Gender and Race/Ethnicity Differences in Mental Health Care Use before and during the Great Recession Jie Chen, PhD Rada Dagher, PhD Abstract This study examines the changes in health care utilization for mental health disorders among patients who were diagnosed with depressive and/or anxiety disorders during the Great Recession 2007–2009 in the USA. Negative binomial regressions are used to estimate the association of the economic recession and mental health care use for females and males separately. Results show that prescription drug utilization (e.g., antidepressants, psychotropic medications) increased significantly during the economic recession 2007–2009 for both females and males. Physician visits for mental health disorders decreased during the same period. Results show that racial disparities in mental health care might have increased, while ethnic disparities persisted during the Great Recession. Future research should separately examine mental health care utilization by gender and race/ethnicity.
Introduction According to the National Bureau of Economic Research, the Great Economic Recession of the USA 2007–2009 was marked by a significant decline in production and employment.1 The unemployment rate increased from 4.5% in 2006 to 9.5% in 2009.1 Substantial reductions in household income were observed during the same period.2 The impact of the economic recession on mental health care utilization is a double-edged sword. On one hand, the demand for mental health care increases substantially during economic hardships. The literature shows consistent adverse effects of job loss on the risk of depression and heavy drinking, and a moderate positive association between economic contraction and suicide and Address correspondence to Jie Chen, PhD, Department of Health Services Administration, School of Public Health, University of Maryland, 3310A School of Public Health Building, College Park, MD 20742-2611, USA. Phone: +1-3014059053; Fax: +1-301-4052542; Email: [email protected]. Rada Dagher, PhD, Department of Health Services Administration, School of Public Health, University of Maryland, 3310B School of Public Health Building, College Park, MD, 20742-2611, USA. Phone: +1-301-4051210; Email: [email protected]
)
Journal of Behavioral Health Services & Research, 2014. 1–12. c 2014 National Council for Behavioral Health. DOI 10.1007/s11414-014-9403-1
Mental Health Care during the Recession
antisocial behavior.3 Meanwhile, economic hardship can also result in perceptions of insecurity and stress, and an increase in the risk of mental disorders4,5 and mental health care utilization.6–9 On the other hand, mental health coverage deteriorates during the same time. State and local governments are likely to cut back mental health care coverage during the recession budget cuts. The loss of employment-based private health insurance adds another barrier to have mental health care. A recent report shows that the annual spending on mental health care by private health insurance decreased from 7.0% in 2004–2007 to 2.1% in 2007–2009.10 Mental health care utilization patterns might differ by gender during the economic recession. In general, the literature shows that females have higher medical care utilization rates than males in a variety of health services (primary care, specialty care, emergency treatment, etc.),11,12 including mental health care utilization.13 Lower rates of mental health treatment among men compared to women is a consistent finding in the literature.14,15 This is possibly due to a greater perceived stigma of seeking mental health care among men in comparison with women and greater ability among women than men to identify nonspecific feelings of distress and recognize the presence of a mental health problem.16,17 In addition, the Great Economic Recession caused disproportionately more job losses for males than for females because more jobs were lost in the construction and manufacturing sectors than in the service sector.18 Thus, it is likely that males were more likely than females to encounter barriers to mental health care during the recession. It has been well documented that African Americans and Latinos have worse access to mental health services than whites.19,20 During the recent economic recession, racial/ethnic minorities experienced more job losses and housing foreclosures, and hence, were exposed to a higher likelihood of losses in health insurance coverage and reductions in wealth.21–23 Inflation-adjusted median wealth fell 66% among Latino households, 53% among African American households, and 16% among white households.2 Unemployment rates were also higher among African Americans and Latinos than whites, with 25% of African Americans and Latinos losing their jobs during 2008 and 2010, compared to 15% of whites.24,25 Thus, racial and ethnic minorities may have encountered more access barriers to mental health care during the Great Recession. This study examines the utilization of two major cost-effective treatments for depressive and anxiety disorders, prescription drug utilization and physician office visits,26–28 during the recent economic recession 2007–2009 in the USA. Depression and anxiety are two highly prevalent mental disorders that are often comorbid and cause substantial disability if not treated.29 Moreover, both disorders are associated with increased health care expenditures and high economic costs to society.30,31These mental disorders are highly undertreated in the USA due to poor health insurance coverage and financial barriers.32 This study adds to the literature on the relationship between economic downturns and mental health by examining the different associations of the 2007–2009 economic recession and mental health care utilization by gender and race/ethnicity. The hypotheses are (1) gender disparities in the utilization of mental health care during the recession may have increased and (2) racial/ethnic disparities in the utilization of mental health care may also have increased during the recession.
Methods Data This study uses the nationally representative dataset of Medical Expenditure Panel Survey (MEPS) of 2000–2009.32 The MEPS has several sub-files. The MEPS consolidated file contains detailed information on patients’ demographics and socioeconomic characteristics. The MEPS medical condition files collect data on respondents’ chronic diseases and the associated health care utilization for each of these diseases. The medical condition files provide synthesized data from different MEPS sub-files including drug utilization and physician visits for each primary disease
The Journal of Behavioral Health Services & Research
2014
reported by the respondent. The prescription drugs identified in this study include antidepressants, anti-anxiety medications, and psychotropic medications that are used to treat depressive and anxiety disorders. Physician visits are also calculated if patients visit the physicians to treat depression or anxiety as their primary disorder. Chronic diseases are self-reported by the patients, and then are coded by professional coders to fully specified International Classification of Diseases, 9th Revision ( ICD9) codes. As documented in the MEPS, medical providers and pharmacies are contacted to validate data on ICD9 codes and services the respondents have used. The MEPS medical condition files are linked to the consolidated files to get comprehensive information on patients’ demographics (e.g., gender, race/ ethnicity) and socioeconomic status (e.g. education, income). This dataset enables the authors to identify patients who were primarily diagnosed with depressive (ICD9=311) or anxiety (ICD9=300) disorders, and observe the corresponding prescription drug utilization and physician visits specific to depression and anxiety treatment during the survey years. The outcome variables are the annual utilization of prescription drugs and physician visits that treat primary depressive and anxiety disorders. The analyses include adults aged 18 to 64 years old, who are diagnosed with depressive or anxiety disorders as the primary disorders. The sample of females totals 16,482, including 11,569 non-Hispanic whites (whites), 2,943 Latinos, and 1,970 non-Hispanic African Americans (African Americans), and the sample of males totals to 6,835, including 5,164 whites, 1,068 Latinos, and 603 African Americans.
Independent variables Recession year indicators The objective of this study is to examine the changes in mental health care utilization during the Great Economic Recession 2007–2009. The longitudinal survey years from 2000–2009 provide the analysis capacity to observe the trends of utilization during the last decade. It is worth noting that in the past decade, there was another economic recession in 2001 (from March 2001 to November 2001) in the USA.33 The duration of the 2001 recession was short, and the consequences were relatively mild (e.g. the unemployment rate was 4%–6% during 2001 recession) compared to the recent Great Recession. Nevertheless, it is also interesting to see the changes of utilization by gender and race/ethnicity during the 2001 recession. Hence, the authors consider 2001, 2007, 2008, and 2009 as the recession years and construct the interaction terms of each of these recession years with race and ethnicity. The interaction terms are included to examine the different utilization patterns among the races and ethnicities during the recessions. To capture the gender differences, the analyses examine mental health care utilization for females and males separately. Other covariates The analyses comprise a number of independent variables that are associated with mental health care utilization.34,35 These variables include respondents’ age, marital status (married or not), educational attainment (no high school degree, high school degree, college degree, advanced degree), family income (less than 100% federal poverty line (FPL), 100%–200% FPL, more than 200% FPL), health insurance coverage (no health insurance coverage, public health insurance, private health insurance), health care access (having a usual source of care), employment status (employed, unemployed), Metropolitan Statistics Area (urban, rural), and US Census Region (North East, Midwest, South, West). Health outcome measures are controlled as proxies to the severity of mental health status. These variables include self-reported physical health (excellent/very good, good, fair/poor), self-reported mental health (excellent/very good, good, fair/poor), and the SF short-form 12 (SF12): physical component summary (PCS) and mental component summary (MCS) scores.36–38 These measures are considered as valid instruments for measuring health-related quality of life and mental health status, and have been widely adopted in the literature.39
Mental Health Care during the Recession
Analysis The study first presents the trends of utilization of prescription drugs and physician visits among patients with depression and anxiety using nationally representative statistics from 2000–2009. These statistics are calculated and weighted using the sampling weights provided by the MEPS. Authors then show the sample summary statistics by gender and race/ethnicity. Means tests are conducted to compare the racial and ethnic differences in each covariate by gender, with whites as the reference group. Negative binomial models are used to estimate the association between the economic recession and mental health care utilization.40,41 The model specification is as follows: Number of prescription drugs used ¼ f β 0 þ β 1 Latino þ β 2 African American þ β 3 year indicator þ β 4 Latino* Recession Year Indicator þ β 5 African American*Recession Year Indicator þ β 6 X Þ where f() represents the negative binomial function. X includes other demographic and socioeconomic variables. βs represent the coefficients to be estimated in the model. The above model is estimated separately by gender. The incidence rate ratios (IRRs) are reported from the negative binomial regressions. The IRRs indicate the estimated incidence ratio relative to its reference group. The same model specification is used to examine the association of the economic recessions with physician visits that treat mental disorders. Finally, based on the negative binomial models, the frequency of prescription drug utilization and physician visits are estimated by gender and race/ethnicity across the years, adjusted by all the other covariates. All regressions are adjusted for sampling weights provided in the MEPS to ensure that the results are nationally representative. All statistical analyses are conducted using Stata 12.
Results Table 1 presents the trends of utilization of prescription drugs and physician visits from 2000 to 2009 by gender and race/ethnicity. The prescription drug utilization increased in the recession years 2007–2009 among white females, Latinas, and white males. The rates of prescription drug utilization among African American females and males decreased in 2008 and 2009 compared to survey years before the Great Recession. African American females had relatively high rates of prescription drug utilization in 2007 compared to any other survey year. The prescription drug utilization of Latino males was lower in 2007–2009 compared to 2005. The rates of prescription drug utilization were generally lower in 2001 compared to the years preceding or after the 2001 economic recession, except among Latino males. The differences between whites versus Latinos were more pronounced compared to the differences between whites versus African Americans. Racial and ethnic disparities were also more pronounced among females compared to males. Compared to 2005–2006, statistics show that the utilization of physician visits was relatively higher in 2007–2008 among whites and Latinos. African Americans (both males and females) had lower rates of physician visits during 2007. Trends of physician visits were relatively similar across race and ethnicity. The only racial difference was observed in 2008 and 2001, with African Americans (both females and males) using significantly fewer physician visits compared to whites. Table 2 presents the sample summary statistics of patients diagnosed with depressive and anxiety disorders by gender and race/ethnicity. Compared to white females, Latinas and African American females reported worse physical and mental health, lower education, and family income, and were more likely to be uninsured. Similar trends were observed among males. Table 3 presents the results of the negative binomial regressions, treating the count of prescription drug utilization and physicians visits as the outcome variables separately. Compared to white females, Latinas and African American females used significantly fewer prescription drugs (IRR=0.75, pG0.001; IRR=0.71, pG0.001), and African American females had significantly fewer
The Journal of Behavioral Health Services & Research
2014
Table 1 Prescription drug utilization and physician visits among patients with depression and/or anxiety by gender and race/ethnicity from 2000–2009 Prescription drug utilization Females
Males
Whites
Latinos
African Americans
Whites
Latinos
African Americans
2000 1.82 2001 1.83 2002 1.88 2003 1.84 2004 1.82 2005 1.86 2006 1.92 2007 1.95 2008 2.24 2009 2.21 Physician visits 2000 2.72 2001 2.97 2002 3.02 2003 3.16 2004 2.48 2005 2.49 2006 2.32 2007 2.76 2008 3.91 2009 3.01
1.29* 1.22*** 1.25*** 1.24*** 1.24*** 1.43** 1.31*** 1.44*** 1.57*** 1.73**
1.23* 1.26** 1.43* 1.34** 1.42* 1.85 1.67 1.99 1.38*** 1.53***
1.82 1.57 1.60 1.61 1.71 1.68 1.65 1.72 2.07 2.02
0.87*** 1.15 0.94*** 1.02** 1.13** 1.59 1.00*** 0.82*** 1.16*** 1.23***
1.67 1.14 1.25 1.74 1.51 1.56 1.61 1.13 1.04*** 1.42*
2.55 2.26 2.71 2.57 3.37 3.01 3.05 2.03 2.77 3.50
1.58 2.15 2.09 2.68 3.65 3.49 2.74 3.03 1.74** 2.87
3.32 3.86 2.43 2.81 2.79 3.74 2.88 2.19 2.41 1.87
5.49 2.58 2.46 2.31 1.95 3.11 2.72 2.90 3.11 2.44
3.48 0.87*** 1.32* 3.51 1.97 2.73 2.67 2.34 0.87*** 1.36
Estimates are nationally representative by adjusting the sampling weights provided by the Medical Expenditure Panel Survey ***pG0.001; **pG0.01; *pG0.05, the reference groups are the White females/males in each survey year
physician visits (IRR=0.71, p=0.01). Compared to white males, Latino males had significantly lower rates of prescription drug utilization (IRR=0.72, pG0.001) and physician visits (IRR=0.72, pG0.05). Year indicators show that prescription drug utilization of females was stable from 2000–2007, but increased significantly in 2008 (IRRs=1.20, pG0.001) and 2009 (IRRs=1.20, pG0.001). Physician visits among females demonstrated a similar trend. Year indicators are generally not significant in the regressions among the male population. Results show that only males had significantly lower physician visits in 2009 (IRR=0.55, pG0.001). The interaction terms between the recession year indicators and races/ethnicities among females show that compared to white females, African American females used more prescription drugs in 2007 (IRR=1.26, pG0.05) and fewer physician visits in 2008 (IRR=0.54, pG0.05). The interaction terms between the recession year indicators and races/ethnicities of males indicate that African American males utilized fewer prescription drugs in 2008 (IRR=0.61, pG0.05), and fewer physician visits in 2008 (IRR=0.42, pG0.05) and 2001 (IRR=0.28, pG0.001).
Mental Health Care during the Recession
Table 2 Sample summary statistics of patients with depression and/or anxiety by gender and race/ethnicity Females
Males
Whites
Latinos
African Americans
Whites
Latinos
African Americans
n=12,639
n=3,207
n=2,227
n=5,679
n=1,173
n=673
Mean
Mean
Mean
Mean
Mean
Mean
0.08* 0.22*** 0.27** 0.27*** 0.17*** 0.46***
0.07 0.18 0.23 0.32 0.21* 0.20***
0.08 0.14 0.23 0.29 0.25 0.51
0.13*** 0.19*** 0.25 0.26 0.17*** 0.47*
0.10 0.14 0.23 0.31 0.22* 0.33***
0.43*** 0.30 0.28***
0.45*** 0.29 0.26***
0.33 0.30 0.37
0.38*** 0.28 0.34**
0.45*** 0.28 0.27***
0.31*** 0.34** 0.35*** 0.45** 0.40***
0.37*** 0.30*** 0.32*** 0.42*** 0.39***
0.29 0.34 0.37 0.46 0.41
0.33** 0.33 0.34 0.46 0.41
0.40*** 0.29** 0.31** 0.43*** 0.41
0.52*** 0.32*** 0.07*** 0.09***
0.33*** 0.48 0.07*** 0.12***
0.22 0.46 0.15 0.16
0.50*** 0.39*** 0.06*** 0.05***
0.32*** 0.48 0.09*** 0.11***
0.33***
0.42***
0.16
0.26***
0.34***
0.31*** 0.35*** 0.46*** 0.80***
0.26*** 0.32*** 0.48*** 0.86***
0.19 0.65 0.30 0.85
0.29*** 0.44*** 0.34*** 0.72***
0.26*** 0.40*** 0.53*** 0.83
0.25*** 0.38*** 0.37*** 0.90***
0.12*** 0.41*** 0.47*** 0.84***
0.14 0.66 0.19 0.77
0.28*** 0.43*** 0.29*** 0.92***
0.16 0.42*** 0.41*** 0.87***
0.17*** 0.08*** 0.30*** 0.45***
0.14*** 0.21*** 0.55*** 0.10***
0.16 0.27 0.35 0.21
0.16 0.08*** 0.29*** 0.47***
0.13* 0.21*** 0.53*** 0.13***
Age 18–24 0.08 25–34 0.16 35–44 0.24 45–54 0.29 55–64 0.23 Married 0.48 Self-reported health status Poor/Fair 0.30 Good 0.30 Very good/excellent 0.40 Self-reported mental health status Poor/Fair 0.25 Good 0.36 Very good/excellent 0.39 SF12-PCS 0.46 SF12-MCS 0.41 Education No high school degree 0.20 High school degree 0.48 College degree 0.14 Advanced degree 0.18 Family income G100% Federal poverty 0.19 line (FPL) 100%–200% FPL 0.18 9200% FPL 0.63 Unemployed 0.33 Having usual source of care 0.90 Health insurance Uninsured 0.10 Private health insurance 0.69 Public health insurance 0.21 Urban 0.76 US region Northeast 0.15 Midwest 0.28 South 0.37 West 0.21
***pG0.001; **pG0.01; *pG0.05, the reference groups are the White females/males
The Journal of Behavioral Health Services & Research
2014
Table 3 also shows significant associations between other covariates and physician visits and prescription drug utilization for mental disorders. Particularly, age, education, family income, health care access, and insurance coverage were positively associated with mental health care utilization. Based on the negative binomial regression models, the authors estimate the association between the recession year indicators 2007–2009 and the utilization of prescription drugs and physician visits, adjusting for all the other covariates. Figure 1 shows the overall increasing trends in prescription drug utilization during the recent recession by gender and race/ethnicity. Results show that during the 2007–2009 recession, prescription drug utilization for mental disorders increased by 11% among females (increased from 1.91 to 2.12 for white females, 1.44 to 1.60 for Latinas, and 1.35 to 1.50 for African American females), and 8%–9% among males (increased from 1.71 to 1.85 for white males, 1.24 to 1.35 for Latino males, and 1.29 to 1.40 for African American males), after controlling for all the covariates. Figure 2 shows the estimated frequency of physician visits, after adjusting for all the covariates. Females and males of all racial and ethnic groups had lower rates of physician visits during the recession. The model estimates that physician visits decreased by 7%–8% among females (decreased from 3.06 to 2.85 for white females, 2.65 to 2.45 for Latinas, and 2.21 to 1.96 for African American females) and decreased by 25% among males (decreased from 3.06 to 2.31 for white males, 2.9 to 2.17 for Latino males, and 2.22 to 1.66 for African American males).
Discussion This study shows mixed evidence of utilization patterns of prescription drugs and physician visits by gender. Females had a greater increase in prescription drugs utilization, and males had a greater reduction in physician visits during the Great Recession. The sample size of females who had been diagnosed with depression or anxiety is almost three times the size of males. The female and male populations are similar in the general populations in the USA. The disproportionately high ratio of females in the sample may indicate gender differences in healthcare-seeking behavior, particularly in mental health care possibly because of the greater stigma of seeking mental health care among males and the greater ability of females to identify their mental health problems.16,17 Meanwhile, increased utilization among females during the recession might reflect their worse mental health status and higher demand for mental health care, due to job insecurity or stress during the economic recession.4,5 Since males are more likely to lose jobs in the recession compared to females18, one would expect that males are more likely to experience mental health problems and have high demand for mental health care. However, this study shows lower physician visits among males during the Great Recession. The following reasons are speculated. Males are more likely to take the financial responsibility of the family, and sacrifice physician visits to save money. The difference in physician visits can also be explained by gender differences in health care-seeking behaviors, particularly for mental health services for the reasons discussed earlier. Gender differences in health insurance coverage may also contribute to the gender differences in utilization. The results show that the rate of being uninsured is 3%–4% points higher, and the rate of being covered by public health insurance is 2%–8% points lower among males compared to females. The lack of health insurance coverage among male populations with depressive and anxiety disorders can be an important barrier for them to access health care, especially during the recession. It is worth noting that there is substantial variation in state Medicaid coverage of mental health care, and the levels of benefits by gender vary widely. For example, Medicaid typically covers only low-income pregnant women and their children and women’s coverage usually ends 6 weeks after delivery.42 Some states have a “medically needy” category that could include men, but the FPL is usually 50% or less, which excludes many men.43
Mental Health Care during the Recession
Table 3 Negative binomial results of differences in prescription drug use and physician visits before and during the recession by gender and race/ethnicity Females Prescription drug use IRR Whites Latinos African Americans Age 18–24 25–34 35–44 45–54 55–64 Married Self-reported health status Poor/fair Good Very good/excellent Self-reported mental health status Poor/fair Good Very good/excellent SF12-PCS SF12-MCS Education No high school degree High school degree College degree Advanced degree Family income G100% federal poverty line (FPL) 100–200% FPL 9200% FPL Unemployed Having usual source of care Health insurance Uninsured Private health insurance Public health insurance Urban US region North East Midwest South
P
Males Physician visits IRR
P
Prescription drug use IRR
P
Physician visits IRR
P
Reference 0.75 0.00 0.71 0.00
Reference 1.01 0.89 0.71 0.01
Reference 0.72 0.00 0.84 0.08
Reference 0.72 0.04 0.87 0.52
Reference 1.37 0.00 1.66 0.00 1.80 0.00 1.81 0.00 0.96 0.17
Reference 1.22 0.11 1.20 0.17 1.21 0.12 1.08 0.53 0.71 0.00
Reference 1.31 0.02 1.45 0.00 1.45 0.00 1.51 0.00 1.08 0.07
Reference 1.32 0.13 1.10 0.59 0.99 0.97 0.92 0.63 0.66 0.00
Reference 0.99 0.84 1.02 0.54
Reference 0.94 0.43 1.19 0.06
Reference 1.05 0.38 1.09 0.18
Reference 1.07 0.63 1.25 0.14
Reference 0.83 0.00 0.69 0.00 0.83 0.09 0.37 0.00
Reference 0.56 0.00 0.35 0.00 1.11 0.75 0.05 0.00
Reference 0.76 0.00 0.65 0.00 0.90 0.60 0.47 0.00
Reference 0.56 0.00 0.33 0.00 0.81 0.63 0.05 0.00
Reference 1.07 0.03 1.16 0.00 1.07 0.07
Reference 1.17 0.02 2.17 0.00 1.98 0.00
Reference 1.08 0.14 1.02 0.74 1.13 0.09
Reference 1.01 0.96 1.16 0.32 1.54 0.02
Reference 1.08 0.02 1.19 0.00 1.17 0.00 1.54 0.00
Reference 0.94 0.48 1.06 0.52 1.45 0.00 1.37 0.00
Reference 1.02 0.82 1.06 0.42 1.21 0.00 1.80 0.00
Reference 0.82 0.14 1.07 0.60 1.25 0.04 1.65 0.00
Reference 1.33 0.00 1.53 0.00 0.99 0.75
Reference 1.22 0.06 1.63 0.00 1.54 0.00
Reference 1.28 0.00 1.42 0.00 1.07 0.11
Reference 1.21 0.19 1.62 0.00 1.68 0.00
Reference 1.01 0.83 1.04 0.24
Reference 0.76 0.00 0.69 0.00
Reference 1.04 0.58 1.10 0.10
Reference 0.83 0.18 0.84 0.26
The Journal of Behavioral Health Services & Research
2014
Table 3 (continued) Females Prescription drug use
West Year indicator 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Interaction terms Latino * 2001 Latino * 2007 Latino * 2008 Latino * 2009 African American African American African American African American Constant
* * * *
2001 2007 2008 2009
Males Physician visits
Prescription drug use
Physician visits
IRR
P
IRR
P
IRR
P
IRR
P
0.88
0.00
0.74
0.00
0.87
0.04
0.73
0.02
Reference 1.02 0.71 1.02 0.73 0.99 0.87 1.02 0.72 1.05 0.34 1.05 0.33 1.07 0.23 1.20 0.00 1.20 0.00
Reference 1.17 0.17 1.10 0.37 1.10 0.44 1.01 0.91 1.05 0.67 0.94 0.60 0.94 0.68 1.28 0.05 1.03 0.83
Reference 0.88 0.22 0.90 0.26 0.94 0.51 0.98 0.79 0.99 0.87 0.91 0.30 0.98 0.79 1.13 0.19 1.11 0.25
Reference 1.05 0.82 0.83 0.35 0.88 0.55 0.79 0.24 1.12 0.62 0.89 0.59 0.66 0.06 0.74 0.16 0.55 0.00
0.98 1.07 1.01 1.06 0.88 1.26 0.83 0.90 0.89
0.80 0.70 0.69 0.86 0.81 1.19 0.54 1.22 4.13
1.15 0.80 0.92 1.00 0.82 0.75 0.61 0.74 0.78
1.15 1.67 2.13 2.16 0.28 0.79 0.42 0.71 6.54
0.83 0.50 0.90 0.52 0.40 0.04 0.12 0.35 0.28
0.25 0.12 0.10 0.48 0.45 0.41 0.03 0.49 0.00
0.39 0.19 0.66 0.98 0.42 0.36 0.03 0.15 0.19
0.64 0.08 0.07 0.12 0.00 0.51 0.02 0.37 0.00
The IRRs indicate the estimated incident ratio relative to its reference group. For example, the IRR of the variable “Latino” in the female regression is 0.75. It indicates that Latinas had a rate of 0.75 times fewer prescription drugs used compared to Whites, holding other variables constant
The overall trends of the estimates show increased utilization of prescription drugs and decreased physician visits during the same time period. Physician visits and prescription drugs are usually considered as complementary goods, i.e., patients receive prescription drugs from physician visits, and thus, increase the utilization of prescription drugs reflect increased physician visits. The negative relationship between prescription drug utilization and physician visits during the economic recession may indicate that physician visits and prescription drugs are more likely to be substitutes to each other, due to the higher prices and limited budgets people face. Patients need to make choices between these two services, and may end up using the services with lower payments, i.e., prescription drugs. Since the sample in this study includes populations who have been diagnosed with depression and anxiety already, these patients may likely resort to prescription drug utilization (using refills, for example), without consulting physicians. Future research is needed to estimate the relationship between physician visits and prescription drug utilization during the economic recession.
Mental Health Care during the Recession
Figure 1 Estimated frequency of prescription drug utilization among patients with depression and/or anxiety by gender and race/ethnicity before and during the Great Recession 2.5
2
2.12 1.91
1.85 1.71
1.6 1.44
1.5
1.5 1.35 1.24
1.35
1.29
1.4
before 2007
1
2007-2009 0.5
0 Whites
Latinos
African Amercians
Whites
Females
Latinos
African Amercians
Males
This study shows that racial and ethnic minorities might have faced more barriers to access to mental health care during the Great Recession. Both male and female African Americans had a reduction in physician visits. African American males also had a more significant reduction in prescription drugs, while African American females had an increase in prescription drugs during the recession years of 2007 and 2008. Latinos, on the other hand, faced a modest change in mental health care utilization compared to whites. These findings are consistent with previous literature, which shows that racial and ethnic minorities experienced poorer access to health care than whites before the Great Recession and that access may have worsened during the recession.44 However,
Figure 2 Estimated frequency of physician visits among patients with depression and/or anxiety by gender and race/ethnicity before and during the Great Recession 3.5 3
3.06 2.85
2.5
3.09 2.65 2.45 2.1
2.31 1.96
2.9 2.17
2
2.22 1.66
1.5
before 2007
1
2007-2009
0.5 0 Whites
Latinos
Females
African Amercians
Whites
Latinos
African Amercians
Males
The Journal of Behavioral Health Services & Research
2014
the analysis can only identify patients with diagnosed depression and anxiety. Since mental disorders are generally under treated and under diagnosed, the racial/ethnic differences may be more substantial when taking into account mental disorders other than depression and anxiety. The results also show that compared to private health insurance, having public health insurance, such as Medicaid or other local/state-funded insurance, is associated with higher mental health care use, particularly physician visits. Recent estimates show a significant reduction in mental health spending by the private sector during the economic recession.8 More importantly, the annual growth rate of out-of-pocket payments on mental health care dropped from 6.7% to 0.2% during the same period.10 Although it is likely that patients might have switched from brand name drugs to generics, the substantial reduction in growth rates might also reflect the reduced utilization and/ or unaffordability of mental health care under private health insurance coverage. Factors associated with increased drug utilization and physician visits differed by gender. These findings indicate that strategies to improve treatment adherence may work differently by gender. For example, results show that higher family income is associated with higher prescription drug utilization for females, but not males. In addition, years of schooling are more likely to increase prescription drug utilization and physician visits for females, but not for males. It is likely that the strategies of improving treatment adherence by improving health literacy may work better among females. Financial subsidies to improve mental health care access may also work better among females. On the other hand, strategies focusing on reducing the stigma associated with mental health care utilization or accommodating cultural background may work better among males. This study has several important limitations. First, the association of the economic recession with mental health care utilization may have been underestimated. The utilization of mental health care is only observed among the patients diagnosed with primary depressive or anxiety disorders. Mental health care utilization is not calculated if the respondents had depressive or anxiety as secondary disorders. Moreover, this study uses 3-digit ICD9 codes to categorize the diseases. More specific ICD9 codes can work better to match the mental health condition with mental health care utilization. Second, mental health care utilization is patient self-reported, so there might be recall bias. However, these reports of mental health care utilization have been further validated by patients’ doctors and pharmacists. Third, this study examines two of the most cost effective and most common treatments of depression and anxiety. Alternative forms of care, such as hospital utilization, consultation with friends, looking for religious help, may increase during the recession. The authors are also not able to specify the location of the physician office. It is likely that the visits increased at the federally qualified health centers and free clinics during the recession. Fourth, given the data limitation, this study is not able to tell the generic/brand name status of the prescription drug. It is likely that increased prescription drug utilization is due to switching from brand name drugs to generics. Fourth, to capture the severity of mental disorders, the authors control for four mental and physical health measures in the analyses: self-reported mental health status, self-reported physical health status, SF12-MCS score, and SF12-PCS score. But it is likely that the severity of the mental disorders or other comorbidities associated with mental disorders was not fully captured. Fifth, given the MEPS survey design, the authors are not able to conduct a longitudinal analysis. Thus, it is difficult to derive the causal relationship of the economic recession and mental health care use. It is likely that the trends of prescription drug use and physician visits during 2007–2009 were due to other unobserved factors, such as the policy variation by geographic area. It will be interesting to see the impact of the economic recession on long term mental health outcomes.
Implications for Behavioral Health The Affordable Care Act (ACA) will improve mental health care coverage through the expansion of Medicaid or increased provision of private health insurance, and function as a safety
Mental Health Care during the Recession
net for people with mental health disorders. Implementation of the health insurance exchanges or marketplace will provide opportunities for people who have no employer-sponsored insurance and earn above the Medicaid eligibility line to purchase health insurance at more affordable rates than those charged by the private health insurance market. States that plan to expand Medicaid will make mental health care coverage available to both males and females if they meet eligibility criteria. Hence, the gender differences potentially can be reduced by the ACA. However, not every state will expand Medicaid eligibility, and the states that are not planning to expand Medicaid typically have higher proportions of poor and uninsured adults (e.g., in the Southeast of the USA). In addition to the ACA, the increased availability of generic psychiatric drugs45 and the recently implemented law of the Mental Health Parity and Addiction Equity Act46 have the potential to facilitate access to prescription drugs. The integrated care of mental health treatment advocated in recent years has been considered as one of the core clinical features to improve mental health.47 Under the integrated care model, patients will be more likely to receive effective treatment for mental disorders.48 Future research should examine the impact of these policies on mental health care and should separately examine mental health care utilization by gender and race/ethnicity. Conflict of Interest The authors declare no conflict of interest.
References 1. U.S. Bureau of Labor Statistics. The recession of 2007–2009. Available online at http://www.bls.gov/spotlight/2012/recession/pdf/ recession_bls_spotlight.pdf. Accessed May 15, 2013. 2. Kochhar R, Fry R, Taylor P. Twenty-to-one: health gaps rise to record highs between whites, blacks and Hispanics. Pew Research Center, 2011. Available online at http://www.pewsocialtrends.org/files/2011/07/SDT-Wealth-Report_7-26-11_FINAL.pdf. Accessed May 15, 2013. 3. Goldman-Mellor S, Saxton K, Catalano R. Economic contraction and mental health: A review of the evidence, 1990–2009. Internal Journal of Mental Health 2010; 39(2): 6-31. 4. Tausig M, Fenwick R. Recession and well-being. Journal of Health & Social Behavior 1999; 40: 1-16. 5. Viinamaki H, Koskela K, Niskanen L. Rapidly declining mental wellbeing during unemployment. European Psychiatry 1996; 10: 215221. 6. Catalano R. The health effects of economic insecurity. American Journal of Public Health 1991; 81(9): 1148-1152. 7. Rugulies R, Thielen K, Nygaard E, et al. Job insecurity and the use of antidepressant medication among Danish employees with and without a history of prolonged unemployment: A 3.5-year follow-up study. Journal of Epidemiology & Community Health 2010; 64: 75–81. 8. Catalano R. Health, medical care, and economic crisis. New England Journal of Medicine 2009; 360(8):749-51. 9. Catalano R, Goldman-Mellor S, Saxton K, et al. The health effects of economic decline. Annual Review of Public Health 2011; 32: 431-50. 10. Levit KR, Mark TL, Coffey RM, et al. Federal spending on behavioral health accelerated during recession as individuals lost employer insurance. Health Affairs 2013; 32: 952–962. 11. Bertakis K, Azari R, Helms L, et al. Gender differences in the utilization of health care services. Journal of Family Practice 2000; 49(2): 147-152. 12. Owens, GM. Gender differences in health care expenditures, resource utilization, and quality of care. Journal of Managed Care Pharmacy 2008; 14(3) (Suppl S): S2-S6. 13. Olfson M, Marcus SC, Druss B, et al. National trends in the outpatient treatment of depression. The Journal of American Medical Association 2002; 287(2):203–209. 14. Kessler RC, Zhao S, Katz SJ, et al. Past year use of outpatient services for psychiatric problems in the National Comorbidity Survey. American Journal of Psychiatry 1999; 156: 115- 123. 15. 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. Archives of General Psychiatry 1993; 50(2):85–94. 16. Williams JB, Spitzer RL, Linzer M, et al. Gender differences in depression in primary care. American Journal of Obstetrics & Gynecology 1995; 173: 654- 659. 17. Kessler RC, Brown RL, Broman CL. Sex differences in psychiatric help-seeking: evidence from four large-scale surveys. Journal of Health and Social Behavior 1981; 22: 49- 64. 18. Taylor P, Fry R, Cohn D, et al. Women, men and the new economics of marriage. Pew Research Center. 2010. 19. Harman JS, Edlund MJ, Fortney JC. Disparities in the adequacy of depression treatment in the United States. Psychiatric Services 2004; 55:1379–1385. 20. Harris K, Edlund M, Larson S. Racial and ethnic differences in mental health problems and use of mental health care. Medical Care 2005; 43:775–784. 21. Riva M, Bambra C, Easton S, et al. Hard times or good times? Inequalities in the health effects of economic change. International Journal of Public Health 2011; 56: 3–5.
The Journal of Behavioral Health Services & Research
2014
22. Trevino FM, Moyer ME, Valdez RB, et al. Health insurance coverage and utilization of health services by Mexican Americans, mainland Puerto Ricans, and Cuban Americans. The Journal of American Medical Association 1991; 265(2): 233-237. 23. Blendon R, Aiken L, Freeman H, et al. Access to medical care for black and white Americans. The Journal of American Medical Association 1989; 261(2): 278-281. 24. U.S. Bureau of Labor Statistics. The Recession of 2007-2009. 2012. Available online at http://www.bls.gov/spotlight/2012/recession/pdf/ recession_bls_spotlight.pdf. Accessed May 15, 2013. 25. The Commonwealth Fund. Realizing health reform’s potential: When unemployed means uninsured: the toll of job loss on health coverage, and how the Affordable Care Act will help. 2011. Available online at http://www.commonwealthfund.org/~/media/Files/ Publications/Issue%20Brief/2011/Aug/1540_Doty_when_unemployed_means_uninsured_COBRA_reform%20brief.pdf. Accessed May 15, 2013. 26. Holahan J. The 2007–09 recession and health insurance coverage. Health Affairs 2011; 30(1):145–152. 27. US Department of Health, Human Services. Mental health: A report of the surgeon general—executive summary. Rockville: US 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. 28. Jonghe F, Hendricksen M, Dekker J. Psychotherapy alone and combined with pharmacotherapy in the treatment of depression. Br J Psychiatry. 2004; 185: 37–45. 29. Norcross, C., Goldfried, M. Handbook of psychotherapy integration (clinical psychology). 2nd ed. New York, NY: Oxford University Press, 2005. 30. Lecrubier Y. The burden of depression and anxiety in general medicine. Journal of Clinical Psychiatry 2001; 62 (Suppl 8): 4-9. 31. Donohue JM, Pincus HA. Reducing the societal burden of depression: a review of economic costs, quality of care and effects of treatment. Pharmacoeconomics 2007; 25: 7-24. 32. Wang PS, Aguilar-Gaxiola S, Alonso J, et al. Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. Lancet 2007; 370: 841–850. 33. Cohen JW, Cohen SB, Banthin JS. The medical expenditure panel survey: a national information resource to support healthcare cost research and inform policy and practice. Medical Care 2009; 47(7 Suppl 1):S44–50. 34. Hall R, Feldstein M, Bernanke B, et al. The business-cycle peak of March 2001. National Bureau of Economic Research. Available online at http://www.nber.org/cycles/november2001/ Accessed Dec 14, 2013. 35. Cook BL, McGuire T, Miranda J. Measuring trends in mental health care disparities, 2000 2004. Psychiatric Services 2007; 58(12): 15331540. 36. Chen J, Rizzo J. Racial and ethnic disparities in psychotherapy services—evidence from U.S. national survey data. Psychiatric Services 2010; 61:364-372. 37. Ware JE, Kosinski M, Keller SD. A 12-item short-form health survey: Construction of scales and preliminary tests of reliability and validity. Medical Care 1996; 34:220. 38. Salyers MP, Bosworth HB, Swanson JW, et al. Reliability and validity of the SF-12 health survey among people with severe mental illness. Medical Care 2000; 38:1141-1150. 39. Cheak-Zamora NC, Wyrwich KW, McBride TD. Reliability and validity of the SF-12v2 in the medical expenditure panel survey. Quality of Life Research 2009; 18, 727-735. 40. Centers for Disease Control and Prevention. Non-specific Psychological Distress. 2013. Available online at http://www.cdc.gov/ mentalhealth/data_stats/nspd.htm. Accessed May 15, 2013. 41. Jones A. Health econometrics. In: Culyer AJ, Newhouse JP (Eds). Handbook of Health Economics. Amsterdam: Elsevier; 2000. 42. Zarkin GA, Bray JW, Babor TF, et al. Alcohol drinking patterns and health care utilization in a managed care organization. Health Services Research 2004; 39(3):553–570. 43. Center on Budget and Policy Priorities. Expanding Medicaid will benefit both low-income women and their babies. 2013. Available online at http://www.cbpp.org/files/Fact-Sheet-Impact-on-Women.pdf. Accessed Dec. 14, 2013 44. Kaiser Family Foundation. Medicaid medically needy enrollees by eligibility category. Available online at http://kff.org/medicaid/stateindicator/enrollment-by-eligibility-category/ Accessed Dec. 14, 2013 45. Chen J, Vargas-Bustamante A, Mortensen K, et al. Using quantile regression to examine health care expenditures during the Great Recession. Health Services Research 2013. doi: 10.1111/1475-6773.12113. [Epub ahead of print] 46. SAMHSA. Mental Health Parity and Addiction Equity Act. Available online at http://www.samhsa.gov/healthreform/parity/. Accessed May 15, 2013. 47. SAMHSA-HRSA Center for Integrated health solutions. Integrated care models. Available online at http://www.integration.samhsa.gov/ integrated-care-models. Accessed May 15, 2013. 48. Agency Healthcare Research and Quality. Integration of mental health/substance abuse and primary care. Available online at http:// www.ahrq.gov/research/findings/evidence-based-reports/mhsapc-evidence-report.pdf. Accessed May 15, 2013.
Mental Health Care during the Recession
Introduction According to the National Bureau of Economic Research, the Great Economic Recession of the USA 2007–2009 was marked by a significant decline in production and employment.1 The unemployment rate increased from 4.5% in 2006 to 9.5% in 2009.1 Substantial reductions in household income were observed during the same period.2 The impact of the economic recession on mental health care utilization is a double-edged sword. On one hand, the demand for mental health care increases substantially during economic hardships. The literature shows consistent adverse effects of job loss on the risk of depression and heavy drinking, and a moderate positive association between economic contraction and suicide and Address correspondence to Jie Chen, PhD, Department of Health Services Administration, School of Public Health, University of Maryland, 3310A School of Public Health Building, College Park, MD 20742-2611, USA. Phone: +1-3014059053; Fax: +1-301-4052542; Email: [email protected]. Rada Dagher, PhD, Department of Health Services Administration, School of Public Health, University of Maryland, 3310B School of Public Health Building, College Park, MD, 20742-2611, USA. Phone: +1-301-4051210; Email: [email protected]
)
Journal of Behavioral Health Services & Research, 2014. 1–12. c 2014 National Council for Behavioral Health. DOI 10.1007/s11414-014-9403-1
Mental Health Care during the Recession
antisocial behavior.3 Meanwhile, economic hardship can also result in perceptions of insecurity and stress, and an increase in the risk of mental disorders4,5 and mental health care utilization.6–9 On the other hand, mental health coverage deteriorates during the same time. State and local governments are likely to cut back mental health care coverage during the recession budget cuts. The loss of employment-based private health insurance adds another barrier to have mental health care. A recent report shows that the annual spending on mental health care by private health insurance decreased from 7.0% in 2004–2007 to 2.1% in 2007–2009.10 Mental health care utilization patterns might differ by gender during the economic recession. In general, the literature shows that females have higher medical care utilization rates than males in a variety of health services (primary care, specialty care, emergency treatment, etc.),11,12 including mental health care utilization.13 Lower rates of mental health treatment among men compared to women is a consistent finding in the literature.14,15 This is possibly due to a greater perceived stigma of seeking mental health care among men in comparison with women and greater ability among women than men to identify nonspecific feelings of distress and recognize the presence of a mental health problem.16,17 In addition, the Great Economic Recession caused disproportionately more job losses for males than for females because more jobs were lost in the construction and manufacturing sectors than in the service sector.18 Thus, it is likely that males were more likely than females to encounter barriers to mental health care during the recession. It has been well documented that African Americans and Latinos have worse access to mental health services than whites.19,20 During the recent economic recession, racial/ethnic minorities experienced more job losses and housing foreclosures, and hence, were exposed to a higher likelihood of losses in health insurance coverage and reductions in wealth.21–23 Inflation-adjusted median wealth fell 66% among Latino households, 53% among African American households, and 16% among white households.2 Unemployment rates were also higher among African Americans and Latinos than whites, with 25% of African Americans and Latinos losing their jobs during 2008 and 2010, compared to 15% of whites.24,25 Thus, racial and ethnic minorities may have encountered more access barriers to mental health care during the Great Recession. This study examines the utilization of two major cost-effective treatments for depressive and anxiety disorders, prescription drug utilization and physician office visits,26–28 during the recent economic recession 2007–2009 in the USA. Depression and anxiety are two highly prevalent mental disorders that are often comorbid and cause substantial disability if not treated.29 Moreover, both disorders are associated with increased health care expenditures and high economic costs to society.30,31These mental disorders are highly undertreated in the USA due to poor health insurance coverage and financial barriers.32 This study adds to the literature on the relationship between economic downturns and mental health by examining the different associations of the 2007–2009 economic recession and mental health care utilization by gender and race/ethnicity. The hypotheses are (1) gender disparities in the utilization of mental health care during the recession may have increased and (2) racial/ethnic disparities in the utilization of mental health care may also have increased during the recession.
Methods Data This study uses the nationally representative dataset of Medical Expenditure Panel Survey (MEPS) of 2000–2009.32 The MEPS has several sub-files. The MEPS consolidated file contains detailed information on patients’ demographics and socioeconomic characteristics. The MEPS medical condition files collect data on respondents’ chronic diseases and the associated health care utilization for each of these diseases. The medical condition files provide synthesized data from different MEPS sub-files including drug utilization and physician visits for each primary disease
The Journal of Behavioral Health Services & Research
2014
reported by the respondent. The prescription drugs identified in this study include antidepressants, anti-anxiety medications, and psychotropic medications that are used to treat depressive and anxiety disorders. Physician visits are also calculated if patients visit the physicians to treat depression or anxiety as their primary disorder. Chronic diseases are self-reported by the patients, and then are coded by professional coders to fully specified International Classification of Diseases, 9th Revision ( ICD9) codes. As documented in the MEPS, medical providers and pharmacies are contacted to validate data on ICD9 codes and services the respondents have used. The MEPS medical condition files are linked to the consolidated files to get comprehensive information on patients’ demographics (e.g., gender, race/ ethnicity) and socioeconomic status (e.g. education, income). This dataset enables the authors to identify patients who were primarily diagnosed with depressive (ICD9=311) or anxiety (ICD9=300) disorders, and observe the corresponding prescription drug utilization and physician visits specific to depression and anxiety treatment during the survey years. The outcome variables are the annual utilization of prescription drugs and physician visits that treat primary depressive and anxiety disorders. The analyses include adults aged 18 to 64 years old, who are diagnosed with depressive or anxiety disorders as the primary disorders. The sample of females totals 16,482, including 11,569 non-Hispanic whites (whites), 2,943 Latinos, and 1,970 non-Hispanic African Americans (African Americans), and the sample of males totals to 6,835, including 5,164 whites, 1,068 Latinos, and 603 African Americans.
Independent variables Recession year indicators The objective of this study is to examine the changes in mental health care utilization during the Great Economic Recession 2007–2009. The longitudinal survey years from 2000–2009 provide the analysis capacity to observe the trends of utilization during the last decade. It is worth noting that in the past decade, there was another economic recession in 2001 (from March 2001 to November 2001) in the USA.33 The duration of the 2001 recession was short, and the consequences were relatively mild (e.g. the unemployment rate was 4%–6% during 2001 recession) compared to the recent Great Recession. Nevertheless, it is also interesting to see the changes of utilization by gender and race/ethnicity during the 2001 recession. Hence, the authors consider 2001, 2007, 2008, and 2009 as the recession years and construct the interaction terms of each of these recession years with race and ethnicity. The interaction terms are included to examine the different utilization patterns among the races and ethnicities during the recessions. To capture the gender differences, the analyses examine mental health care utilization for females and males separately. Other covariates The analyses comprise a number of independent variables that are associated with mental health care utilization.34,35 These variables include respondents’ age, marital status (married or not), educational attainment (no high school degree, high school degree, college degree, advanced degree), family income (less than 100% federal poverty line (FPL), 100%–200% FPL, more than 200% FPL), health insurance coverage (no health insurance coverage, public health insurance, private health insurance), health care access (having a usual source of care), employment status (employed, unemployed), Metropolitan Statistics Area (urban, rural), and US Census Region (North East, Midwest, South, West). Health outcome measures are controlled as proxies to the severity of mental health status. These variables include self-reported physical health (excellent/very good, good, fair/poor), self-reported mental health (excellent/very good, good, fair/poor), and the SF short-form 12 (SF12): physical component summary (PCS) and mental component summary (MCS) scores.36–38 These measures are considered as valid instruments for measuring health-related quality of life and mental health status, and have been widely adopted in the literature.39
Mental Health Care during the Recession
Analysis The study first presents the trends of utilization of prescription drugs and physician visits among patients with depression and anxiety using nationally representative statistics from 2000–2009. These statistics are calculated and weighted using the sampling weights provided by the MEPS. Authors then show the sample summary statistics by gender and race/ethnicity. Means tests are conducted to compare the racial and ethnic differences in each covariate by gender, with whites as the reference group. Negative binomial models are used to estimate the association between the economic recession and mental health care utilization.40,41 The model specification is as follows: Number of prescription drugs used ¼ f β 0 þ β 1 Latino þ β 2 African American þ β 3 year indicator þ β 4 Latino* Recession Year Indicator þ β 5 African American*Recession Year Indicator þ β 6 X Þ where f() represents the negative binomial function. X includes other demographic and socioeconomic variables. βs represent the coefficients to be estimated in the model. The above model is estimated separately by gender. The incidence rate ratios (IRRs) are reported from the negative binomial regressions. The IRRs indicate the estimated incidence ratio relative to its reference group. The same model specification is used to examine the association of the economic recessions with physician visits that treat mental disorders. Finally, based on the negative binomial models, the frequency of prescription drug utilization and physician visits are estimated by gender and race/ethnicity across the years, adjusted by all the other covariates. All regressions are adjusted for sampling weights provided in the MEPS to ensure that the results are nationally representative. All statistical analyses are conducted using Stata 12.
Results Table 1 presents the trends of utilization of prescription drugs and physician visits from 2000 to 2009 by gender and race/ethnicity. The prescription drug utilization increased in the recession years 2007–2009 among white females, Latinas, and white males. The rates of prescription drug utilization among African American females and males decreased in 2008 and 2009 compared to survey years before the Great Recession. African American females had relatively high rates of prescription drug utilization in 2007 compared to any other survey year. The prescription drug utilization of Latino males was lower in 2007–2009 compared to 2005. The rates of prescription drug utilization were generally lower in 2001 compared to the years preceding or after the 2001 economic recession, except among Latino males. The differences between whites versus Latinos were more pronounced compared to the differences between whites versus African Americans. Racial and ethnic disparities were also more pronounced among females compared to males. Compared to 2005–2006, statistics show that the utilization of physician visits was relatively higher in 2007–2008 among whites and Latinos. African Americans (both males and females) had lower rates of physician visits during 2007. Trends of physician visits were relatively similar across race and ethnicity. The only racial difference was observed in 2008 and 2001, with African Americans (both females and males) using significantly fewer physician visits compared to whites. Table 2 presents the sample summary statistics of patients diagnosed with depressive and anxiety disorders by gender and race/ethnicity. Compared to white females, Latinas and African American females reported worse physical and mental health, lower education, and family income, and were more likely to be uninsured. Similar trends were observed among males. Table 3 presents the results of the negative binomial regressions, treating the count of prescription drug utilization and physicians visits as the outcome variables separately. Compared to white females, Latinas and African American females used significantly fewer prescription drugs (IRR=0.75, pG0.001; IRR=0.71, pG0.001), and African American females had significantly fewer
The Journal of Behavioral Health Services & Research
2014
Table 1 Prescription drug utilization and physician visits among patients with depression and/or anxiety by gender and race/ethnicity from 2000–2009 Prescription drug utilization Females
Males
Whites
Latinos
African Americans
Whites
Latinos
African Americans
2000 1.82 2001 1.83 2002 1.88 2003 1.84 2004 1.82 2005 1.86 2006 1.92 2007 1.95 2008 2.24 2009 2.21 Physician visits 2000 2.72 2001 2.97 2002 3.02 2003 3.16 2004 2.48 2005 2.49 2006 2.32 2007 2.76 2008 3.91 2009 3.01
1.29* 1.22*** 1.25*** 1.24*** 1.24*** 1.43** 1.31*** 1.44*** 1.57*** 1.73**
1.23* 1.26** 1.43* 1.34** 1.42* 1.85 1.67 1.99 1.38*** 1.53***
1.82 1.57 1.60 1.61 1.71 1.68 1.65 1.72 2.07 2.02
0.87*** 1.15 0.94*** 1.02** 1.13** 1.59 1.00*** 0.82*** 1.16*** 1.23***
1.67 1.14 1.25 1.74 1.51 1.56 1.61 1.13 1.04*** 1.42*
2.55 2.26 2.71 2.57 3.37 3.01 3.05 2.03 2.77 3.50
1.58 2.15 2.09 2.68 3.65 3.49 2.74 3.03 1.74** 2.87
3.32 3.86 2.43 2.81 2.79 3.74 2.88 2.19 2.41 1.87
5.49 2.58 2.46 2.31 1.95 3.11 2.72 2.90 3.11 2.44
3.48 0.87*** 1.32* 3.51 1.97 2.73 2.67 2.34 0.87*** 1.36
Estimates are nationally representative by adjusting the sampling weights provided by the Medical Expenditure Panel Survey ***pG0.001; **pG0.01; *pG0.05, the reference groups are the White females/males in each survey year
physician visits (IRR=0.71, p=0.01). Compared to white males, Latino males had significantly lower rates of prescription drug utilization (IRR=0.72, pG0.001) and physician visits (IRR=0.72, pG0.05). Year indicators show that prescription drug utilization of females was stable from 2000–2007, but increased significantly in 2008 (IRRs=1.20, pG0.001) and 2009 (IRRs=1.20, pG0.001). Physician visits among females demonstrated a similar trend. Year indicators are generally not significant in the regressions among the male population. Results show that only males had significantly lower physician visits in 2009 (IRR=0.55, pG0.001). The interaction terms between the recession year indicators and races/ethnicities among females show that compared to white females, African American females used more prescription drugs in 2007 (IRR=1.26, pG0.05) and fewer physician visits in 2008 (IRR=0.54, pG0.05). The interaction terms between the recession year indicators and races/ethnicities of males indicate that African American males utilized fewer prescription drugs in 2008 (IRR=0.61, pG0.05), and fewer physician visits in 2008 (IRR=0.42, pG0.05) and 2001 (IRR=0.28, pG0.001).
Mental Health Care during the Recession
Table 2 Sample summary statistics of patients with depression and/or anxiety by gender and race/ethnicity Females
Males
Whites
Latinos
African Americans
Whites
Latinos
African Americans
n=12,639
n=3,207
n=2,227
n=5,679
n=1,173
n=673
Mean
Mean
Mean
Mean
Mean
Mean
0.08* 0.22*** 0.27** 0.27*** 0.17*** 0.46***
0.07 0.18 0.23 0.32 0.21* 0.20***
0.08 0.14 0.23 0.29 0.25 0.51
0.13*** 0.19*** 0.25 0.26 0.17*** 0.47*
0.10 0.14 0.23 0.31 0.22* 0.33***
0.43*** 0.30 0.28***
0.45*** 0.29 0.26***
0.33 0.30 0.37
0.38*** 0.28 0.34**
0.45*** 0.28 0.27***
0.31*** 0.34** 0.35*** 0.45** 0.40***
0.37*** 0.30*** 0.32*** 0.42*** 0.39***
0.29 0.34 0.37 0.46 0.41
0.33** 0.33 0.34 0.46 0.41
0.40*** 0.29** 0.31** 0.43*** 0.41
0.52*** 0.32*** 0.07*** 0.09***
0.33*** 0.48 0.07*** 0.12***
0.22 0.46 0.15 0.16
0.50*** 0.39*** 0.06*** 0.05***
0.32*** 0.48 0.09*** 0.11***
0.33***
0.42***
0.16
0.26***
0.34***
0.31*** 0.35*** 0.46*** 0.80***
0.26*** 0.32*** 0.48*** 0.86***
0.19 0.65 0.30 0.85
0.29*** 0.44*** 0.34*** 0.72***
0.26*** 0.40*** 0.53*** 0.83
0.25*** 0.38*** 0.37*** 0.90***
0.12*** 0.41*** 0.47*** 0.84***
0.14 0.66 0.19 0.77
0.28*** 0.43*** 0.29*** 0.92***
0.16 0.42*** 0.41*** 0.87***
0.17*** 0.08*** 0.30*** 0.45***
0.14*** 0.21*** 0.55*** 0.10***
0.16 0.27 0.35 0.21
0.16 0.08*** 0.29*** 0.47***
0.13* 0.21*** 0.53*** 0.13***
Age 18–24 0.08 25–34 0.16 35–44 0.24 45–54 0.29 55–64 0.23 Married 0.48 Self-reported health status Poor/Fair 0.30 Good 0.30 Very good/excellent 0.40 Self-reported mental health status Poor/Fair 0.25 Good 0.36 Very good/excellent 0.39 SF12-PCS 0.46 SF12-MCS 0.41 Education No high school degree 0.20 High school degree 0.48 College degree 0.14 Advanced degree 0.18 Family income G100% Federal poverty 0.19 line (FPL) 100%–200% FPL 0.18 9200% FPL 0.63 Unemployed 0.33 Having usual source of care 0.90 Health insurance Uninsured 0.10 Private health insurance 0.69 Public health insurance 0.21 Urban 0.76 US region Northeast 0.15 Midwest 0.28 South 0.37 West 0.21
***pG0.001; **pG0.01; *pG0.05, the reference groups are the White females/males
The Journal of Behavioral Health Services & Research
2014
Table 3 also shows significant associations between other covariates and physician visits and prescription drug utilization for mental disorders. Particularly, age, education, family income, health care access, and insurance coverage were positively associated with mental health care utilization. Based on the negative binomial regression models, the authors estimate the association between the recession year indicators 2007–2009 and the utilization of prescription drugs and physician visits, adjusting for all the other covariates. Figure 1 shows the overall increasing trends in prescription drug utilization during the recent recession by gender and race/ethnicity. Results show that during the 2007–2009 recession, prescription drug utilization for mental disorders increased by 11% among females (increased from 1.91 to 2.12 for white females, 1.44 to 1.60 for Latinas, and 1.35 to 1.50 for African American females), and 8%–9% among males (increased from 1.71 to 1.85 for white males, 1.24 to 1.35 for Latino males, and 1.29 to 1.40 for African American males), after controlling for all the covariates. Figure 2 shows the estimated frequency of physician visits, after adjusting for all the covariates. Females and males of all racial and ethnic groups had lower rates of physician visits during the recession. The model estimates that physician visits decreased by 7%–8% among females (decreased from 3.06 to 2.85 for white females, 2.65 to 2.45 for Latinas, and 2.21 to 1.96 for African American females) and decreased by 25% among males (decreased from 3.06 to 2.31 for white males, 2.9 to 2.17 for Latino males, and 2.22 to 1.66 for African American males).
Discussion This study shows mixed evidence of utilization patterns of prescription drugs and physician visits by gender. Females had a greater increase in prescription drugs utilization, and males had a greater reduction in physician visits during the Great Recession. The sample size of females who had been diagnosed with depression or anxiety is almost three times the size of males. The female and male populations are similar in the general populations in the USA. The disproportionately high ratio of females in the sample may indicate gender differences in healthcare-seeking behavior, particularly in mental health care possibly because of the greater stigma of seeking mental health care among males and the greater ability of females to identify their mental health problems.16,17 Meanwhile, increased utilization among females during the recession might reflect their worse mental health status and higher demand for mental health care, due to job insecurity or stress during the economic recession.4,5 Since males are more likely to lose jobs in the recession compared to females18, one would expect that males are more likely to experience mental health problems and have high demand for mental health care. However, this study shows lower physician visits among males during the Great Recession. The following reasons are speculated. Males are more likely to take the financial responsibility of the family, and sacrifice physician visits to save money. The difference in physician visits can also be explained by gender differences in health care-seeking behaviors, particularly for mental health services for the reasons discussed earlier. Gender differences in health insurance coverage may also contribute to the gender differences in utilization. The results show that the rate of being uninsured is 3%–4% points higher, and the rate of being covered by public health insurance is 2%–8% points lower among males compared to females. The lack of health insurance coverage among male populations with depressive and anxiety disorders can be an important barrier for them to access health care, especially during the recession. It is worth noting that there is substantial variation in state Medicaid coverage of mental health care, and the levels of benefits by gender vary widely. For example, Medicaid typically covers only low-income pregnant women and their children and women’s coverage usually ends 6 weeks after delivery.42 Some states have a “medically needy” category that could include men, but the FPL is usually 50% or less, which excludes many men.43
Mental Health Care during the Recession
Table 3 Negative binomial results of differences in prescription drug use and physician visits before and during the recession by gender and race/ethnicity Females Prescription drug use IRR Whites Latinos African Americans Age 18–24 25–34 35–44 45–54 55–64 Married Self-reported health status Poor/fair Good Very good/excellent Self-reported mental health status Poor/fair Good Very good/excellent SF12-PCS SF12-MCS Education No high school degree High school degree College degree Advanced degree Family income G100% federal poverty line (FPL) 100–200% FPL 9200% FPL Unemployed Having usual source of care Health insurance Uninsured Private health insurance Public health insurance Urban US region North East Midwest South
P
Males Physician visits IRR
P
Prescription drug use IRR
P
Physician visits IRR
P
Reference 0.75 0.00 0.71 0.00
Reference 1.01 0.89 0.71 0.01
Reference 0.72 0.00 0.84 0.08
Reference 0.72 0.04 0.87 0.52
Reference 1.37 0.00 1.66 0.00 1.80 0.00 1.81 0.00 0.96 0.17
Reference 1.22 0.11 1.20 0.17 1.21 0.12 1.08 0.53 0.71 0.00
Reference 1.31 0.02 1.45 0.00 1.45 0.00 1.51 0.00 1.08 0.07
Reference 1.32 0.13 1.10 0.59 0.99 0.97 0.92 0.63 0.66 0.00
Reference 0.99 0.84 1.02 0.54
Reference 0.94 0.43 1.19 0.06
Reference 1.05 0.38 1.09 0.18
Reference 1.07 0.63 1.25 0.14
Reference 0.83 0.00 0.69 0.00 0.83 0.09 0.37 0.00
Reference 0.56 0.00 0.35 0.00 1.11 0.75 0.05 0.00
Reference 0.76 0.00 0.65 0.00 0.90 0.60 0.47 0.00
Reference 0.56 0.00 0.33 0.00 0.81 0.63 0.05 0.00
Reference 1.07 0.03 1.16 0.00 1.07 0.07
Reference 1.17 0.02 2.17 0.00 1.98 0.00
Reference 1.08 0.14 1.02 0.74 1.13 0.09
Reference 1.01 0.96 1.16 0.32 1.54 0.02
Reference 1.08 0.02 1.19 0.00 1.17 0.00 1.54 0.00
Reference 0.94 0.48 1.06 0.52 1.45 0.00 1.37 0.00
Reference 1.02 0.82 1.06 0.42 1.21 0.00 1.80 0.00
Reference 0.82 0.14 1.07 0.60 1.25 0.04 1.65 0.00
Reference 1.33 0.00 1.53 0.00 0.99 0.75
Reference 1.22 0.06 1.63 0.00 1.54 0.00
Reference 1.28 0.00 1.42 0.00 1.07 0.11
Reference 1.21 0.19 1.62 0.00 1.68 0.00
Reference 1.01 0.83 1.04 0.24
Reference 0.76 0.00 0.69 0.00
Reference 1.04 0.58 1.10 0.10
Reference 0.83 0.18 0.84 0.26
The Journal of Behavioral Health Services & Research
2014
Table 3 (continued) Females Prescription drug use
West Year indicator 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Interaction terms Latino * 2001 Latino * 2007 Latino * 2008 Latino * 2009 African American African American African American African American Constant
* * * *
2001 2007 2008 2009
Males Physician visits
Prescription drug use
Physician visits
IRR
P
IRR
P
IRR
P
IRR
P
0.88
0.00
0.74
0.00
0.87
0.04
0.73
0.02
Reference 1.02 0.71 1.02 0.73 0.99 0.87 1.02 0.72 1.05 0.34 1.05 0.33 1.07 0.23 1.20 0.00 1.20 0.00
Reference 1.17 0.17 1.10 0.37 1.10 0.44 1.01 0.91 1.05 0.67 0.94 0.60 0.94 0.68 1.28 0.05 1.03 0.83
Reference 0.88 0.22 0.90 0.26 0.94 0.51 0.98 0.79 0.99 0.87 0.91 0.30 0.98 0.79 1.13 0.19 1.11 0.25
Reference 1.05 0.82 0.83 0.35 0.88 0.55 0.79 0.24 1.12 0.62 0.89 0.59 0.66 0.06 0.74 0.16 0.55 0.00
0.98 1.07 1.01 1.06 0.88 1.26 0.83 0.90 0.89
0.80 0.70 0.69 0.86 0.81 1.19 0.54 1.22 4.13
1.15 0.80 0.92 1.00 0.82 0.75 0.61 0.74 0.78
1.15 1.67 2.13 2.16 0.28 0.79 0.42 0.71 6.54
0.83 0.50 0.90 0.52 0.40 0.04 0.12 0.35 0.28
0.25 0.12 0.10 0.48 0.45 0.41 0.03 0.49 0.00
0.39 0.19 0.66 0.98 0.42 0.36 0.03 0.15 0.19
0.64 0.08 0.07 0.12 0.00 0.51 0.02 0.37 0.00
The IRRs indicate the estimated incident ratio relative to its reference group. For example, the IRR of the variable “Latino” in the female regression is 0.75. It indicates that Latinas had a rate of 0.75 times fewer prescription drugs used compared to Whites, holding other variables constant
The overall trends of the estimates show increased utilization of prescription drugs and decreased physician visits during the same time period. Physician visits and prescription drugs are usually considered as complementary goods, i.e., patients receive prescription drugs from physician visits, and thus, increase the utilization of prescription drugs reflect increased physician visits. The negative relationship between prescription drug utilization and physician visits during the economic recession may indicate that physician visits and prescription drugs are more likely to be substitutes to each other, due to the higher prices and limited budgets people face. Patients need to make choices between these two services, and may end up using the services with lower payments, i.e., prescription drugs. Since the sample in this study includes populations who have been diagnosed with depression and anxiety already, these patients may likely resort to prescription drug utilization (using refills, for example), without consulting physicians. Future research is needed to estimate the relationship between physician visits and prescription drug utilization during the economic recession.
Mental Health Care during the Recession
Figure 1 Estimated frequency of prescription drug utilization among patients with depression and/or anxiety by gender and race/ethnicity before and during the Great Recession 2.5
2
2.12 1.91
1.85 1.71
1.6 1.44
1.5
1.5 1.35 1.24
1.35
1.29
1.4
before 2007
1
2007-2009 0.5
0 Whites
Latinos
African Amercians
Whites
Females
Latinos
African Amercians
Males
This study shows that racial and ethnic minorities might have faced more barriers to access to mental health care during the Great Recession. Both male and female African Americans had a reduction in physician visits. African American males also had a more significant reduction in prescription drugs, while African American females had an increase in prescription drugs during the recession years of 2007 and 2008. Latinos, on the other hand, faced a modest change in mental health care utilization compared to whites. These findings are consistent with previous literature, which shows that racial and ethnic minorities experienced poorer access to health care than whites before the Great Recession and that access may have worsened during the recession.44 However,
Figure 2 Estimated frequency of physician visits among patients with depression and/or anxiety by gender and race/ethnicity before and during the Great Recession 3.5 3
3.06 2.85
2.5
3.09 2.65 2.45 2.1
2.31 1.96
2.9 2.17
2
2.22 1.66
1.5
before 2007
1
2007-2009
0.5 0 Whites
Latinos
Females
African Amercians
Whites
Latinos
African Amercians
Males
The Journal of Behavioral Health Services & Research
2014
the analysis can only identify patients with diagnosed depression and anxiety. Since mental disorders are generally under treated and under diagnosed, the racial/ethnic differences may be more substantial when taking into account mental disorders other than depression and anxiety. The results also show that compared to private health insurance, having public health insurance, such as Medicaid or other local/state-funded insurance, is associated with higher mental health care use, particularly physician visits. Recent estimates show a significant reduction in mental health spending by the private sector during the economic recession.8 More importantly, the annual growth rate of out-of-pocket payments on mental health care dropped from 6.7% to 0.2% during the same period.10 Although it is likely that patients might have switched from brand name drugs to generics, the substantial reduction in growth rates might also reflect the reduced utilization and/ or unaffordability of mental health care under private health insurance coverage. Factors associated with increased drug utilization and physician visits differed by gender. These findings indicate that strategies to improve treatment adherence may work differently by gender. For example, results show that higher family income is associated with higher prescription drug utilization for females, but not males. In addition, years of schooling are more likely to increase prescription drug utilization and physician visits for females, but not for males. It is likely that the strategies of improving treatment adherence by improving health literacy may work better among females. Financial subsidies to improve mental health care access may also work better among females. On the other hand, strategies focusing on reducing the stigma associated with mental health care utilization or accommodating cultural background may work better among males. This study has several important limitations. First, the association of the economic recession with mental health care utilization may have been underestimated. The utilization of mental health care is only observed among the patients diagnosed with primary depressive or anxiety disorders. Mental health care utilization is not calculated if the respondents had depressive or anxiety as secondary disorders. Moreover, this study uses 3-digit ICD9 codes to categorize the diseases. More specific ICD9 codes can work better to match the mental health condition with mental health care utilization. Second, mental health care utilization is patient self-reported, so there might be recall bias. However, these reports of mental health care utilization have been further validated by patients’ doctors and pharmacists. Third, this study examines two of the most cost effective and most common treatments of depression and anxiety. Alternative forms of care, such as hospital utilization, consultation with friends, looking for religious help, may increase during the recession. The authors are also not able to specify the location of the physician office. It is likely that the visits increased at the federally qualified health centers and free clinics during the recession. Fourth, given the data limitation, this study is not able to tell the generic/brand name status of the prescription drug. It is likely that increased prescription drug utilization is due to switching from brand name drugs to generics. Fourth, to capture the severity of mental disorders, the authors control for four mental and physical health measures in the analyses: self-reported mental health status, self-reported physical health status, SF12-MCS score, and SF12-PCS score. But it is likely that the severity of the mental disorders or other comorbidities associated with mental disorders was not fully captured. Fifth, given the MEPS survey design, the authors are not able to conduct a longitudinal analysis. Thus, it is difficult to derive the causal relationship of the economic recession and mental health care use. It is likely that the trends of prescription drug use and physician visits during 2007–2009 were due to other unobserved factors, such as the policy variation by geographic area. It will be interesting to see the impact of the economic recession on long term mental health outcomes.
Implications for Behavioral Health The Affordable Care Act (ACA) will improve mental health care coverage through the expansion of Medicaid or increased provision of private health insurance, and function as a safety
Mental Health Care during the Recession
net for people with mental health disorders. Implementation of the health insurance exchanges or marketplace will provide opportunities for people who have no employer-sponsored insurance and earn above the Medicaid eligibility line to purchase health insurance at more affordable rates than those charged by the private health insurance market. States that plan to expand Medicaid will make mental health care coverage available to both males and females if they meet eligibility criteria. Hence, the gender differences potentially can be reduced by the ACA. However, not every state will expand Medicaid eligibility, and the states that are not planning to expand Medicaid typically have higher proportions of poor and uninsured adults (e.g., in the Southeast of the USA). In addition to the ACA, the increased availability of generic psychiatric drugs45 and the recently implemented law of the Mental Health Parity and Addiction Equity Act46 have the potential to facilitate access to prescription drugs. The integrated care of mental health treatment advocated in recent years has been considered as one of the core clinical features to improve mental health.47 Under the integrated care model, patients will be more likely to receive effective treatment for mental disorders.48 Future research should examine the impact of these policies on mental health care and should separately examine mental health care utilization by gender and race/ethnicity. Conflict of Interest The authors declare no conflict of interest.
References 1. U.S. Bureau of Labor Statistics. The recession of 2007–2009. Available online at http://www.bls.gov/spotlight/2012/recession/pdf/ recession_bls_spotlight.pdf. Accessed May 15, 2013. 2. Kochhar R, Fry R, Taylor P. Twenty-to-one: health gaps rise to record highs between whites, blacks and Hispanics. Pew Research Center, 2011. Available online at http://www.pewsocialtrends.org/files/2011/07/SDT-Wealth-Report_7-26-11_FINAL.pdf. Accessed May 15, 2013. 3. Goldman-Mellor S, Saxton K, Catalano R. Economic contraction and mental health: A review of the evidence, 1990–2009. Internal Journal of Mental Health 2010; 39(2): 6-31. 4. Tausig M, Fenwick R. Recession and well-being. Journal of Health & Social Behavior 1999; 40: 1-16. 5. Viinamaki H, Koskela K, Niskanen L. Rapidly declining mental wellbeing during unemployment. European Psychiatry 1996; 10: 215221. 6. Catalano R. The health effects of economic insecurity. American Journal of Public Health 1991; 81(9): 1148-1152. 7. Rugulies R, Thielen K, Nygaard E, et al. Job insecurity and the use of antidepressant medication among Danish employees with and without a history of prolonged unemployment: A 3.5-year follow-up study. Journal of Epidemiology & Community Health 2010; 64: 75–81. 8. Catalano R. Health, medical care, and economic crisis. New England Journal of Medicine 2009; 360(8):749-51. 9. Catalano R, Goldman-Mellor S, Saxton K, et al. The health effects of economic decline. Annual Review of Public Health 2011; 32: 431-50. 10. Levit KR, Mark TL, Coffey RM, et al. Federal spending on behavioral health accelerated during recession as individuals lost employer insurance. Health Affairs 2013; 32: 952–962. 11. Bertakis K, Azari R, Helms L, et al. Gender differences in the utilization of health care services. Journal of Family Practice 2000; 49(2): 147-152. 12. Owens, GM. Gender differences in health care expenditures, resource utilization, and quality of care. Journal of Managed Care Pharmacy 2008; 14(3) (Suppl S): S2-S6. 13. Olfson M, Marcus SC, Druss B, et al. National trends in the outpatient treatment of depression. The Journal of American Medical Association 2002; 287(2):203–209. 14. Kessler RC, Zhao S, Katz SJ, et al. Past year use of outpatient services for psychiatric problems in the National Comorbidity Survey. American Journal of Psychiatry 1999; 156: 115- 123. 15. 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. Archives of General Psychiatry 1993; 50(2):85–94. 16. Williams JB, Spitzer RL, Linzer M, et al. Gender differences in depression in primary care. American Journal of Obstetrics & Gynecology 1995; 173: 654- 659. 17. Kessler RC, Brown RL, Broman CL. Sex differences in psychiatric help-seeking: evidence from four large-scale surveys. Journal of Health and Social Behavior 1981; 22: 49- 64. 18. Taylor P, Fry R, Cohn D, et al. Women, men and the new economics of marriage. Pew Research Center. 2010. 19. Harman JS, Edlund MJ, Fortney JC. Disparities in the adequacy of depression treatment in the United States. Psychiatric Services 2004; 55:1379–1385. 20. Harris K, Edlund M, Larson S. Racial and ethnic differences in mental health problems and use of mental health care. Medical Care 2005; 43:775–784. 21. Riva M, Bambra C, Easton S, et al. Hard times or good times? Inequalities in the health effects of economic change. International Journal of Public Health 2011; 56: 3–5.
The Journal of Behavioral Health Services & Research
2014
22. Trevino FM, Moyer ME, Valdez RB, et al. Health insurance coverage and utilization of health services by Mexican Americans, mainland Puerto Ricans, and Cuban Americans. The Journal of American Medical Association 1991; 265(2): 233-237. 23. Blendon R, Aiken L, Freeman H, et al. Access to medical care for black and white Americans. The Journal of American Medical Association 1989; 261(2): 278-281. 24. U.S. Bureau of Labor Statistics. The Recession of 2007-2009. 2012. Available online at http://www.bls.gov/spotlight/2012/recession/pdf/ recession_bls_spotlight.pdf. Accessed May 15, 2013. 25. The Commonwealth Fund. Realizing health reform’s potential: When unemployed means uninsured: the toll of job loss on health coverage, and how the Affordable Care Act will help. 2011. Available online at http://www.commonwealthfund.org/~/media/Files/ Publications/Issue%20Brief/2011/Aug/1540_Doty_when_unemployed_means_uninsured_COBRA_reform%20brief.pdf. Accessed May 15, 2013. 26. Holahan J. The 2007–09 recession and health insurance coverage. Health Affairs 2011; 30(1):145–152. 27. US Department of Health, Human Services. Mental health: A report of the surgeon general—executive summary. Rockville: US 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. 28. Jonghe F, Hendricksen M, Dekker J. Psychotherapy alone and combined with pharmacotherapy in the treatment of depression. Br J Psychiatry. 2004; 185: 37–45. 29. Norcross, C., Goldfried, M. Handbook of psychotherapy integration (clinical psychology). 2nd ed. New York, NY: Oxford University Press, 2005. 30. Lecrubier Y. The burden of depression and anxiety in general medicine. Journal of Clinical Psychiatry 2001; 62 (Suppl 8): 4-9. 31. Donohue JM, Pincus HA. Reducing the societal burden of depression: a review of economic costs, quality of care and effects of treatment. Pharmacoeconomics 2007; 25: 7-24. 32. Wang PS, Aguilar-Gaxiola S, Alonso J, et al. Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. Lancet 2007; 370: 841–850. 33. Cohen JW, Cohen SB, Banthin JS. The medical expenditure panel survey: a national information resource to support healthcare cost research and inform policy and practice. Medical Care 2009; 47(7 Suppl 1):S44–50. 34. Hall R, Feldstein M, Bernanke B, et al. The business-cycle peak of March 2001. National Bureau of Economic Research. Available online at http://www.nber.org/cycles/november2001/ Accessed Dec 14, 2013. 35. Cook BL, McGuire T, Miranda J. Measuring trends in mental health care disparities, 2000 2004. Psychiatric Services 2007; 58(12): 15331540. 36. Chen J, Rizzo J. Racial and ethnic disparities in psychotherapy services—evidence from U.S. national survey data. Psychiatric Services 2010; 61:364-372. 37. Ware JE, Kosinski M, Keller SD. A 12-item short-form health survey: Construction of scales and preliminary tests of reliability and validity. Medical Care 1996; 34:220. 38. Salyers MP, Bosworth HB, Swanson JW, et al. Reliability and validity of the SF-12 health survey among people with severe mental illness. Medical Care 2000; 38:1141-1150. 39. Cheak-Zamora NC, Wyrwich KW, McBride TD. Reliability and validity of the SF-12v2 in the medical expenditure panel survey. Quality of Life Research 2009; 18, 727-735. 40. Centers for Disease Control and Prevention. Non-specific Psychological Distress. 2013. Available online at http://www.cdc.gov/ mentalhealth/data_stats/nspd.htm. Accessed May 15, 2013. 41. Jones A. Health econometrics. In: Culyer AJ, Newhouse JP (Eds). Handbook of Health Economics. Amsterdam: Elsevier; 2000. 42. Zarkin GA, Bray JW, Babor TF, et al. Alcohol drinking patterns and health care utilization in a managed care organization. Health Services Research 2004; 39(3):553–570. 43. Center on Budget and Policy Priorities. Expanding Medicaid will benefit both low-income women and their babies. 2013. Available online at http://www.cbpp.org/files/Fact-Sheet-Impact-on-Women.pdf. Accessed Dec. 14, 2013 44. Kaiser Family Foundation. Medicaid medically needy enrollees by eligibility category. Available online at http://kff.org/medicaid/stateindicator/enrollment-by-eligibility-category/ Accessed Dec. 14, 2013 45. Chen J, Vargas-Bustamante A, Mortensen K, et al. Using quantile regression to examine health care expenditures during the Great Recession. Health Services Research 2013. doi: 10.1111/1475-6773.12113. [Epub ahead of print] 46. SAMHSA. Mental Health Parity and Addiction Equity Act. Available online at http://www.samhsa.gov/healthreform/parity/. Accessed May 15, 2013. 47. SAMHSA-HRSA Center for Integrated health solutions. Integrated care models. Available online at http://www.integration.samhsa.gov/ integrated-care-models. Accessed May 15, 2013. 48. Agency Healthcare Research and Quality. Integration of mental health/substance abuse and primary care. Available online at http:// www.ahrq.gov/research/findings/evidence-based-reports/mhsapc-evidence-report.pdf. Accessed May 15, 2013.
Mental Health Care during the Recession
