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Long-term research objective: To develop and evaluate implementation strategies to promote the adoption of integrated care models to leverage the delivery of evidence-based mental health care to rural residents with depression and serious mental illness.
The research projects for 2007-08 (Year 4) include:
Project 1 Addressing Suicide Potential And Prevention In Rural And Frontier Areas
PI: Dennis Mohatt Contact Person: Mimi McFaul Research Description and Policy Relevance: Depression and suicide are especially relevant today in rural areas because of rapid expansion of the aging population in U.S. rural areas, and the fact that persons 65+ have led in suicide rates since 1970. Rural areas have a higher share of aging residents, with more health problems, and more limited access to health services than urban areas. Additionally, DHHS reports indicate that approximately 20% of U.S. residents aged 55+ have a mental disorder, including depression, which has been shown to be highly related to suicide attempts and completions. Accordingly, the increasing prevalence of older residents in rural areas makes these areas prime candidates for training in suicide-prevention interventions that could be extremely helpful to the principal health care resources in such rural areas – namely, primary health caregivers.
Project 2 Differences in Prescribing Patterns of Psychotropic Medication for Children and Adolescents between Rural and Urban Prescribers
PI: Dennis Mohatt Contact Person: Mimi McFaul Research Description and Policy Relevance: The purpose of this research is to examine possible differences in the prescription of psychotropic medications to youths in rural and urban areas. Multiple studies have indicated a dramatic increase in the number of youth being prescribed psychotropic medication over the past 15 to 20 years. For instance, data indicate that the overall annual rate of psychotropic medication use by children increased from 1.4 per 100 persons in 1987 to 3.9 in 1996, with significant increases found in the use rates of stimulants, antidepressants, other psychotropic medications, and polypharmacy of different classes of psychotropic medications. In a later study, rates of visits by youth resulting in a psychotropic prescription increased from 3.4 percent in 1994-1995 to 8.3 percent in 2000-2001, with annual growth rates rapidly accelerating after 1999. These trends were evident for males and females, and also significant across drug classes. Additionally, there appears to be an increase in the percent of visits by youth to outpatient clinics and emergency rooms that include prescriptions for psychotropic medications. Similar trends have been found in other countries.
Project 3 Assessment Of The Mental Health Funding Marketplace In Urban Vs. Rural Settings
PI: Dennis Mohatt Contact Person: Jeff Harman Research Description and Policy Relevance: The most recent data from the National Comorbidity Study Replication (NCS-R) indicate that rural individuals with MH problems are significantly less likely to receive any MH care for their disorder than individuals in urban and suburban areas. The NCS-R also reports that of those patients who do receive mental health care, rural patients are significantly more likely to receive general medical care only and significantly less likely to receive specialty mental health care. Because patients receiving care in the specialty mental health sector are substantially more likely to receive adequate care (45.4%) than patients receiving care in the general medical sector only (12.7%), this indicates that rural individuals are receiving poorer quality care. Reduced access to MH care in rural areas are undoubtedly due to an inadequate supply of MH specialists. Additionally, primary care (PC) providers, who provide the vast majority of MH care to persons living in rural areas, do not have the training necessary to provide evidence based psychotherapy, thus eliminating one of the primary treatment modalities for people with MH problems. The lack of MH specialists in rural areas is likely due to inadequate incentives for these specialists to practice in rural areas. Furthermore, previous research has shown that health plans are more likely to rely on demand side cost containment strategies for rural enrollees than supply side strategies. This may result in rural residents paying more out-of-pocket for mental health services. Additionally, the source of funding for MH services may differ depending on the type of mental illness.
The research projects for 2006-07 (Year 3) include:
Project 1 Differences in Antipsychotic Medication Prescribing Patterns Between Rural and Urban Prescribers.
PI: James Ciarlo Contact Person: Mimi McFaul Research Description and Policy Relevance: Second-generation (“atypical”) antipsychotics have become the treatment of choice for persons with schizophrenia and other serious mental illnesses. Compared to first generation (“conventional”) antipsychotics, many second generation medications reduce symptoms with fewer problematic side-effects (with the exception of clozapine, which can have life-threatening side effects if not monitored regularly) and related major health problems (e.g., obesity, diabetes, and hyperlipidemia). Introduction of atypical antipsychotics has impacted 1) prescribing patterns across physician specialties, 2) type of drug prescribed (i.e., first or second generation antipsychotics) based on case-mix factors, such as age, race, and type of insurance coverage and 3) medication and/or total treatment costs. It has also facilitated significant discussion of the therapeutic value of “polypharmacy,” meaning, the simultaneous prescription of more than one antipsychotic medication to a single patient. However, one aspect that has seen little empirical attention is how longitudinal trends, benefits, and costs may differ between urban and rural areas.
Project 2 Rural-Urban Differences in Depression Care
PI: James Ciarlo Contact Person: John Fortney Research Description and Policy Relevance: As access to evidence-based treatment for affective disorders (major depressive disorder, dysthymia, and bipolar disorder) improves in urban areas, it is critical to monitor rural-urban differences in the use and quality of treatment over time to identify and address rural disparities, especially for vulnerable populations such as the elderly and ethnic minorities. Private managed care organizations have begun to disseminate evidence-based treatments for affective disorders, especially depression. However, these dissemination programs tend to target primarily urban areas, especially those populations covered by employer-sponsored insurance. As a result, disparities for rural, minority and elderly populations might actually be increasing over time. Thus, it is critical to monitor disparities with respect to the receipt of high quality treatments for affective disorders, especially pharmacotherapy (which has been the focus of most dissemination programs). If disparities continue to exist or are found to be increasing over time, it will provide evidence for policy makers about the need to develop specialized programs to disseminate evidence-based practices into rural areas (targeting vulnerable populations).
Project 3 Webcast: What Rural Primary Care Physicians Need to Know about Treating Patients with Bipolar Disorder
PI: James Ciarlo Contact Person:Mimi McFaul This presentation, featuring a national expert on bipolar disorder, covered the identification, treatment, and associated prescribing strategies related to this diagnosis in the primary care setting. While this presentation did not focus exclusively on providers in rural settings, the information will be useful to those practicing in more isolated settings, those who treat underserved populations, and those communities with limited access to behavioral health resources.
The research projects for 2005-06 (Year 2) include:
Project 1 Stakeholder Benefit from Depression Disease Management: Difference by Rurality
PI: Kathryn Rost Contact Person: Stan Xu Research Description and Policy Relevance: The goal of this project is to identify stakeholders who economically benefit when rural patients receive enhanced depression treatment so that they can be asked to contribute to the increased cost of the program. Studies in predominantly urban cohorts report that enhanced depression treatment economically benefits employers but not health plans; parallel studies in rural cohorts have not been conducted. Because providing depression treatment reduces hospitalizations and outpatient care for physical problems in rural populations but not urban ones, enhanced depression treatment may differentially benefit health plans that cover rural residents. Evidence of economic benefit can encourage health plans to provide enhanced depression treatment to their rural enrollees without raising premiums, because it is in the health plan’s own economic self-interest.
Project 2 Identifying at-risk rural areas for targeting enhanced schizophrenia treatment
PI: Kathryn Rost Contact Person:John Fortney Research Description and Policy Relevance: After studies established that the schizophrenia treatment most patients receive is not evidence-based, policy makers encouraged health care systems to adopt evidence-based programs to improve schizophrenia outcomes. However, early efforts to disseminate these models identified major barriers including poor access, which reduce the intensity, quality and outcomes of care. Research demonstrated that even when communities offered evidence-based practices, lack of fidelity to the treatment models increased the likelihood of hospitalization. Because public mental health systems must address multiple issues with fixed budgets, they will have to prioritize which geographic areas they target. The goal of this project is to identify rural areas that should be targeted for early adoption of evidence-based schizophrenia treatment. This project proposes a scientifically-based method to identify counties in greatest need for quality improvement to inform national, regional, and local decision-makers about distributing scarce resources to areas which would most benefit from improved schizophrenia treatment. Implementation of evidenced-based treatments in high risk areas has the potential to simultaneously improve outcomes and reduce inpatient costs.
Project 3 Distance Learning in Depression for Rural Primary Care and Mental Health Providers
PI: Kathryn Rost Contact Person:Mimi McFaul Research Description and Policy Relevance: This training was meant to supplement knowledge of depression treatment that primary care physicians already possess. It advances knowledge by describing state-of-the-art approaches to depression care. The training has two parts: 1) core content and 2) an overview of evidence-based practices (EBPs) for treating depression in primary care. The Core Content is from the MacArthur Initiative on Depression & Primary Care, which includes 4 basic components: 1. Recognition & Diagnosis2. Patient Education 3. Treatment 4. Monitoring. Overview of EBPs for Treating Depression in Primary Care portion of the web cast covered collaborative care models of depression treatment in primary care; describing ways to either integrate mental health clinicians within one’s practice or train primary care staff in the four areas above to improve referral and/or treatment..
The research projects for 2004-05 (Year 1) include:
Project 1 Community level risk factors for depression hospitalizations
PI: Kathryn Rost Contact Person: John Fortney Research Description and Policy Relevance: The goal of this research was to identify rural areas that should be targeted for early adoption of evidence-based depression treatments based on elevated rates of depression related hospitalizations. Using county-level data from the Statewide Inpatient Database, Census, Department of Agriculture, and Area Resource File, predictors of elevated hospitalizations rates were identified using spatial regression models. This investigation demonstrated that: (1) rural counties have lower rates of depression-related hospitalization than urban counties, (2) rurality fails to predict depression-related hospitalization in models that control for community-level demographic, economic and health system risk factors, (3) community-level risk factors explain a respectable ~30% of the variance in depression-related hospitalization rates, and (4) while these risk factors identify high risk areas in the 10 states we studied, they cannot be used to identify high risk areas in other states.
Project 2 Differential Effectiveness of Enhanced Depression Treatment for Rural and Urban Primary Care Patients
PI: Kathryn Rost Contact Person:Mimi McFaul Research Description and Policy Relevance: Rural primary care practices encounter greater challenges when they try to improve the quality of care their depressed patients receive than their urban counterparts. Rather than assume that ‘one size fits all’, investigators need to evaluate whether current models to enhance primary care depression treatment have comparable effectiveness in improving outcomes in rural and urban patients. If current models are less successful with rural patients, current models need to be refined before they are disseminated to the ‘real world’. One explanation for reduced effectiveness is that current models are not sufficiently intensive to increase rural patient’s interest or ability to access evidence-based care, reflecting that rural patients have greater attitudinal and/or distance barriers to antidepressant medication or specialty care counseling. An alternative explanation is that current models succeed in getting rural and urban patients to engage in evidence-based care at comparable rates, but that rural patients face additional factors that hinder their recovery. The proposed study will be the first study in the literature to examine rural-urban differences in enhanced depression treatment effectiveness, as well as the first study to explore potential explanations for the differences observed. Policy makers/health plan administrators need to know whether the current models of enhanced depression treatment ‘work’ in rural practices as well as they do in urban ones to inform their decisions about whether the models should be adopted ‘as is’ or refined before adoption. Depressed rural patients will also benefit from this line of research because it will help ensure that programs they receive really ‘work’.
Project 3 Preventing Hospitalization in Depressed Rural Patients
PI: Kathryn Rost Contact Person:Mimi McFaul Research Description and Policy Relevance: Research in the early 1990s indicated that depressed rural Arkansans were more likely than their urban counterparts to be hospitalized for depression and other health reasons over the course of a year. The first goal of Project 3 is to explore whether depressed rural patients residing in multiple statesare more likely than their urban counterparts to be hospitalized for depression and other health reasons over the course of two years. It is critical to replicate previous findings in a broader geographic area if this research is going to influence rural national health policy. It is also critical to establish whether differences still exist in an era where hospital admissions are more tightly controlled. The second goal of Project 3 is to explore whether any current rural-urban hospitalization differences are reduced in models which control for previous intensive outpatient specialty care utilization, suggesting that rural providers may still be substituting more restrictive/expensive forms of depression treatment when intensive outpatient specialty care is less available. This line of research will contribute to the discussion of whether/how reduction of ‘excess’ hospitalizations in depressed rural populations could provide additional monies to expand outpatient specialty care programs. The third goal of Project 3 is to explore rural-urban differences in the prevalence and consequences of administrative constraints on intensive outpatient specialty care use. This innovative line of research stems from rural primary clinician observations that barriers to outpatient specialty care have a greater deterrent effect in rural populations than in urban ones. This research is designed to fill an important gap in the literature at a timely moment, as national, regional, and local policy makers/plan administrators are looking for potential sources of funding to support the new costs of associated with enhanced depression treatment (e.g., telephone counseling programs) and new technologies to support specialty care access (e.g., telemedicine). This line of research will also benefit rural community members by motivating policy makers/plan administrators to barriers with strong deterrent effects in rural populations.