Paul N. Pfeiffer, MD

 To assess quality of depression care during the high-risk period following a psychiatric hospitalization.

 Retrospective administrative data analysis.

 Using Veterans Health Administration (VHA) administrative data, we assessed mental health follow-up within 7 and 30 days of psychiatric hospitalizations for major depression from 2004 to 2008. Adequate antidepressant medication coverage and number of psychotherapy visits were assessed within 90 days of discharge. Multivariable logistic regression was used to identify patient demographic and clinical characteristics associated with each quality indicator.

 Of the 45,587 patients discharged from a psychiatric inpatient stay with a diagnosis of major depressive disorder, 39.4% and 75.8% received an outpatient visit within 7 and 30 days of discharge, respectively; 58.7% of patients received adequate antidepressant coverage (72 of 90 days) and 12.9% received adequate psychotherapy encounters (8 visits). Receipt of outpatient mental health visits and of adequate psychotherapy were less likely among patients who were male, aged <35 or >65 years, had >3 major general medical comorbidities, lived >30 miles from a VHA clinic, or whose hospital length of stay was <7 days. Patients with comorbid substance use disorders were less likely to receive adequate antidepressant treatment.

 To optimize evidence-based depression care after a psychiatric hospitalization, health systems might increase receipt of psychotherapy by considering potential barriers related to age, medical condition, and distance. Patients with comorbid substance use disorders or their providers may need additional services to support antidepressant treatment.

	To enhance treatment of depression during the high-risk period following a psychiatric hospitalization, health systems should:

		Ensure timely access to outpatient mental health care and consider additional transition support, particularly for patients without mental health encounters prior to their psychiatric admission.

		Increase receipt of an adequate course of psychotherapy. Patients aged either <35 or >65 years, those with >3 serious medical comorbidities, and those residing >30 miles from a clinic were particularly less likely to receive psychotherapy.

		Increase antidepressant medication coverage for depressed patients with comorbid substance use disorders.

	Immediately following discharge from a psychiatric hospitalization, patients are at high risk for functional impairment, rehospitalization, and suicide.

 Suicide risk is high among depressed patients, and it is nearly 5 times higher during the 12 weeks after a psychiatric hospitalization compared with other time periods.

 To reduce risks of adverse outcomes, it is important for health systems to optimize the quality of depression care immediately following psychiatric hospitalization.

	Quality of post-discharge depression care encompasses several domains, including timeliness of follow-up with outpatient mental health providers and the delivery of an adequate course of antidepressant treatment or psychotherapy. To date, research studies of factors associated with postdischarge follow-up have not focused on care for patients with depression. Among general populations of psychiatric inpatients, nearly half of patients that schedule a post-hospitalization follow-up appointment do not show up for the first appointment, and slightly less than half have no follow-up within 30 days of discharge.

 Prior studies of depression-treatment indicators have focused on new and recurrent episodes of depression in predominantly outpatient settings, rather than during the high-risk, post-hospital period.

 One study of patients diagnosed with depression measured adherence to antidepressant medication regimens following a psychiatric hospitalization and found nearly half had inadequate adherence; however, the study excluded patients with no follow-up appointments and did not examine antidepressant treatment in the context of other quality indicators.

	In this study, we examined administrative data from the Veterans Health Administration (VHA) to determine the patient characteristics associated with the quality of post-hospital depression care across various quality indicators. The VHA provides comprehensive inpatient and outpatient specialty mental health care to eligible veterans and has an electronic medical record system to support communication between inpatient and outpatient services and across facilities. By describing factors affecting post-hospital care in a large integrated health system, study findings may inform both VHA and non-VHA efforts to improve post-hospital transition care.

	Patient data were obtained from the VHA’s National Registry for Depression, which includes comprehensive inpatient and outpatient records, including diagnoses, pharmacy records, and demographic information on all patients receiving treatment for depression within the VHA.

 Patients were included if they received a diagnosis of major depressive disorder (MDD;

 International Classification of Diseases, 9th Edition, Clinical Modification [ICD-9-CM]

 codes 296.3 or 296.2) during an inpatient psychiatric hospitalization between fiscal years 2004 and 2008. We excluded patients who had diagnoses of bipolar disorder, schizoaffective disorder, or schizophrenia, because these patients may require substantially different post-discharge care. The study was conducted following an institutional review board approval of database analyses through the Veterans Affairs Ann Arbor Healthcare System.

	For each patient, we identified the first inpatient psychiatric stay that included a diagnosis of MDD during the study period and used the discharge date from that hospitalization as the index discharge date. Adequacy of outpatient follow-up was determined using 2 indicators: whether patients received an outpatient visit with a mental health provider within 7 days and within 30 days of the index discharge date. These have been included as measures in the National Committee for Quality Assurance’s 

Healthcare Effectiveness Data and Information Set 

(HEDIS), which tracks performance on health-related quality measures among commercial, Medicare, and Medicaid health plans within the United States.

 Analysis of these measures was limited to patients who did not have another inpatient admission within 7 or 30 days, respectively.

	Adequacy of antidepressant treatment was determined by whether patients received at least a 72-day supply of an antidepressant during the initial 90 days following the index discharge date and refilled their medication at least once after their initial discharge prescription. A similar measure was shown to predict decreased odds of psychiatric hospitalization among VHA outpatients initiating treatment for depression.

 Coverage for 72 out of 90 days corresponds to a medication possession ratio of 0.80 (80%), a commonly used cut off for adequacy of medication receipt.

 The requirement of at least 1 refill was chosen so that a large initial prescription would not automatically satisfy the measure. Adequate psychotherapy was defined as the receipt of 8 individual or group psychotherapy visits (Current Procedural Technology [CPT] codes: 90804-90815, 90845, 90847, 90849, 90853, 90857) during the 90-day period following the index discharge date. These CPT codes include insight-oriented, behavior-modifying, supportive, family, and multi-family psychotherapy and psychoanalysis. A cut-off of 8 visits was used for adequate treatment based on manualized clinical trials of psychotherapy for depression and prior retrospective studies of psychotherapy adequacy.

 Analysis of receipt of adequate antidepressant treatment and adequate psychotherapy in the 90 days following psychiatric hospitalization was limited to patients who had <30 inpatient days during the follow-up period.

	Demographic characteristics included age (categorized as <35, 35-49, 50-64, 65-79, 80 years), gender, race (white, black, other, unknown), Hispanic ethnicity, and marital status (married or unmarried). The distance patients lived from their nearest VHA facility was approximated using a straightline distance from the population centroid of the patient’s ZIP code of residence (categorized as <30 miles, 30 to 60 miles, or >60 miles).

	Comorbid mental health conditions diagnosed during the index hospitalization were categorized as substance use disorder, post-traumatic stress disorder (PTSD), other anxiety disorders, or personality disorder. General medical comorbidity was measured using the Charlson Comorbidity Index

 and scores were categorized as 0 (least morbidity), 1-2, or 

	Length of stay during the index hospitalization was categorized as <7 days, 7 to 14 days, 15 to 30 days, or >30 days. We also created indicators of whether patients had mental health visits, received antidepressant treatment, or received psychotherapy in the 90 days before the index hospitalization.

	Continuous variables (eg, age, distance, inpatient length of stay) were categorized to facilitate interpretation of resulting odds ratios (ORs) and because prior studies have demonstrated non-linear relationships between patient characteristics, such as age and depression care.

	We calculated the frequencies of each quality indicator by each of the covariates. In bivariate analyses for each covariate, we used X

 tests to determine whether there were significant differences in receipt of the quality indicators.

	Multivariable logistic regressions were then used to predict receipt of each of the quality indicators adjusting for all covariates simultaneously. We also calculated Spearman rank correlation coefficients to assess the relationship between all possible pairs of covariates. Alpha was set at 0.05 for all comparisons. All analyses were conducted in SAS version 9.2 (SAS Institute Inc, Cary, North Carolina).

	The demographic and clinical characteristics of the 45,587 patients discharged from an inpatient psychiatry stay with a diagnosis of MDD between 2004 and 2008 are shown in 

. Patients had a mean age of 51.6 years; 89.2% were male; 72.6% were white, and 21.2% were black; and 5.5% were Hispanic. Comorbidity with other mental health conditions was common, with 46.5% having a comorbid substance use disorder, 33.7% having comorbid PTSD, and 11.7% having a comorbid anxiety disorder other than PTSD. Only 25.8% of patients had none of these other diagnoses during their hospital stay.

	Among all patients sampled, 39.4% received a mental health follow-up visit within 7 days of hospital discharge and 75.8% received a mental health follow-up visit within 30 days. Adequate antidepressant coverage was provided to 58.7% of patients; 12.9% of patients received adequate psychotherapy in the 90 days postdischarge. X

 tests demonstrated a statistically significant relationship between each of the covariate measures and at least 1 of the outcomes. We retained all covariates for the multivariate models and subsequently report only those results.

. In adjusted analyses, patients were less likely to receive a follow-up mental health appointment within 7 days if they were aged 

65 years (OR 0.77, 95% confidence interval [CI] 0.70-0.85) for age 65-79 vs <35 years); male (OR 0.91, 95% CI 0.85-0.97); married (OR 0.93, 95% CI 0.89-0.97); residing 

30 miles from a VHA clinic (OR 0.71, 95% CI 0.66-0.76 for 30-60 miles vs <30 miles); had 

1 major medical comorbidities (OR 0.78, 95% CI 0.70-0.86 for Charlson 3 or more vs 0); or received antidepressant treatment prior to hospitalization (OR 0.94, 95% CI 0.89- 0.98; 

	Patients were more likely to follow up within 7 days if they were aged 35 to 49 years versus <35 (OR 1.14, 95% CI 1.06-1.22 for age 35-49 vs <35); had a comorbid substance use disorder (OR 1.39, 95% CI 1.34-1.45); had comorbid PTSD (1.11, 95% CI 1.06-1.16); had a hospital length of stay for 

7 days (OR 1.26, 95% CI 1.18-1.34 for 15-30 days vs <7 days); had any outpatient mental health encounter before being hospitalized (OR 1.34, 95% CI 1.27-1.42); or had a psychotherapy encounter prior to being hospitalized (OR 1.57, 95% CI 1.49-1.66).

 Similar trends were seen for receiving a mental health follow-up within 30 days except that black, unknown, and other race were associated with decreased odds of follow-up (OR 0.89, 95% CI 0.84-0.94 for black vs white patients); patients who were aged 50 to 64 years (OR 1.48, 95% CI 1.37-1.60 vs age <35); married (OR 1.19, 95% CI 1.13-1.25); had a comorbid anxiety disorder other than PTSD; (OR 1.12, 95% CI 1.04-1.21) or had prior antidepressant use (OR 1.27, 95% CI 1.20-1.34) had increased odds of follow-up. Having a comorbid substance use disorder was no longer associated with follow-up.

Adequate Antidepressant Treatment Duration.

 Receipt of adequate antidepressant use was more likely among patients who were aged >35 years (OR 1.47, 95% CI 1.36-1.58 for age 35-49 vs <35) but <80 years (OR 1.12, 95% CI 0.97-1.28 for age 80 vs <35); were married (OR 1.33, 95% CI 1.27-1.39); had comorbid PTSD (OR 1.07, 95% CI 1.02-1.12) or other anxiety disorder (OR 1.25, 95% CI 1.17-1.34); lived 30 to 60 miles from a VHA clinic (OR 1.15, 95% CI 1.07-1.23 vs <30 miles); had a hospital length of stay >7 days (OR 1.34, 95% CI 1.28-1.41 for 7 to 14 days vs <7 days); or had antidepressant use (OR 3.08, 95% CI 2.93-3.23) or psychotherapy (OR 1.09, 95% CI 1.03-1.15) prior to hospitalization. Patients were less likely to receive adequate antidepressant treatment if they were male (OR 0.78, 95% CI 0.73-0.84), black (OR 0.56, 95% CI 0.53-0.59 vs white) or other or unknown race, Hispanic (OR 0.82, 95% CI 0.75-0.90); had a comorbid substance use disorder (OR 0.66, 95% CI 0.63-0.69) or personality disorder (OR 0.86, 95% CI 0.81-0.92); or had 

3 Charlson comorbidities (OR 0.85, 95% CI 0.77-0.93 vs Charlson of 0).

 Receipt of adequate psychotherapy was more likely among patients aged 35 to 64 years compared with younger or older patients (OR 1.37, 95% CI 1.23-1.53 for 35-49 vs <35). Blacks were not significantly different from whites in receipt of psychotherapy, and Hispanic patients were less likely to receive adequate psychotherapy (OR 0.79, 95% CI 0.69-0.90 vs non-Hispanic). Living 

30 miles from a VHA clinic (OR 0.56, 95% CI 0.50-0.64 for 30-60 miles compared with <30 miles); having 

3 Charlson comorbidities (OR 0.62, 95% CI 0.53-0.74 vs Charlson of 0); and having received an antidepressant prior to hospitalization (OR 0.89, 95% CI 0.83-0.95) were associated with decreased odds of receiving adequate psychotherapy. Having a comorbid substance use disorder (OR 1.47, 95% CI 1.38-1.56); PTSD (OR 1.39, 95% CI 1.31-1.48); length of hospital stay of 

7 days (OR 1.34, 95% CI 1.25-1.43 for 7-14 days vs <7 days); or psychotherapy prior to the hospitalization (OR 2.51, 95% CI 2.31-2.73) were all associated with increased odds of adequate psychotherapy after discharge.

 The largest correlations among the covariates were between Charlson comorbidity index and age (

 <.001), and being married and having a substance use disorder (

	Effective transition from inpatient to outpatient care is intended to sustain the process of recovery and to prevent relapse, readmission, or worse outcomes. The post-hospital transition may be particularly important for patients with MDD because it is the highest risk period for suicide. Per the HEDIS quality measure, we found that fewer than half of patients hospitalized for major depression had outpatient mental health follow-up within 7 days of discharge (39.4%), similar to the rate found in the general US population among Medicare (38.1%) and Medicaid (42.6%) beneficiaries in 2008.

 Follow-up within 30 days of discharge was substantially more common (75.8%). Unfortunately, follow-up within these time frames has not yet been shown to improve the outcomes of depressed patients. Follow-up within 30 days of discharge was not associated with reduced risk of suicide among psychiatric inpatients in a prior VHA study, but 7-day follow-up or the effect on longer-term outcomes of follow-up among patients with depression was not included in this prior study and should be a focus for subsequent work.

	Many patients received adequate psychopharmacologic treatment following a hospitalization for depression (58.7%) while relatively few patients received adequate psychotherapy post-discharge (12.9%), despite the fact that post-hospital needs likely remain high. The rate of adequate psychotherapy post-discharge is higher than that observed among VHA patients, who are primarily outpatients, newly diagnosed with depression (<5%), but it is lower than that observed among US community residents with depression or anxiety disorders (16%-23%).

 Such differences in receipt of care may reflect a general treatment bias toward pharmacologic treatment among providers or patients within the VHA, and, potentially, additional biases favoring pharmacologic treatment for patients with severe versus milder forms of depression. However, because 39% of patients received at least 1 psychotherapy visit within 90 days prior to their hospitalization, patients may be referred for psychotherapy after a hospitalization yet may have difficulty adhering to an adequate course of treatment in the post-hospital period. Although little information is available regarding the role of psychotherapy for depression following a psychiatric hospitalization, combining psychotherapy with pharmacologic treatment of depression is cost-effective and is particularly more effective than either modality alone for patients with severe or chronic depression.

 Extensive training in evidence-based psychotherapies has been made available to VHA providers; whether this improves access to psychotherapy for recently hospitalized patients is yet to be determined.

Articles

Different patient characteristics predict adequate antidepressant treatment after hospitalization, received by 58.7% of patients, versus adequate psychotherapy, received by 12.9% of patients.

Depression Care Following Psychiatric Hospitalization in the Veterans Health Administration

: We sought to determine what demographic and clinical factors are associated with receipt of initial mental health treatment. 

: A total of 1177 patients completed structured clinical interviews (Michigan Screening for Treatment and Research Triage) when they called to authorize mental health benefits. Measures included age, sex, alcohol use, drug use, anxiety, depression, medical history, behavioral health treatment history, psychosocial stressors, functioning, and suicidality. Multivariate analyses determined the association between these variables and a behavioral health claim within 90 days of the interview.

: Among those completing interviews, 85% attended initial mental health treatment. Factors significantly associated with increased odds of treatment initiation were good self-rated health (odds ratio [OR] = 1.70; 95% confidence interval [CI] = 1.15, 2.50), support of family or friends (OR = 1.71; 95% CI = 1.11, 2.65), previous outpatient mental health visits (OR = 1.56; 95% CI = 1.11, 2.19), and recent alcohol use (OR = 1.41; 95% CI = 1.00, 1.97). Factors associated with decreased odds of treatment initiation were recent period of total disability (OR = 0.62; 95% CI = 0.45, 0.87), any previous suicide attempt (OR = 0.56; 95% CI = 0.36, 0.87), 6 or more physician visits for medical reasons this year (OR = 0.64; 95% CI = 0.44, 0.92), and legal problems (OR = 0.31; 95% CI = 0.16, 0.61). In multivariate analyses, family support, history of medical visits, and recent alcohol use were no longer significant predictors.

: Most individuals in this insured population who completed an initial telephone assessment had an initial behavioral health claim. However, patients with greater health or social service needs were at higher risk for not obtaining treatment, suggesting the need for greater outreach and attention by providers and insurers.

In this analysis of 1177 patients who completed a structured clinical screening interview (Michigan Screening for Treatment and Research Triage) to obtain authorization for behavioral health benefits, we found that:

85% of patients completing the telephone screening had an initial behavioral health clinic claim.

Patients without a behavioral health claim were less likely to have good self-rated health and previous outpatient mental health care. They were more likely to have periods of disability, a previous suicide attempt, greater use of medical services, and legal problems.

Clinicians may assume that patients who do not show up for initial treatment are in as much or greater need of treatment as patients who do present for care.

Development of targeted interventions to assist patients with treatment engagement appears warranted.

Although mental health services are recommended for most common mental disorders, epidemiologic studies show that the majority of those suffering from mental illness are not receiving treatment.

 Factors associated with limited access to care, such as living in a rural area, low average income, and lack of insurance, may lead to the underutilization of mental healthcare services.

 Research demonstrates that “no-show” patients are more likely to be younger, male, and unmarried; to have children; and to have less mental healthcare experience.

In addition to clinicians remaining alert for symptoms of mental health disorders, using formal screening tools to identify patients who manifest symptoms, and diagnosing those who meet criteria, patients must recognize a need for treatment, make the initial contact, attend the first visit, and adhere to a recommended course of action before they can benefit from treatment.

 Patients who have made initial contact to receive mental health services have progressed in this treatment-seeking pathway; however, many do not take the next step in obtaining needed care—completing an initial behavioral health visit. Prior studies have reported that among patients attempting to access care in community mental health settings, approximately 25%-40% do not show up for their first appointment.

 These prior studies focused largely on community mental health settings, often serving a predominately seriously mentally ill population. Frequently, these studies also were limited by small sample sizes and lack of key patient information, such as symptom burden, family support, and current levels of functioning, which bear on the need for mental health treatment.

In this study, we used data from a standardized telephone intake interview routinely conducted by a managed behavioral healthcare organization affiliated with a university medical center. The standardized interview, which was used as a component of the organization’s routine triage and referral activity, included detailed information on patients’ mental health symptoms, home and work environments, suicidal ideation, and substance use, allowing us to examine demographic and clinical factors associated with patients’ initial behavioral health treatment. Identifying factors that predict failure to follow up with behavioral health treatment may lead to targeted interventions to  improve engagement in care.

The study population consisted of patients initially assessed for treatment by a managed behavioral healthcare organization associated with a large Midwestern university between January 1, 2003, and March 31, 2006. Patients routinely completed a telephone-based assessment interview (Michigan Screening for Treatment and Research Triage [M-START]) when they called to request authorization for services. All patients who called to authorize their benefits were approved to initiate care. The care management system tracks interview dates, and assessments are not completed more than once in a 1-year period. Furthermore, all participants were continuously enrolled for the duration of the study, and no participants completed more than 1 interview.

We examined whether patients had a behavioral health claim within the 90 days after their M-START interview. Although wait times may be associated with not showing up for treatment,

 we chose a 90-day window for 2 reasons: (1) this time window is a standard metric used by the National Committee for Quality Assurance to evaluate effectiveness of acute treatment for depression among managed care organizations

 and (2) this time window was sufficient for all patients to be able to be seen by the behavioral health provider (ie, all members should have been able to be seen within 90 days if they chose to do so).

The M-START interview is a comprehensive telephonebased, computer-assisted structured interview, consisting of triage and need-relevant measures of psychiatric symptoms that allow for referral to appropriate specialties as needed, health and functional assessments, and psychosocial supports. M-START is administered by trained clinical social workers and takes approximately 10-15 minutes to complete. The interview includes stem questions from validated and reliable clinical instruments (eg, the Patient Health Questionnaire [PHQ-9]

 for depression, the Structured Clinical Interview for 

 for mood and anxiety disorders, the CAGE

 for alcohol use). Additional items were generated from the expert opinion of 23 clinicians and researchers. The Delphi method

 was used to ask the experts to narrow down an initial list of potential items into a brief interview designed to identify patient treatment needs by indicating their rankings of importance of individual items.

In particular, patients are asked about their age, alcohol use, anxiety, behavioral health treatment history, depression symptom severity (using PHQ-99), drug use, sex, psychosocial issues in their environment (eg, family and relationships, significant loss, legal problems), medical history, functional impairment (eg, inability to work or carry out normal activities), and suicidality.

Patient M-START interview data then were linked to outpatient behavioral health claims from the managed care organization that administered the interviews. Behavioral health claims were identified based on 

We first conducted bivariate analyses using 

 tests (for categorical or dichotomous measures), comparing patients who had a behavioral health claim within 90 days of their M-START interview with those who did not have a claim during that time period. As we conducted 48 bivariate tests, we used the false discovery rate

 to adjust for multiple comparisons. In this case, our adjusted 

 values for significance were ([n + 1]/[n*2])*0.05 = (49/96)*0.05 = 0.026. All predictors identified as potential significant predictors of behavioral health claims at the 

 ≤.026 level were used in multivariable analyses. Next, we used stepwise logistic regression analysis to evaluate which factors influenced whether a patient had a behavioral health claim within the 90-day period. We removed predictors that were no longer significant in the full model, with the exception of age, sex, and PHQ-9 score, which were left in regardless of significance because of their relevance as demographic and clinical factors associated with behavioral health treatment.

Between January 1, 2003, and March 31, 2006, 1177 patients completed an M-START interview. Of those, 1006 (85%) had an outpatient behavioral health claim within 90 days after their M-START interview. Baseline characteristics of the population completing interviews are presented in 

In univariate analyses, the following characteristics were associated with increased odds of behavioral treatment initiation: good self-rated health (odds ratio [OR] = 1.70; 95% confidence interval [CI] = 1.15, 2.50), having support of family or friends (OR = 1.71; 95% CI = 1.11, 2.65), having made any outpatient mental health treatment visits in the past 2 years (OR = 1.56; 95% CI = 1.11, 2.19), and having consumed alcohol in the past 3 months (OR = 1.41; 95% CI = 1.00, 1.97). Conversely, the following characteristics were associated with decreased odds of treatment initiation: functional impairment (being totally unable to work or carry out normal activities for any days in the past 30 days [OR = 0.62; 95% CI = 0.45, 0.87]), having ever made a suicide attempt (OR = 0.56; 95% CI = 0.36, 0.87), having had 6 or more doctor visits for medical reasons this year (OR = 0.64; 95% CI = 0.44, 0.92), and having legal problems (OR = 0.31; 95% CI = 0.16, 0.61).

, model 3), factors that continued to increase the odds of treatment initiation included good selfrated health (OR = 1.55; 95% CI = 1.01, 2.37) and having any mental health outpatient visits in the last 2 years (OR = 1.82; 95% CI = 1.27, 2.60). Alternatively, factors that decreased the odds of behavioral treatment initiation included functional impairment (being totally unable to work or carry out normal activities for any days in the past 30 days [OR = 0.65; 95% CI = 0.45, 0.94]), having ever made a suicide attempt (OR = 0.61; 95% CI = 0.38, 0.98), and having legal problems (OR = 0.30; 95% CI = 0.15, 0.61). Family support was no longer a significant predictor in fully adjusted analyses. In fully adjusted models containing both medical visits and self-rated health, neither was a significant predictor as a result of the strong relationship between the 2 factors (

 = .032). For this reason and given the ubiquity of the selfrated health measure in research and clinical settings, the “medical visits” measure was dropped from the final model (see 

This study presents new findings regarding demographic and clinical factors that are associated with showing up for initial outpatient behavioral health treatment among privately insured individuals. In this population, the large majority of the patients who called to initiate treatment subsequently had a behavioral health claim. This finding differs from those of previous studies that have reported higher no-show rates, although most of these studies were conducted in community mental health populations.

Interestingly, our follow-up rates were similar to those found in a study conducted in a community mental health center in the Netherlands. That study also found long waiting times, lack of motivation, and resolution of the problem as the primary reasons why patients did not follow through with initial treatment. The authors concluded that measures to reduce the no-show rate may be counterproductive by discouraging active coping.

Unfortunately, in the present study, patients who did not have a behavioral health claim appeared to be those who were most functionally impaired. Although one would expect that patients with more psychiatric illnesses or greater symptom severity would be in greater need of treatment, the presence of psychiatric symptoms from a variety of disorders (depression, anxiety, panic, posttraumatic stress disorder,  obsessivecompulsive disorder) and the severity of depressive symptoms as measured by PHQ-9 did not appear to affect the likelihood of following through with a behavioral health visit. More troubling, patients with poor selfrated health, difficulty functioning at work and in other activities, past suicide attempts, or with legal problems were less likely to initiate behavioral healthcare. Conversely, patients who had prior experience with the mental health system were more likely to engage in care.

Our findings suggest that health plans and providers cannot assume that patients who initiate contact for accessing mental health services but then fail to show for their initial treatment are individuals who have less need of care—indeed, these individuals may have greater need for treatment. Not only are no-shows detrimental from the perspective of patient health and well-being, but they also are disruptive to providers and overall workflow.

 As a result, there may be an institutional incentive for insurers to ensure that patients follow through with care. Behavioral health organizations and provider clinics may need to inquire about patients’ functional capacity at the time of mental health intake and assist those who report poor health or functional compromise in following through with care. Reminder calls prior to appointments are one demonstrated way that healthcare plans have decreased no-shows.

 Healthcare organizations also may need to regularly call no-show patients to further ascertain patient need and encourage follow-up for compromised individuals as part of a “best practice” of dealing with noncompliance with treatment.

 Furthermore, care management programs such as depression disease management programs have been demonstrated to improve both coordination of care among providers and patient adherence and outcomes.

We note that initiating care is an essential but not sufficient condition for successful mental health treatment. Thus, future research is needed regarding demographic, clinical, and treatment predictors of continued treatment and of adequate treatment trials. 

Although this study used a comprehensive, structured interview to provide new information on possible correlates of behavioral health treatment initiation, several limitations must be noted. The population included in our study had a high follow-up rate with behavioral health treatment (85%), which may be higher than expected based on previous research for several reasons. This population already was more inclined than the general population to follow through with care, as these patients had already taken the first steps to initiate a phone call and seek to authorize mental health benefits. Furthermore, this population represented insured individuals who perhaps had higher rates of employment, income, and overall socioeconomic status, factors that also may be associated with follow-through with treatment. Prior research with a university employee population indicates that even when insurance benefits and access to care are constant and easily attainable, whites and those with high incomes consume more mental health benefits than other people do.

Another concern is that we can’t say anything from our data about the quality of the treatment a patient received, nor do we have any follow-up data on severity of emotional distress or changes in the course of illness and outcome over time. We do not have any claims data on possible prior behavioral health treatment (eg, specific providers, inpatient stays, psychiatric emergency room visits) other than patients’ responses to the question regarding whether they had previously had outpatient behavioral healthcare in the past 2 years. We also note that our focus was on specialty behavioral health treatment and not on potential treatment for emotional distress in primary care settings, as the M-START interview is specifically tailored to patients seeking to use behavioral health benefits.

To know more about a patient’s prior and current illness and treatment trajectory over time, we would need more data on both frequency and type of behavioral health treatment, as well as type of provider, medication adherence, and a follow-up period longer than 90 days. This information would perhaps provide greater insight into why a patient may not end up having a behavioral health claim after calling to initiate benefits. However, our focus here was not on quality of care and overall treatment outcomes, but rather on trying to identify who does and does not come in for that first visit, and what factors may be associated with the likelihood of attendance. Further research including a qualitative component might help identify reasons why patients do not follow through with treatment after calling to authorize visits.

Finally, there can be questions about the generalizability of findings from 1 interview and 1 managed care plan, with patients seeking care in an academic medical setting. Patients who have other types of healthcare, providers, and locations may have a different likelihood of and characteristics associated with behavioral health treatment initiation. Furthermore, there are limitations associated with using patient self-report data (eg, the data from the M-START interview) in assessing the true underlying nature of patients’ disease. However, despite these limitations, this study provided a unique opportunity to examine these issues by pulling together data from both an intake screen and from behavioral health claims to identify treatment initiation.

It is heartening that most patients who completed an initial telephone assessment went on to have a behavioral health claim within 90 days after their interview. However, patients who may have had greater health or social service needs were less likely to have initiated treatment, whereas those patients with better health and experience with the mental health treatment system were more likely to initiate treatment. This study extended prior work on the process of treatment engagement by examining a large number of demographic, social, and clinical characteristics associated with treatment initiation after assessment. Our findings suggest that patients experiencing the greatest need for services may be least likely to initiate treatment, necessitating greater outreach and attention by providers.

The authors would like to acknowledge the contributions of Thomas Spafford and Michelle Kaston, BS, to earlier drafts of this manuscript.

From the Health Services Research and Development Center of Excellence (KZ, DEW, MV), Department of Veterans Affairs, Ann Arbor, MI; the Department of Psychiatry (KZ, PNP, RJM, JSK, HW, DJD, MMB, MV), University of Michigan, Ann Arbor; and the Blue Care Network of Michigan (DJD), Ann Arbor.

This publication was made possible by the University of Michigan’s Department of Psychiatry and Venture Investment Funds, the Department of Veterans Affairs HSR&D’s RCD 98-350 Career Development Award, and Coordinating Mental Health Services in Integrated Delivery Systems (principal investigator, Marcia Valenstein, MD).

The authors (KZ, PNP, RJM, JSK, HW, DEW, DJD, MMB, MV) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Concept and design (KZ, PNP, RJM, DJD, MV); acquisition of data (KZ, JSK, HW, MV); analysis and interpretation of data (KZ, RJM, DEW, DJD, MMB, MV); drafting of the manuscript (KZ, PNP, HW, DJD); critical revision of the manuscript for important intellectual content (KZ, PNP, DJD, MMB, MV); statistical analysis (KZ, RJM, DEW); provision of study materials or patients (JSK); obtaining funding (MV); and administrative, technical, or logistic support (JSK, HW, DEW, DJD, MMB). 

Kara Zivin, PhD, Department of Psychiatry, University of Michigan, 4250 Plymouth Rd, Box 5765, Ann Arbor, MI 48109. E-mail: kzivin@umich.edu.

1. American Psychiatric Association, Work Group on Major Depressive Disorder

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Paul N. Pfeiffer, MD

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