Current News and Trends Affecting Behavioral Health Care

Introduction

Patients suffering from depression can have higher treatment rates, better health outcomes, and a greater chance of remaining employed for at least a year when treated in primary care practices that use a specifically designed quality improvement program. This was the finding of a study headed by Kenneth B. Wells, MD, MPH, senior scientist at RAND and professor of psychiatry at UCLA School of Medicine. The study was published in the January 12, 2000, issue of the Journal of the American Medical Association.

Dr Wells and colleagues developed and tested evidence-based intervention materials (training guides, slides, brochures, and videos) designed for clinicians, nurse specialists, psychotherapists, and patients by incorporating them into a quality improvement program. They found that the materials helped manage the depression of 50% to 60% of patients in the test group; this contrasts with depression management in 40% to 50% of patients in the control group and is equivalent to a 20% to 30% comparative or relative improvement in quality of care. The program did not require any services beyond those already covered by the patients' health plans. In addition, there was a 5% increase in the likelihood that patients would still be employed after a year of treatment, showing that overall employment rates can be affected by improved treatment. According to the researchers, this substantial improvement represents an even greater benefit if generalized to the larger population of depressed patients.

The quality improvement program, as used in this study, was a resource tool kit for primary care practices. It offered training and materials for clinicians, staff, and patients about depression, its treatment, and how to better communicate information about the treatment process. The study found that patients with both severe and mild forms of depression improved their outcomes under the program and that the program was similarly effective whether it provided extra resources for medication management or for psychotherapy.

"This is very good news for physicians, practices, and most of all for patients with depression -- a condition that specifically undermines the sense of hope," says Dr Wells. "Our findings show that practices can be flexible in how they approach improving care for depression, without having to target just sicker patients. They can offer a range of treatments to patients with the expectation that outcomes, including employment retention, will improve."

The researchers wanted to see if using a quality improvement program in managed care primary care practices under natural conditions would improve the quality of care to patients. The study involved 46 primary care clinics in 7 US managed care organizations, which adapted the materials to their own policies. Doctors and patients in the clinics retained full choice over the type of treatment chosen, and payment was provided under the patients' regular coverage. Clinics were community based and were chosen to be diverse in geography, organization, demographics, and type of insurance (uninsured patients were included in one site). The researchers also made an effort to oversample Mexican American patients to examine whether they would benefit from the program. Spanish-language materials were developed specifically for this purpose.

To order the quality improvement study package, contact RAND Distribution Services by telephone at (310) 451-7002, fax at (310) 451-6915, or e-mail (order@rand.org).

Overall use of illicit drugs among teenagers generally remained unchanged from last year, according to the 25th annual Monitoring the Future Survey released by the Department of Health and Human Services.

The 1999 study of drug use among 8th, 10th, and 12th graders found that illicit drug use, including the use of marijuana, generally remained unchanged during the last year. The survey marks the third year in a row that overall drug use among teenagers has declined or stayed level in all categories: lifetime, past-year, and past-month use. Among the few statistically significant changes reported were increases in the use of MDMA (ecstasy) among 10th and 12th graders; decreases in the use of crack cocaine among 8th and 10th graders; and increases in the use of steroids among 8th and 10th graders.

Among 8th graders, disapproval of trying marijuana once or twice increased for the second year in a row.

Teens' use of alcohol and cigarettes also remained unchanged for the most part among the three grade levels, although daily use of alcohol decreased among seniors, and past-month use of cigarettes decreased among 8th graders from 1998 to 1999.

Past-year crack cocaine use finally began to decrease among 8th graders, after the rate had tripled between 1991 (0. 7%) and 1998 (2. 1%). In 1999, the rate decreased to 1. 8%. Additionally, past-month crack cocaine use decreased from 1. 1% in 1998 to 0. 8% in 1999 among 10th graders.

Past-year and past-month use of steroids increased among 8th and 10th graders in 1999. Past-year use increased from 1. 2% in 1998 to 1. 7% in 1999 among teens in both grades. Among teenaged males specifically, past-year use among 8th graders increased from 1. 6% in 1998 to 2. 5% in 1999. Among 10th grade males, past-year use increased from 1. 9% in 1998 to 2. 8% in 1999.

Scientists have discovered a new molecular marker for Alzheimer's disease (AD) -- a normal cellular protein that piles up in nerve cells ravaged by the disease. Except for a minority of cases (6% to 7%) caused by faulty genes, scientists do not yet know what causes AD.

A research team supported by the NIH examined the brains of people who had died of AD and found abnormally large amounts of casein kinase-1 (CK-1) present inside vacuoles in the nerve cells. The findings indicate that a high CK-1 level in vacuoles may be a useful marker for AD, along with the two other long-recognized cellular abnormalities associated with the disease: plaques and tangles. Results of the study appear in the October 1999 issue of the American Journal of Pathology.

Previous research had already shown that such vacuoles, called GVD (granulovacuolar degeneration) bodies, are a prominent feature in about half of all AD cases. Scientists also already knew that the vacuoles tended to accumulate in a region of the brain called the hippocampus that is particularly vulnerable in AD and is normally very important for learning and memory. Nonetheless, GVD bodies have remained poorly understood by scientists because they have been stubbornly difficult to locate within autopsied brain tissue. Until now, no good markers for GVD bodies were available to scientists studying AD. The new work not only enables researchers to use CK-1 as a molecular label for studying GVD bodies, but it also forges a link between GVD bodies and the more commonly studied plaques and tangles typical of the brains of patients who had had AD.

The researchers turned up a 30-fold increase of one particular form of CK-1 inside GVD bodies within the hippocampus region of AD-affected brain material. This is the largest preponderance of a kinase yet discovered in AD brain tissue. The results suggest that CK-1 might play a role in setting the stage for, or in accelerating, brain cell death associated with AD.

National Institute of Mental Health researchers report that some children whose symptoms of obsessive-compulsive disorder (OCD) and tic disorders were worsened by a common streptoccocal infection have been successfully treated with plasma exchange (PEX) and intravenous immunoglobulin (IVIG).

In previous studies, the research group had observed that in a small number of children suffering from the obsessional thoughts and compulsive behaviors typical of OCD and tic disorders, symptoms suddenly became worse following infection with group A ß-hemolytic streptococci. Evidence for causes of the syndrome, known as PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections), pointed to an autoimmune response to the infection, leading to inflammation in the brain's basal ganglia.

Thirty children aged 9 to 15 years with severe, infection-induced worsening of OCD or tic disorders, including Tourette syndrome, participated in the double-blind, placebo-controlled study. Of the 29 children who completed the trial, 10 received PEX, 9 received IVIG, and 10 received placebo. Both PEX and IVIG produced substantial improvement in obsessive-compulsive symptoms, anxiety, and overall functioning; PEX also improved tic symptoms. Ratings done 1 month after treatment revealed that patients in the PEX and the IVIG groups were much improved. In contrast, symptoms changed little in children who received placebo. The treatment gains of PEX and IVIG remained at 1-year follow-up, with 14 of 17 subjects "much" or "very much" improved over baseline.

The 1-month follow-up consisted of a neurologic examination to rate symptom severity. After that evaluation, if a child taking placebo had no symptom improvement, IVIG or PEX was offered, so 1-year ratings are not available for the placebo group. At the 1-year assessment, obsessive-compulsive symptoms, tic severity, psychosocial functioning, and symptom severity remained improved. Among subjects who received IVIG, there was a 58% improvement in OCD symptoms; among those who received PEX, there was a 70% improvement. Eighty-two percent of the children had symptom reductions of at least 50%.

Findings are reported in the October 2, 1999, issue of The Lancet.

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