A.2
Prototype Indicator Set: Depression

BACKGROUND

Depression is a serious, frequently recurring mental health problem. Estimates are that about 11 percent of adults aged 15 to 54 experience depression within a 12-month period (Kessler et al., 1994). It occurs among all age groups, races, ethnic groups, and levels of education and income, and its impact is felt by individuals and their families, health care providers, employers, and others in the community. In the form of either depressive symptoms or actual depressive disorder, it impairs physical, cognitive, social, and occupational functioning to an extent comparable to chronic illnesses such as diabetes and coronary heart disease (Wells et al., 1989). It is also associated with suicide and higher mortality rates for other causes of death. The economic impact of depression includes direct costs of treatment and indirect costs of reduced productivity, absence from work or school, and premature death (Johnson et al., 1992; Conti and Burton, 1994). Depression and depressive symptoms are also associated with physical complaints that contribute to increased use of health care services (Johnson et al., 1992; Simon et al., 1995a).

A diverse mix of biological, psychosocial, and environmental factors are associated with increased risk for depression (IOM, 1994). It is more common in women and in people with a family history of depressive disorder. It tends to appear first in early



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Improving Health in the Community: A Role for Performance Monitoring A.2 Prototype Indicator Set: Depression BACKGROUND Depression is a serious, frequently recurring mental health problem. Estimates are that about 11 percent of adults aged 15 to 54 experience depression within a 12-month period (Kessler et al., 1994). It occurs among all age groups, races, ethnic groups, and levels of education and income, and its impact is felt by individuals and their families, health care providers, employers, and others in the community. In the form of either depressive symptoms or actual depressive disorder, it impairs physical, cognitive, social, and occupational functioning to an extent comparable to chronic illnesses such as diabetes and coronary heart disease (Wells et al., 1989). It is also associated with suicide and higher mortality rates for other causes of death. The economic impact of depression includes direct costs of treatment and indirect costs of reduced productivity, absence from work or school, and premature death (Johnson et al., 1992; Conti and Burton, 1994). Depression and depressive symptoms are also associated with physical complaints that contribute to increased use of health care services (Johnson et al., 1992; Simon et al., 1995a). A diverse mix of biological, psychosocial, and environmental factors are associated with increased risk for depression (IOM, 1994). It is more common in women and in people with a family history of depressive disorder. It tends to appear first in early

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Improving Health in the Community: A Role for Performance Monitoring adulthood, but a first episode may occur in childhood, adolescence, or later years of adulthood. The postpartum period is a time of increased risk for new mothers, and some people experience recurrent depression associated with seasonal changes (seasonal affective disorder). Stressful life events or circumstances are also recognized as risk factors: death of a spouse or child, divorce or other marital disruptions, assault or abuse, social isolation, job loss or stress, and poverty (IOM, 1994). Community conditions, such as a poor economy or violence, can reinforce individual experience. Depression may occur with or result from some medical conditions and other mental disorders, and some medications can produce depression. Use of tobacco and alcohol is more common among persons reporting depressed moods (Schoenborn and Horm, 1993), and substance abuse may produce symptoms of depression (Depression Guideline Panel, 1993a). Recurrence of depression, incomplete recovery between episodes, and previous suicide attempts are associated with increased risk for future depressive disorder (Depression Guideline Panel, 1993a). Because 50 percent of those who experience one episode of depression have a second episode (Depression Guideline Panel, 1993a), primary prevention is an important goal. Particular personality traits or good social support may limit the impact of some risk factors. Overall, evidence for the effectiveness of primary prevention is not conclusive (IOM, 1994), but targeted prevention may have promise (e.g., Beardslee et al., 1993; Clarke et al., 1995). In addition, interventions in a variety of settings (e.g., schools, workplaces, homes, neighborhoods) have been shown to reduce depressive symptoms (Muñoz, 1993; IOM, 1994). Once depression occurs, appropriate treatment can improve outcomes among people of all ages and can reduce the risk of relapse or recurrence (IOM, 1990; Depression Guideline Panel, 1993a; Sturm and Wells, 1995). Treatment with medication or psychotherapy is generally effective for depressive disorder, and other interventions (e.g., enhancing social support) can reduce depressive symptoms (Muñoz, 1993; IOM, 1994). Several factors may, however, hinder access to optimal treatment. Some people do not seek care or do not continue treatment to avoid the stigma still attached to mental health care. Lack of health insurance or limited coverage for mental health services may create financial constraints. Language and cultural barriers may also contribute (e.g., Padgett et al., 1994). In addition, many cases are not diagnosed or are not treated appropriately (Depression Guideline

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Improving Health in the Community: A Role for Performance Monitoring Panel, 1993a; Sturm and Wells, 1995). The underdiagnosis and undertreatment of depression in primary care settings has led to the development of a set of clinical practice guidelines (Depression Guideline Panel, 1993a,b). Insufficient awareness among providers that the elderly will benefit from treatment is also a concern (e.g., Callahan et al., 1996). The committee has chosen to consider performance indicators for depression because it and other mental disorders impose a substantial burden on the health and well-being of individuals and the community. Opportunities to reduce that burden are available and should receive attention from many parts of the community, including health care providers, employers, insurers, public-sector agencies that provide health and social services, schools, community groups, and the public at large. ''FIELD" SET OF PERFORMANCE INDICATORS By reviewing the domains of the field model, it is possible to suggest a varied set of indicators that might be used to examine a community's efforts to address the prevention and treatment of depression and the reduction of high levels of depressive symptoms. Currently, there is better evidence supporting the efficacy and effectiveness of treatment and symptom reduction than of preventive interventions. Additional research may identify effective preventive interventions, especially for groups at increased risk for depression. Disease The disease burden of depression is reflected in both individuals whose symptoms meet diagnostic criteria for depressive disorder and those with high symptom levels without a diagnosable disorder. In the United States as a whole, about 11 percent of the adult population is estimated to have a depressive disorder over a 12-month period (Kessler et al., 1994). Lifetime prevalence is about 19 percent overall and reaches 24 percent among women (Kessler et al., 1994). Depressive symptoms also contribute to morbidity in the population (Wells et al., 1989; Johnson et al., 1992; Sherbourne et al., 1994). Johnson and colleagues (1992) estimated that about 23 percent of the population (not including those with a depressive disorder) had ever experienced periods with two or more depressive symptoms. Rates may rise over time; there is evidence that in younger birth cohorts, depression is oc-

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Improving Health in the Community: A Role for Performance Monitoring curring at higher rates and with an earlier age of onset (Cross-National Collaborative Group, 1992). Data for 1993 from the Youth Risk Behavior Surveillance System (YRBSS) indicate that 24 percent of high school students thought seriously about attempting suicide in the year preceding the survey (CDC, 1995). The prevalence in the community of depressive symptoms and depressive disorders could be valuable health status measures with which to monitor the need for and impact of therapeutic and preventive interventions. Obtaining detailed prevalence data on a community-wide basis would require a community survey with valid and reliable screening questions. It might be possible to assess depression in subgroups of the population through periodic screening in settings such as health plans, work sites, human services agencies, and faith groups. Screening in schools, which might be appropriate for adolescent populations, would require instruments that have been validated for use with that age group. Prevalence estimates will vary depending on the diagnostic tools and criteria used. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; APA, 1994) is the current standard for diagnostic criteria, but various instruments have been used in surveys to screen for symptoms (Zung, 1965; Beck et al., 1974; Radloff, 1977) and to establish a diagnosis of depression (Robins et al., 1981; WHO, 1990). A less formal assessment of the prevalence of depressive symptoms in the community might be based on a question available for the Behavioral Risk Factor Surveillance System (BRFSS) on the number of days in the past month with depressed mood. Special sampling in individual state BRFSS surveys or adding residence information (e.g., zip codes) might be a way to obtain county-level data. Indicators might include the following: Proportion of the adult population (18 years of age and older) with current depressive symptoms meeting diagnostic criteria (DSM-IV) for depressive disorder. Proportion of the adult population currently experiencing two or more depressive symptoms, but not meeting diagnostic criteria for a depressive disorder. These two indicators would be based on the results of surveys using the more formal types of screening and diagnostic tools noted above. Using a minimum of three or four symptoms would give a more conservative estimate of the prevalence of depression.

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Improving Health in the Community: A Role for Performance Monitoring Proportion of high school students who report having thought seriously during the previous 12 months about attempting suicide. Thinking seriously about suicide is a symptom of depression. Although not all students who think about suicide will have a depressive disorder, this group is likely to be at higher risk for depression than other students. The question is based on one used by the YRBSS. Proportion of the adult population reporting 14 or more days, during the past 30 days, of feeling sad, blue, or depressed.This measure is based on a BRFSS question. The 14-day duration of depressed feelings reflects the DSM-IV criterion that symptoms persist for at least two weeks for diagnosis of major depression. This indicator could help identify groups in the population that might be at increased risk for depression. It would not provide a strict measure of symptom levels or diagnosable depression comparable to those based on more detailed screening and diagnostic assessments, but it would be easier to obtain at the community level. Health and Function, Well-Being The impact of depression on health and function and on well-being is felt by depressed individuals themselves and by others such as family members or other care givers, employers, and health care providers. A community prevalence survey might be used to obtain information on functional impairments related to depression. The Medical Outcomes Study, which found that impairment from depression was at least as severe as several common chronic illnesses, examined functioning in terms of physical limitations, ability to fill usual role (work, school, etc.), social limitations, and bed days (Wells et al., 1989). Well-being was assessed based on perceptions of current health and pain. Other measures might also be used as indicators of the impact of depression on function and well-being. Questions have been developed for the BRFSS on impairment due to depression or other emotional problems. Numbers or rates of hospitalizations for depressive disorders, which could be obtained in some states from a hospital discharge data system, might suggest levels of severe depression. Declining use of inpatient treatment for depression may, however, limit the future usefulness of such a measure.

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Improving Health in the Community: A Role for Performance Monitoring Length of disability claims related to depressive disorders could be another indicator of the impact on function and well-being. Communities might also try to determine what proportion of the population with depressive symptoms or a depressive disorder is not receiving treatment and, therefore, is at increased risk for impairment of function and well-being. Examining the demographic and socioeconomic characteristics of those not being treated could help communities assess where additional services are needed, whether specific provider groups should give greater attention to depression among their patients, and whether steps might be required to improve access to or acceptance of appropriate services. Managed care organizations (MCOs), schools, and others serving defined populations might assess the extent of untreated depression in those populations. One manifestation of the impact of depression on function and well-being is its association with higher mortality rates from a variety of causes, with the link to suicide being particularly strong. About half of all suicides are estimated to be associated with depression (U.S. Preventive Services Task Force, 1996). Numbers of recorded suicides would be available from state vital record systems. Numbers of calls to suicide hot lines might be another indicator to consider, but it would be necessary to determine whether changes in call volume could be correlated with changes in the incidence of suicide or attempted suicide. Some portion of other intentional and unintentional injuries may also be linked to depression. Indicators might include the following: Proportion of the adult population experiencing two or more depressive symptoms who also report limitations in physical activity, role function (work, school, or home), or social activities. An instrument such as the SF-36 (Ware and Sherbourne, 1992), used in conjunction with the screening and diagnostic tools described above, might provide information on functional limitations. Annual number of hospital discharges with a depressive disorder as the principal diagnosis. Hospital diagnostic codes, which are based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM; USDHHS, 1995) would have to be matched to equivalent DSM-IV codes. To use state-based hospital discharge data at

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Improving Health in the Community: A Role for Performance Monitoring the community level, information on residence (e.g., zip code) will be needed. A state-level data system such as this has the advantage of being able to identify hospital care provided outside a specific community. Numbers of hospital discharges are likely to be influenced by a variety of factors unrelated to the prevalence of depressive disorders, such as availability of hospital beds and insurance coverage for hospital care. Currently, no information system comparable to hospital discharge data is available to provide easy access to community-wide data on diagnosis and outpatient care. Such data might be available for specific populations, including members of MCOs or users of community mental health services. For all employers in the community, proportion of total days of short-term disability attributable to depressive disorders. This indicator measures the impact of depression on the ability to work relative to other causes of short-term disability. It reflects the effect on both employees and employers but may understate the impact of depression if employees are reluctant to make a claim for a mental health condition. A decrease can reflect either growth in claims for other conditions or a reduction in claims related to depression. Care should be taken not to create incentives to reduce claims by discouraging appropriate care. Employers would probably have to provide these data. Proportion of the population meeting criteria for a current depressive disorder who are not receiving treatment. A community prevalence survey of the type that has been described above might also be able to collect information on treatment. Determining which of several factors (e.g., economic constraints, reluctance to seek care, no diagnosis made) account for lack of treatment would require further assessment. Number (or rate) of suicides in the community, by age and race or ethnicity. Data will be available from state vital statistics systems but may understate true levels of suicide because some of those deaths are likely to be attributed to other causes. In most communities, the annual number of suicides will be too low to produce stable rates unless data are aggregated over multiple years. If rates are to be compared over time or across communities, they should be age-adjusted using a standard population.

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Improving Health in the Community: A Role for Performance Monitoring Risk Factors: Disease, Genetic Endowment, Individual Behavior, Social Environment, and Physical Environment Factors associated with several of the field model domains have been found to increase the risk of developing depression. Among these factors are specific medical disorders and medications, a family history of depression, previous episodes of depression, prior suicide attempts, social isolation, death of a spouse or child, marital disruption, job stress, unemployment, and poverty. Communities cannot expect to eliminate many of these risk factors, but they can respond through various channels in ways that reduce their impact. Health departments, health plans, social service agencies, schools, nursing homes, and employers, among others, might be expected to facilitate access to services intended to resolve problems or moderate their impact. Health care providers, for example, may be able to withdraw medications that produce symptoms of depression. Employee assistance programs may be able to provide stress reduction services for on-the-job problems or assistance for personal concerns such as marital problems. Schools and school-based clinics might, for example, give special attention to children and adolescents with family disruptions (e.g., divorce or death) or with a personal or family history of depression. Some potential performance indicators related to risk factors are presented in the sections on the field model domains listed above. Individual Response Individual behavior contributes both to increased risk for depression and to successful treatment or symptom reduction. Communities concerned about depression might, for example, try to assess rates of alcohol or substance abuse, both of which appear to induce depression in some people (but do not appear to be caused by depression) (Depression Guideline Panel, 1993a). Physical activity, on the other hand, appears to have therapeutic benefits and may be able to reduce the risk of depression (USDHHS, 1996). Participation in activities that reduce social isolation also moderates the risk of a depressive episode. Healthy People 2000 (USDHHS, 1991) proposed objectives for an increase in (1) the proportion of people who seek help for emotional problems, (2) the proportion of people with mental health

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Improving Health in the Community: A Role for Performance Monitoring problems who use community support programs, and (3) the proportion of people with depression who obtain treatment. (Obtaining treatment is also a function of access to care and the quality of care available.) Individuals' willingness to seek care and follow recommended treatment is another necessary element in the success of any community response to depression. Evidence suggests that many patients treated in primary care settings discontinue prescribed medications before positive effects can be expected (e.g., Simon et al., 1995b). Indicators that might be considered include the following: Proportion of the adult population (18 years of age and older) who report feeling sad, blue, or depressed and also report not engaging in regular exercise. This indicator might monitor the need for, or impact of, public education or counseling about the mental health benefits of exercise. Data might be obtained through questions that have been developed for the BRFSS. As noted elsewhere, special sampling in the state survey may be able to produce community-level data. Alternatively, communities might be able to include BRFSS questions in a local survey. Proportion of the adult population meeting diagnostic criteria for depressive disorder who have sought treatment. Seeking treatment reflects factors such as awareness of symptoms of depression, willingness to seek care, and availability of affordable care. Specific types of treatment covered by this indicator would have to be defined. Among those that might be included are medication, psychotherapy with a mental health professional, counseling from a primary care provider, or counseling through other community sources (e.g., school, work site, faith organization). Of adults with a diagnosis of depressive disorder for whom antidepressant medication has been prescribed, the proportion who take prescribed doses for at least 30 days. Antidepressant medications are not always used in the treatment of depressive disorders but are effective for many people if taken in adequate doses for at least four to six weeks. Minimum dosage guidelines for adults have been established for most antidepressant medications. Information on diagnosis and prescriptions filled may be available from some MCOs (see Simon et al.,

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Improving Health in the Community: A Role for Performance Monitoring 1995b) but might be difficult to monitor for a community as a whole. Social Environment Many aspects of the social environment have implications for the impact of depression in a community and for steps that might be taken if depression is considered a high priority. Monitoring the extent of risk factors may be a useful step. Community-wide indicators might include the divorce rate; rates of violent crime, particularly domestic violence; number of guns in the community; unemployment rates or number of layoffs; proportion of the population near or below the poverty line; and proportion of the population that has lived in the community less than one year. Some of these indicators might be included in a community profile. The profile indicators proposed by the committee include the unemployment rate and the proportion of children living at or below the poverty level. Also part of the social environment are resources available to people who are at increased risk for depression. As noted above, health care providers, schools, employers, social service agencies, and others may be able to identify high-risk individuals and facilitate access to supportive services that can mitigate a risk or respond to depression that has developed. Children and adolescents may benefit from access to mental health services through school-based clinics or other school health services. For the elderly, the need may be for programs that address social isolation or that monitor symptom levels in nursing home residents. Programs for children of depressed parents offered by social service agencies, or perhaps by health plans, respond to current cases of depression and are an effort to reduce the risk of future depression. In communities with diverse subpopulations, the availability of culturally appropriate social and health services can improve social support and may reduce the risk of depression or facilitate access to acceptable forms of care. Employers are affected by depression through lost productivity and through health care and disability claims. Employers also influence access to treatment through coverage for mental health services included in their health insurance plans. Communities may wish to assess what proportion of the population has mental health benefits through employment-based insurance and determine whether those benefits are comparable to coverage for other forms of medical care. The availability of work site resources such

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Improving Health in the Community: A Role for Performance Monitoring as employee assistance programs or counseling services for workers who have been laid off may also be a concern. Indicators might include the following: Proportion of adults, aged 21–65, who are unemployed (looking for but not able to find work). As noted, an unemployment measure appears in the committee's proposed community profile. In communities experiencing major changes in employment patterns, it may be appropriate to monitor the number of people who were laid off during the previous year. Job loss and unemployment increase the risk of depression through loss of income and through less tangible losses of social support and self-esteem. Proportion of the population living at or below poverty levels. A community-based study has suggested that 10 percent of new cases of depression may be attributable to poverty (Bruce et al., 1991). Low income not only increases the risk of developing depression but can also hinder access to treatment. Proportion of the ever-married adult population becoming separated, divorced, or widowed in the previous year. Marital disruption increases the risk of depression and can affect children as well as spouses. Data should be available from the state vital statistics system. Communities in which informal unions are common might want to supplement official vital statistics data with periodic surveys that include questions on changes in such relationships. Proportion of school-age children (6–18 years of age) with access to school-based mental health services. Proportion of employed persons with access to employee assistance programs. These two indicators are measures of the capacity to provide assistance but not of assistance actually sought or received. They should be used in conjunction with other measures that reflect services provided and health status outcomes. Data might be obtained from schools and employers in the community. A community survey might also provide data; results would reflect awareness of services as well as their availability. Proportion of employees in the community whose health

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Improving Health in the Community: A Role for Performance Monitoring bulatory follow-up after hospitalization for depression. Assessment of longer-term follow-up may also be useful. With decreased use of hospitalization, other indicators based on outpatient services may be needed. Appropriateness of prescribed medications is another possible indicator. Indicators for outcomes of care should be considered as well. Changes in symptom levels or diagnostic status at specific intervals following initiation of treatment might be measured. Recurrence of symptoms or disorder can, however, reflect not only potential shortcomings in care but also the onset of a new episode in response to new stressors. Health departments or state mental health agencies might be expected to monitor services provided by hospitals and other facilities. Accreditation standards are also being proposed for behavioral health care provided by MCOs and by managed behavioral health organizations (NCQA, 1996; IOM, 1997). In the future, compliance with those standards should promote the delivery of appropriate care. A means of assessing the quality of outpatient services provided by individual therapists could be valuable to a community but will be difficult to develop. In the public sector, the implementation of Medicaid managed care is dividing responsibility for mental health services between Medicaid and state mental health agencies (SMHAs), but their activities and funding are not always being coordinated (AMBHA and NASMHPD, 1995). SMHA practices emphasizing provider continuity, for example, are not consistent with the competitive contracting often used in Medicaid managed care, which could lead to more frequent changes in service providers. Communities (and states) may want to monitor the impact of these new arrangements on the use of and satisfaction with services and on outcomes of care. Indicators that might be used include the following: Proportion of persons who have completed treatment for a diagnosed depressive disorder who have not experienced a relapse (return of symptoms within six months of completion of treatment). This indicator of the outcome of care could point to inadequate treatment, including its premature termination. Medical record review could identify those cases in which relapse treatment was sought from the same provider. Cases in which people seek care from a different source or decline to seek new care would be harder to identify.

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Improving Health in the Community: A Role for Performance Monitoring Proportion of patients receiving ambulatory follow-up within 30 days of discharge for hospitalization for depression. Patients who require hospitalization tend to be those with more severe depression. Good follow-up care can reduce the risk of relapse and improve outcomes. Inclusion of this indicator in the HEDIS set means that most MCOs should be able to provide such information. It is not routinely collected for patients of fee-for-service providers, however. Increasing reliance on outpatient management of depression means that this indicator will apply to a small and decreasing portion of people treated for depression. Of patients diagnosed with a depressive disorder and prescribed antidepressant medication, the proportion who receive prescriptions for therapeutically effective doses. Appropriate doses of antidepressant medications are effective for many patients, but some prescriptions are written for inadequate dosages or are not continued for a sufficient length of time. This may delay the alleviation of a depressive episode while increasing the cost of care. A related concern not addressed by this indicator is the prescription of inappropriate medication (e.g., minor tranquilizers). This indicator is intended to distinguish provider practices from patient decisions not to follow prescribed dosages. Allowance must be made, however, for initial adjustments in dosage levels and for changes in medication that may be required to reduce side effects. Health plan and prescription service records could provide this information for some patients. For fee-for-service providers, record reviews, or possibly patient surveys, would be needed to obtain data. Proportion of managed care organizations or managed behavioral health organizations serving the community that are accredited by a nationally recognized organization (e.g., the National Committee for Quality Assurance [NCQA] under its proposed Behavioral Health Accreditation program). In both the public and private sectors, an increasing share of mental health services is being provided by MCOs and managed behavioral health organizations. Meeting nationally recognized accreditation standards should increase the likelihood that patients will receive good care. NCQA has proposed but not yet implemented its accreditation program (NCQA, 1996). Once it or other programs are in place, communities should be able to request accreditation information from a provider organization or the accrediting body.

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Improving Health in the Community: A Role for Performance Monitoring SAMPLE INDICATOR SET Nine of the indicators listed above are proposed as a set that a community might use to monitor efforts to reduce the impact of depression among its population. Each indicator is listed with comments on data and measurement considerations and on its implications for accountability. The indicators are a mix of health status, capacity, and process measures that address roles that several segments of the community might be expected to play. Treatment indicators are emphasized over indicators on primary prevention because of the more extensive evidence for the effectiveness of treatment. Over time, however, the mix of indicators should change to reflect new information on opportunities for effective action. In operationalizing a performance monitoring program based on the proposed indicators, a community would have to consider the generally limited availability of standard measures and necessary data. Resource constraints could preclude frequent community surveys, which might otherwise be the most direct source of information. Another consideration should be whether other measures would address depression risks or services that are of more pressing concern in a specific community. Proportion of the adult population (18 years of age and older) reporting 14 or more days, during the past 30 days, of feeling sad, blue, or depressed. This indicator is an assessment of the extent of at least minimal depressive symptoms in the community; it does not, however, apply formal diagnostic criteria. In conjunction with data on age, ethnicity, socioeconomic status, and so on, it could help identify groups in the population that might be at increased risk for depression. The use of a cumulative 14-day experience ensures that very brief periods of depressed mood do not obscure more persistent problems. As noted earlier, this measure is based on a question developed for the BRFSS. It might, therefore, be incorporated into an existing state survey program that could be adapted to provide substate estimates. As a community-wide measure, it would reflect the combined effect of both adverse and positive influences from many sectors. Proportion of high school students who report having thought seriously during the previous 12 months about attempting suicide. This indicator would provide some indication of the risk of

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Improving Health in the Community: A Role for Performance Monitoring depression in adolescents. The measure would not, however, reflect the proportion of students with depressive symptoms that do not include thoughts of suicide. Schools might be expected to facilitate access to mental health services for these students. The school-based survey for the YRBSS includes a question on this topic, and oversampling in conjunction with the state survey or a community-specific survey might be used to collect data. A shorter reference period (e.g., previous month, previous 3 months) would provide more current information, but its impact on the reliability of the data collected should be considered. Proportion of the adult population (18 years of age and older) meeting criteria for a depressive disorder who are not receiving treatment. Untreated episodes of depression generally last several months and are often accompanied by marked functional impairment. They may also increase the risk for subsequent depressive episodes. Not every case of depression requires formal treatment, but in many instances, treatment can shorten the length of an episode and improve long-term outcomes. This indicator will not identify why treatment is not being received (e.g., economic constraints, reluctance to seek care, no diagnosis made), but it could help communities assess the extent of unmet need. Data would probably have to be collected through periodic surveys. In terms of accountability, this indicator would address the role that many sectors of the community (e.g., health care providers, employers, schools, nursing homes, social service agencies, criminal justice agencies) have in facilitating access to care. Number (or rate) of suicides in the community, by age and race or ethnicity. Suicides are an extreme adverse outcome for depression and other mental health problems, and youth suicide is often a special concern. As noted above, about half of all suicides are associated with depression. Many suicide attempts are unsuccessful, but access to firearms increases the likelihood of death. This measure is included in the committee's proposed community profile indicators and is part of the Healthy People 2000 consensus indicator set (CDC, 1991). Data are available from state vital records systems. In most communities, suicide will be a rare event, but it might be treated as a signal to give greater attention to sources of risk for depression and to identification of persons with current depressive disorders. The greatest accountability for addressing

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Improving Health in the Community: A Role for Performance Monitoring risks for suicide might be considered to lie with health care providers, criminal justice facilities, and others who serve groups with known risk factors. Proportion of employed persons with access to employee assistance programs. Employee assistance programs (EAPs) are a resource for work site interventions that might address risks for depression (e.g., stress reduction) and can facilitate access to risk reduction or treatment services outside the workplace. To have an impact, however, employees must be willing and able to use these services. If a community has many small businesses, which are less likely to have an EAP, the proportion of workers with access to such programs will tend to be lower. Estimates might be developed from reports from employers in the community. This indicator targets a specific contribution that employers might be expected to make to community efforts to reduce the adverse impact of depression. Proportion of employees in the community whose health insurance includes coverage for mental health services for themselves; for their families. This indicator is of interest because lack of insurance coverage for mental health services can create a financial barrier to care. In assessing the extent of coverage, communities would have to take into account differences in the kinds of services covered, number of visits allowed, amount of copayment required, and limits on total payments for services. To obtain data, it might be possible to expand or adapt BRFSS questions on access to care. Data might also be obtained from employer reports. State insurance authorities might be able to provide some information but are less likely to be able to provide information on self-insured companies. This indicator addresses the role that employers and insurers have in reducing the financial barriers to mental health services. Proportion of patients receiving ambulatory follow-up within 30 days of discharge for hospitalization for depression. Good follow-up care can reduce the risk of relapse and improve outcomes. This indicator was selected because it has already been operationalized as a HEDIS measure, which should make it easier for communities to implement. Its current use by health plans should also reduce the burden of collecting data.

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Improving Health in the Community: A Role for Performance Monitoring Communities should, however, be considering alternative measures. Hospitalized patients are some of the most severely ill, but with the decreasing use of hospitalization, they are a small and declining proportion of all people receiving treatment for depression. As an indicator on follow-up care, this measure addresses accountability among health care organizations and providers. Of patients diagnosed with a depressive disorder and prescribed antidepressant medication, the proportion who receive prescriptions for therapeutically effective doses. This indicator addresses an issue of particular concern in the treatment of depression. Appropriate doses of antidepressant medications are effective for many patients, but some providers do not prescribe adequate dosages and do not continue medications for adequate periods of time. Use of medications in a manner that is not likely to be effective is a poor use of health care dollars. Guidelines on minimum dosage levels (e.g., see Depression Guideline Panel, 1993b) can provide criteria for evaluating prescriptions. Length of time a medication is used, which is also important in achieving a good response, has not been included in the indicator to simplify the measurement process. Health plan and prescription service records could be a source of data. Because only physicians can prescribe medications, this indicator specifically addresses physician accountability for appropriate treatment practices. Proportion of managed care organizations or managed behavioral health organizations serving the community that are accredited by a nationally recognized organization (e.g., NCQA under its proposed Behavioral Health Accreditation program). This indicator addresses concerns about quality of care. Accreditation should assure the community that past performance has met accepted standards and that specific capacities are in place to provide service in the future. Reference to nationally recognized accreditation standards would permit comparisons across communities. Once an accreditation program is in place, information on specific provider organizations in a community should be readily available from the accrediting group. Provider accountability is addressed by this indicator. As a set, these proposed indicators on depression can give a community a sense of the extent of the current health problem (depressed mood, thoughts of suicide, number of suicides), of risk

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Improving Health in the Community: A Role for Performance Monitoring factors affecting health outcomes (lack of treatment, follow-up care, use of medication), and of resources available to apply to the problem (employee assistance programs, insurance coverage, accreditation of services). The proposed indicators focus on concerns that are specific to depression, but they should be used with other, more general measures of community status that are also depression risk factors (e.g., unemployment and poverty). Some of these general measures are included as indicators in the community profile proposed by the committee. In terms of performance, the set of indicators reflects the community-wide impact of activities and opportunities for action by many stakeholders. For example, the indicators on depressed mood (indicator 1), thoughts of suicide (indicator 2), and lack of treatment for diagnosable depressive disorder (indicator 3) measure the result of actions that might be taken not only by health care providers but also by community groups (e.g., employers, schools, social service agencies, faith groups) to facilitate access to treatment or, perhaps, to offer supportive services that might reduce the need for treatment. Because treatment practices will be relevant to most communities, it is useful to suggest some specific indicators (follow-up care, use of medication) without reference to a community's risk factors. Similarly, the indicator on EAPs (indicator 5) reflects a widely applicable opportunity offered by the workplace to address risks for depression, whether they arise at the workplace or elsewhere. In contrast, many activities that respond to risk factors need to be tailored to the specific form of risk (e.g., social isolation, unemployment, death of a spouse). Communities should supplement (or modify) the proposed set of indicators with others that are appropriate for local circumstances. REFERENCES AMBHA and NASMHPD (American Managed Behavioral Healthcare Association and National Association of State Mental Health Program Directors). 1995. Public Mental Health Systems, Medicaid Re-structuring and Managed Behavioral Healthcare. Behavioral Health Care Tomorrow (Sept/Oct):63–69. APA (American Psychiatric Association). 1994. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. 4th ed. Washington, D.C.: APA. Beardslee, W.R., Salt, P., Porterfield, K., et al. 1993. Comparison of Preventive Interventions for Families with Parental Affective Disorders. Journal of the American Academy of Child and Adolescent Psychiatry 32:254–263. Beck, A.T., Rial, W.Y., and Rickels, K. 1974. Short Form of Depression Inventory: Cross Validation. Psychological Reports 34:1184–1186.

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Improving Health in the Community: A Role for Performance Monitoring Bruce, M.L., Takeuchi, D.T., and Leaf, P.J. 1991. Poverty and Psychiatric Status: Longitudinal Evidence from the New Haven Epidemiologic Catchment Area Study. Archives of General Psychiatry 48:470–474. Callahan, C.M., Dittus, R.S., and Tierney, W.M. 1996. Primary Care Physicians' Medical Decision Making for Late-Life Depression. Journal of General Internal Medicine 11:218–225. CDC (Centers for Disease Control and Prevention). 1991. Consensus Set of Health Status Indicators for the General Assessment of Community Health Status—United States. Morbidity and Mortality Weekly Report 40:449–451. CDC. 1995. Youth Risk Behavior Surveillance—United States, 1993. Morbidity and Mortality Weekly Report 44 (No. SS-1). Clarke, G.N., Hawkins, W., Murphy, M., Sheeber, L.B., Lewinsohn, P.M., and Seeley, J.R. 1995. Targeted Prevention of Unipolar Depressive Disorder in an At-Risk Sample of High School Adolescents: A Randomized Trial of a Group Cognitive Intervention. Journal of the American Academy of Child and Adolescent Psychiatry 34:312–321. Conti, D.J., and Burton, W.N. 1994. The Economic Impact of Depression in a Workplace. Journal of Occupational Medicine 36:983–988. Cross-National Collaborative Group. 1992. The Changing Rate of Major Depression: Cross-National Comparisons. Journal of the American Medical Association 268:3098–3105. Depression Guideline Panel. 1993a. Depression in Primary Care: Volume 1. Detection and Diagnosis . Clinical Practice Guideline, No. 5. AHCPR Pub. No. 93-0550. Rockville, Md.: U.S. Department of Health and Human Services. Depression Guideline Panel. 1993b. Depression in Primary Care: Volume 2. Treatment of Major Depression. Clinical Practice Guideline, No. 5. AHCPR Pub. No. 93-0551. Rockville, Md.: U.S. Department of Health and Human Services. IOM (Institute of Medicine). 1990. The Second Fifty Years: Promoting Health and Preventing Disability. R.L. Berg and J.S. Cassells, eds. Washington, D.C.: National Academy Press. IOM. 1994. Reducing Risks for Mental Disorders: Frontiers for Prevention Intervention Research. P.J. Mrazek and R.J. Haggerty, eds. Washington, D.C.: National Academy Press. IOM. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, D.C.: National Academy Press. Johnson, J., Weissman, M.M., and Klerman, G.L. 1992. Service Utilization and Social Morbidity Associated with Depressive Symptoms in the Community. Journal of the American Medical Association 267:1478–1483. Kessler, R.C., McGonagle, K.A., Zhao, S., et al. 1994. Lifetime and 12-Month Prevalence of DSM-III-R Psychiatric Disorders in the United States: Results from the National Comorbidity Survey. Archives of General Psychiatry 51:8–19. Muñoz, R.F. 1993. The Prevention of Depression: Current Research and Practice. Applied and Preventive Psychology 2:21–33. NCQA (National Committee for Quality Assurance). 1993. Health Plan Employer Data and Information Set and User's Manual, Version 2.0 (HEDIS 2.0). Washington, D.C.: NCQA. NCQA. 1996. NCQA Issues First National Accreditation Standards for Managed Behavioral Health Organizations. Washington, D.C. April 10. (press release)

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Improving Health in the Community: A Role for Performance Monitoring Padgett, D.K., Patrick, C., Burns, B.J., and Schlesinger, H.J. 1994. Ethnicity and the Use of Outpatient Mental Health Services in a National Insured Population. American Journal of Public Health 84:222–226. Radloff, L.S. 1977. The CES-D Scale: A Self-Report Depression Scale for Research in the General Population. Applied Psychology Measures 1:385–401. Robins, L.N., Helzer, J.E., Croughan, J., and Ratcliff, K.S. 1981. National Institute of Mental Health Diagnostic Interview Schedule: Its History, Characteristics, and Validity. Archives of General Psychiatry 38:381–389. Schoenborn, C.A., and Horm, J. 1993. Negative Moods as Correlates of Smoking and Heavier Drinking: Implications for Health Promotion. Advance Data from Vital and Health Statistics, No. 236. Hyattsville, Md.: National Center for Health Statistics. Sherbourne, C.D., Wells, K.B., Hays, R.D., Rogers, W., Burnam, M.A., and Judd, L.L. 1994. Subthreshold Depression and Depressive Disorder: Clinical Characteristics of General Medical and Mental Health Specialty Outpatients. American Journal of Psychiatry 151:1777–1784. Simon, G., Ormel, J., VonKorff, M., and Barlow, W. 1995a. Health Care Costs Associated with Depressive and Anxiety Disorders in Primary Care. American Journal of Psychiatry 152:352–357. Simon, G.E., Lin, E.H.B., Katon, W., et al. 1995b. Outcomes of ''Inadequate" Antidepressant Treatment. Journal of General Internal Medicine 10:663–670. Sturm, R., and Wells, K.B. 1995. How Can Care for Depression Become More Cost-Effective? Journal of the American Medical Association 273:51–58. USDHHS (U.S. Department of Health and Human Services). 1991. Healthy People 2000: National Health Promotion and Disease Prevention Objectives . DHHS Pub. No. (PHS) 91-50212. Washington, D.C.: Office of the Assistant Secretary for Health. USDHHS. 1995. International Classification of Diseases, Ninth Revision, Clinical Modification. 5th ed. DHHS Pub. No. (PHS) 95-1260. Washington, D.C.: National Center for Health Statistics and Health Care Financing Administration. USDHHS. 1996. Physical Activity and Health: A Report of the Surgeon General. Executive Summary. Atlanta, Ga.: Centers for Disease Control and Prevention and President's Council on Physical Fitness. U.S. Preventive Services Task Force. 1996. Guide to Clinical Preventive Services. 2nd ed. Baltimore: Williams and Wilkins. Ware, J.E., and Sherbourne, C.D. 1992. The MOS 36 Item Short-Form Health Survey (SF-36). Medical Care 30:473–483. Wells, K.B., Stewart, A., Hays, R.D., et al. 1989. The Functioning and Well-being of Depressed Patients: Results from the Medical Outcomes Study. Journal of the American Medical Association 262:914–919. WHO (World Health Organization). 1990. Composite International Diagnostic Interview (CIDI, Version 1.0). Geneva: WHO. Zung, W.W.K. 1965. A Self-Rating Depression Scale. Archives of General Psychiatry 12:63–70.

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Improving Health in the Community: A Role for Performance Monitoring TABLE A.2-1 Field Model Mapping for Sample Indicator Set: Depression Field Model Domain Construct Sample Indicators Data Sources Stakeholders Disease Reduce prevalence of depression Proportion of adult population reporting 14 or more days of depressed mood in past month Community survey (BRFSS) Health care providers Health care plans State health agencies Local health agencies Business and industry     Proportion of high school students reporting thoughts of suicide during past 12 months School survey (YRBSS) Education agencies and institutions Community organizations Special health risk groups General public Health and Function, Well-Being Reduce functional impairment from depression Proportion of adults meeting criteria for depressive disorder who are not receiving treatment Community survey Health care providers Health care plans Local health agencies Business and industry   Reduce adverse outcomes of depression Number (or rate) of suicides Death certificates Education agencies and institutions Community organizations Special health risk groups Disease, patient organizations General public Social Environment Improve access to services Proportion of employed persons with access to employee assistance programs Employers Local health agencies Business and industry Community organizations Special health risk groups

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Improving Health in the Community: A Role for Performance Monitoring Field Model Domain Construct Sample Indicators Data Sources Stakeholders   Reduce financial barriers to treatment Proportion of employees with insurance coverage for mental health services for themselves; for their families Employers, insurance licensing authority Health care plans Local government Business and industry General public Health Care Ensure that the health care system is following appropriate treatment practices Proportion of patients receiving ambulatory follow-up within 30 days after discharge for hospitalization for depression Patient records; claims files Health care providers Health care plans Special health risk groups General public     Proportion of depressed patients prescribed anti-depressant medications who receive prescriptions for therapeutically effective doses Patient records; prescription services; claims files Health care providers Health care plans Special health risk groups General public     Proportion of MCOs or managed behavioral health organizations that are accredited by a nationally recognized organization Behavioral health care providers; accrediting organizations Health care plans Business and industry Special health risk groups General public NOTE: BRFSS, Behavioral Risk Factor Surveillance System; MCO, managed care organization; YRBSS, Youth Risk Behavior Surveillance System.