheduled followup visits for smokers, perhaps because of their experience with adult smokers. Overall, doctors used more tobacco interventions when they were familiar with the PHS guidelines (family doctors were more familiar than pediatricians, at 48 percent vs. 27 percent), spent more time with adolescent patients (female doctors spent more time, at 26 vs. 21 minutes), and spent more time alone with patients (enhancing rapport and confidentiality).

PI: Barbara D. Lardy, M.P.H., American Association of Health Plans (Small Conference Grant)
Grant No.: R13 HS09807
Grant Period: 2/1/98-7/31/98
Title: Addressing Tobacco in Managed Care

Description: This conference provided an opportunity for various managed care plans to meet and learn about tobacco control guidelines from AHRQ (then the Agency for Health Care Policy and Research), including the guidelines for identification and treatment of tobacco use and addiction. The conference also provided an opportunity for the managed care plans to develop implementation strategies for the guidelines and to identify significant challenges and gaps in research.

Findings: Full proceedings of the conference were published in Tobacco Control, Volume 7 Supplement, Winter 1998. This report is available for a fee from the National Technical Information Service, 1-800-553-NTIS. The NTIS accession no. is PB99-144156. The proceedings include presentations, question and answer sessions, and descriptions of various studies conducted regarding tobacco control in the managed care setting, including a few that examine the impacts of implementations of the AHRQ smoking cessation guidelines. Additional information is available at www.aahp.org/atmc.htm.

PI: Edward F. Lawlor, Ph.D., University of Chicago (Small Conference Grant)
Grant No.: R13 HS09361
Grant Period: 12/1/96-3/31/97
Title: Chicago Health Services Research Symposium

Description: The objective of this conference was to bring together the research and policy communities to define selected issues, problems, and phenomena in the delivery of health services and to present a research agenda/strategy for study, in an effort to make health services research more accessible to health professional organizations, researchers, public officials, community groups, and others. The symposium involved 350 participants representing local, State, and regional governments; academic institutions; advocacy agencies; health institutions; and trade associations from seven States in the Midwest. Topical sessions focused on, among other issues, substance abuse and mental health.

Findings: Conference proceedings are available for a fee from the National Technical Information Service, 800-553-NTIS. The NTIS accession no. is PB98-126360.

PI: Stephen Mick, Ph.D., University of Michigan
Grant No.: R01 HS05998
Grant Period: 9/30/88-9/30/91
Title: Rural Hospital Management Strategies and Viability

Description: The project examined the determinants, characteristics, and impacts of strategic management responses by rural hospitals to changes in their environment during the 1980s. Management responses over the 1983-88 period were studied, including (1) horizontal integration, particularly linkages with urban hospitals and with other rural hospitals in the service area; (2) vertical integration; (3) diversification; (4) divestment/downsizing; (5) staff recruitment; (6) marketing; and (7) efforts to increase efficiency. Environmental changes studied as possible determinants of these responses included implementation of the Medicare Prospective Payment System (PPS), changes in local demographics (e.g., population decline and/or aging), and changes in local economies (e.g., declines in employment). Impacts of the first four categories of management responses on hospitals' economic performance during 1984-87 also were examined, including impacts on costs, service volumes, and financial status.

Findings: This retrospective panel study of 797 rural U.S. hospitals shows that less than one in five (18.7 percent) had any alcohol and chemical abuse (ACA) service. These findings support other studies which show that the availability of such services may not meet population need or demand. Hospitals located in more densely populated counties with higher per capita income and more physicians per 1,000 population were positively associated with ACA services. Other hospitals positively associated with ACA services were those in the New England, Mid-Atlantic, and East North Central areas, and those with a large number of beds, psychiatric services, other nonphysician personnel, and psychiatrists. The presence of psychiatric services was a key correlate of ACA services, and the scarcity of psychiatric personnel in rural areas appears to be a major reason for the infrequency of rural hospital-sponsored ACA services.

PI: Eugene Oddone, M.D., Duke University
Grant No.: T32 HS00079
Grant Period: 7/1/98-6/30/03
Title: Health Services Research Fellowship

Description: This postdoctoral fellowship program provides opportunities for clinical and research doctorates to develop health services research skills in primary care. The objectives of the program are to provide fellows with: clinical research training, exposure to efficient ambulatory care practice settings, and the administrative skills necessary to become productive academicians in health services research. Seventy-five percent of the fellowship involves didactic training in research methodology and participating in research. Fellows take seven formal courses that cover research methodology, statistics, and clinical research. Electives are available in the areas of clinical trials, health services research, analysis of genetic data, and psychometrics and reliability. The program incorporates the philosophy that clinical research skills are learned best by carrying an independent idea through to its completion rather than assisting in the completion of an ongoing project.

Findings: Being able to accurately evaluate substance abuse in veterans suffering from post-traumatic stress disorder (PTSD) is important for assessment and treatment planning. Some suspect that veterans seeking treatment for PTSD may not be truthful about substance abuse because they fear losing entitlement to PTSD-related financial compensation, yet few veterans seeking help for PTSD lie about substance abuse. These researchers compared drug urine screening results with self-reports of drug use by 341 male veterans referred to a Veterans Affairs Medical Center PTSD specialty clinic. Through urine tests, patients were screened for use of amphetamines, barbiturates, benzodiazepines, cannabinoids, cocaine, opiates, and phencyclidine. Veterans also completed a questionnaire asking about their use of these and other drugs during the previous 6 months. Only 8 percent of veterans with drug screens denied using substances that were detected by urine screen. Self-reports and urine results were consistent in 71 percent of cases. Veterans diagnosed with PTSD who reported substance abuse were more likely to use only marijuana or depressants (79 percent) than stimulants (21 percent). Those who underreported substance use had lower socioeconomic status than accurate reporters or overreporters (those reporting use of drugs not detected by urine testing). However, underreporters did not differ from the others by race, age, level of combat exposure, PTSD diagnosis, or other factors. If all those who refused drug testing, denied using drugs, or underreported substance use (as detected by urine drug screens) were grouped together, only 11 percent of veterans studied would have underreported substance use. Given the validity of self-reports and their many advantages (low cost, ease of administration, and noninvasiveness), they are desirable for this population, conclude the researchers.

PI: Thomas Ricketts, Ph.D., University of North Carolina, Chapel Hill
Contract No: 290-03-0038
Contract Period: 9/30/94-3/29/96
Title: Drug Abuse Among Nonmetropolitan and Rural Adolescents: The Need and Availability of Services

Description: The purpose of this task order was to provide the Federal Government with the information necessary for decisionmaking concerning substance abuse and treatment services for adolescents in nonmetropolitan and rural areas. A literature review of prior research on substance use was conducted to answer relevant questions regarding the issue. A secondary data analysis of treatment services, as well as analysis of the National Drug and Alcoholism Treatment Unit Survey, was also conducted. The researchers attempted to answer several questions regarding prevalence of substance use, patterns of substance use, factors influencing substance users, consequences of substance use, substance abuse treatment services available, barriers to access and utilization of treatment services, financing of treatment services, public/private integration of treatment services, and effectiveness of treatment services for youths.

Findings: Rates of substance abuse in urban adolescents converged with rates of substance abuse in rural adolescents, due more to a sharp decline in substance abuse by urban adolescents than to a sharp increase in substance abuse by rural adolescents. Across rural communities, there is significant variation in rates of substance abuse. No studies were found that addressed the progression from infrequent substance abuse to dependence in nonmetropolitan and rural adolescents, and none were found to indicate that the nonmetropolitan and rural adolescent populations progress differently or face different risks than metropolitan adolescents. Very little research was found regarding nonmetropolitan and rural area treatment services for adolescents. Nonmetropolitan areas had fewer substance abuse treatment providers and less specialized treatment services than metropolitan areas. Nonmetropolitan area adolescents were more likely to receive outpatient treatment services. Nonmetropolitan area treatment providers had fewer barriers to access and use and relied more on State and Federal Government funding than metropolitan area providers.

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Current as of January 2003
Internet Citation: Compendium of Research Related to Mental Health. January 2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/factsheets/mental/mentalcomp/index.html