DHHS Publication No. (SMA) 04-3906 Printed 2004

DHHS Publication No.
(SMA) 04-3906
Printed 2004
ii Special Report
Acknowledgments
This report was prepared for the Substance Abuse and Mental Health Services Administration
(SAMHSA) under contract number 02M00915301D. The co-authors of this report are Joel
Nitzkin, MD, MPH, of JLN, MD Associates, LLC, and Shelagh Smith, MPH, CHES, of the
Center for Mental Health Services (CMHS), SAMHSA, U.S. Department of Health and
Human Services (DHHS). Shelagh Smith was the Government Project Officer. Alison Aucoin,
MPH, Nancy Kennedy, Dr PH, Center for Substance Abuse Prevention (CSAP), and Ronald
Manderscheid, PhD, CMHS, provided advice and counsel to the authors. The authors appre-
ciate the editing provided by Nancy McKenzie of Z-Tech Corporation.
Disclaimer
The views, opinions, and content of this publication are those of the authors and do not nec-
essarily reflect the views or policies of SAMHSA or DHHS.
Public Domain Notice

All material appearing in this report is in the public domain and may be reproduced or copied
without permission from SAMHSA. Citation of the source is appreciated. However, this publi-
cation may not be reproduced or distributed for a fee without the specific, written authoriza-
tion of the Office of Communications, SAMHSA, DHHS.
Electronic Access and Copies of Publication

This publication can be accessed electronically through the following Internet World Wide
Web connection: www.samhsa.gov/. For additional free copies of this document, please call
SAMSHA’s National Mental Health Information Center at 1-800-789-2647.
Recommended Citation
Nitzkin, J., & Smith, S. A. Clinical preventive services in substance abuse and mental health
update: From science to services. (2004). DHHS Pub. No. (SMA) 04-3906. Rockville, MD:
Center for Mental Health Services, Substance Abuse and Mental Health Services
Administration.
Originating Office
Office of the Associate Director for Organization and Financing, Center for Mental Health
Services, Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane,
Rockville, MD 20857.
DHHS Publication No. (SMA) 04-3906

Printed 2004
Clinical Preventive Services in Substance Abuse and Mental Health Update iii
iv Special Report
Table of Contents
I. Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
II. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Clinical Preventive Behavioral Services . . . . . . . . . . . . . . . . . . . . . . . . .4
Models of Preventive Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Clinical vs. Community Preventive Services . . . . . . . . . . . . . . . . . . . . . .7
Health Care Delivery System Provision of Preventive
Behavioral Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Organization of This Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
III. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
IV. Overview of Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
V. Pregnant Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Illicit Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
VI. High-Risk Pregnant Women and Children to Age 5 . . . . . . . . . . . . . . . . .39

Social and Economic Dependency . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
Educational Services To Improve the Intelligence of
Selective Infants and Preschool Children . . . . . . . . . . . . . . . . . . . . . . .43
VII. Screening Children and Adolescents (5–18 Years) . . . . . . . . . . . . . . . . . . .49

Screening for Evidence of Behavioral Disorder . . . . . . . . . . . . . . . . . .49
VIII. Adolescents (12–18 Years) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54
Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56
Illicit Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59
Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63
IX. Adults (19 Years and Older) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67
Clinical Preventive Services in Substance Abuse and Mental Health Update v

Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72
Adult Use/Abuse of Illicit Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83
Depression and Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84
Depression in High-Cost Patients Without a Major
Chronic Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99
X. Psychoeducation for Three Categories of Patients . . . . . . . . . . . . . . . . . .101

Why Psychoeducation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101
Psychoeducation for Patients With Chronic Disease . . . . . . . . . . . . .102
Psychoeducation for Patients Scheduled for Surgical Procedures . . . .104
Psychoeducation for Patients With Somatization . . . . . . . . . . . . . . . .105
XI. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107
XII. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109
XIII. Appendix A: Literature Search Methods and Results . . . . . . . . . . . . . .145
XIV. Appendix B: Policy and Management Issues and Guidelines . . . . . . . . .155
XV. Appendix C: Billing for Preventive Behavioral Services . . . . . . . . . . . . .171
XVI. Appendix D: Procedures for Implementation and Evaluation

of Preventive Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .175
Figures
Figure 1.Continuum of Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Tables
Table 1: Summary of Universal Preventive Service Guidelines . . . . . . . . . . . . . .19
Table 2: Summary of Selective Preventive Service Guidelines . . . . . . . . . . . . . .20
Table 3: Tabular Summary of Initial PubMed Search for 1998–2002 . . . . . . .146
Table 4: Notes on Randomized Controlled Trials in

Advanced Searches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .147-148
vi Special Report
Table 5: Searches From 1964 to 2002 To Collect Negative Studies . . . . . . . . .149
Table 6: Preliminary Analysis of SAMHSA 2000 Monograph:

Search for Negative Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . .150-151
Table 7: Topics from SAMHSA 2000 Monograph Reflected in

This Monograph (SAMHSA 2004) . . . . . . . . . . . . . . . . . . . . . . . . . .152
Table 8: Preventive Medicine, Individual Counseling, and/or

Risk Factor Reduction Intervention Provided to an
Individual as a Separate Procedure . . . . . . . . . . . . . . . . . . . . . . . . . .172
Table 9: Preventive Medicine Comprehensive Evaluations . . . . . . . . . . . . . . .173
Clinical Preventive Services in Substance Abuse and Mental Health Update vii
I. Executive Summary
T
his report has been prepared to summarize the most promising
preventive interventions of a behavioral nature intended to impact
mental and substance use disorders, or in some cases, medical
outcomes. This review focuses on prevention interventions that are primarily
delivered by health care systems. Interventions provided in schools, worksites,
communities, and criminal justice systems were excluded, as were
population-based interventions.
The information provided here increases the A common barrier is that although rigorous
rigor of a previous literature review research exists, often there is a lag time in
published by SAMHSA in 2000 by Dorfman applying research findings to practice.
and updates it. That report was a first of its The literature included in this monograph
kind in that it reviewed the literature to was published in English between 1964 and
identify preventive interventions in mental mid-2003. More than 3,000 papers and
health and substance abuse that offer related documents were reviewed, and of
evidence for a positive effect on individuals, those, approximately 530 were appropriate
while imposing no additional cost to health to be included in this report. Most of the
plans, based on rigorous research studies. literature items reviewed are research studies
However, that report confined its discussion summarizing randomized or other controlled
to only those studies with positive effects. trials, as well as other governmental
This newer report fills in the previous gaps recommendations that were based on
by including all studies, regardless of rigorous research studies, such as the
outcome—even those with negative or no precedent-setting universal recommendation
effects—and based on the literature, in 2002 by the Agency for Healthcare
describes the optimal circumstances for Quality Research that adults be screened for
implementing services and tracking costs. depression.
The descriptions may be most useful to Because the field of prevention of mental
health care organizations and providers in or substance use disorders has not yet
determining what preventive services to offer uncovered a “magic bullet” equivalent to a
and how to implement them. The report may vaccine in clinical medicine, we must rely on
also be helpful to employee benefits associated indicators to identify individuals
designers and advisors, managed care who are at risk for developing disorders. For
organizations, employers, researchers, example, we may target known risk factors,
financial managers of health plans, and such as those associated with disadvantaged
decisionmakers for benefit package services. first-time young mothers, or increase
Clinical Preventive Services in Substance Abuse and Mental Health Update 1

protective factors that promote resilience. ■ Psychoeducation to increase early
Based on the rigor of the research presented ambulation of surgical patients,
here, the breadth of applicability among adherence to prescribed regimens of care
interventions, and their potential cost- for patients with chronic diseases, and to
effectiveness for health plans, effective decrease somatization of other patients.
behavioral preventive interventions can be Psychoeducation refers to counseling
classified as basic or “general,” or less integrated with health education to
widely applicable but “targeted” to certain address emotional, perceptual, and
groups at risk or within specific conditions. psychological barriers to compliance
The following interventions discussed here with prescribed regimens of care.
in detail have shown the greatest promise, Somatization refers to true physical
based on the research reviewed, to diminish symptoms and true physical illnesses that
or prevent the development of a mental or are initially psychogenic in nature.
substance use disorder. They can be
categorized as “general” (universally According to the literature, services
applicable) or “targeted” to specific exhibiting the greatest potential to reduce
subgroups with certain risk factors. costs include screening pregnant women for
use of tobacco, alcohol, or drugs, with
■ Universal screening of pregnant women follow-up services; screening and follow-up
for use of tobacco, alcohol, and illicit for depression or other major mental
drugs. illnesses in persons with major, chronic
■ Home visitation for selected pregnant medical illness; and psychoeducation for
women, and some children up to age 5. heavy users of health care services, persons
■ Supplemental educational services for with chronic diseases, or persons scheduled
vulnerable infants from disadvantaged to undergo surgery. This publication presents
families. an analysis of the research basis for
■ Screening children and adolescents for providing these services and guidelines for
behavioral disorders. implementation, data collection, and
■ Screening adolescents for tobacco, management.
alcohol, depression, and anxiety.
■ Screening adults for depression and
anxiety, and use of tobacco and/or
alcohol.
2 Special Report
II. Introduction
T
he Substance Abuse and Mental Health Services Administration
(SAMHSA) is a component of the Federal Government’s Department
of Health and Human Services (DHHS). In 2003, DHHS launched a
campaign called Steps to a Healthier U.S. under the direction of DHHS
Secretary Tommy Thompson. This initiative focuses on chronic disease
prevention and health promotion. The connection between the health of the
mind and the body is generally accepted, with a plethora of literature
documenting that individuals with conditions such as cancer, heart disease,
and hip fracture improve and survive longer when mental disorders such as
depression are prevented or treated successfully.
This monograph explores the need for and mental illness, according to several national
value of preventive services for mental health studies (New Freedom Commission, 2003). If
and substance use disorders in health care milder mental disorders are included, about
settings. These disorders are widespread and 40 million adults aged 18–64 years, or 22
costly, and they exact a high toll on our percent of the population, had a diagnosis of
Nation and around the world. The World a mental disorder (Kessler, McGonagle, Zhao,
Health Organization (WHO) determined the et al., 1994). About 20 percent of children are
“burden of disability” associated with one estimated to have mental disorders with at
major mental illness, unipolar depression, least mild functional impairment (DHHS,
ranked fourth among all leading causes of 1999), and those with serious emotional
disability worldwide. By the year 2020, the disorders make up approximately 5–9 percent
disease burden from depression will rank of all children ages 9–17 (New Freedom
number two, surpassed only by heart disease Commission, 2003).
(Murray & Lopez, 1996). The disability and In 2002, an estimated 22 million
disease burden of various medical conditions Americans aged 12 or older were classified
were estimated by “disability-adjusted life with substance dependence or abuse (9.4
years,” or DALYs. This global burden has percent of the total population) (SAMHSA,
been underrecognized in economic cost and 2002). Of these, 3.2 million were classified
the impact on social structure. with dependence on or abuse of both alcohol
In the United States, who has not been and illicit drugs; 3.9 million were dependent
touched by a family member or a relative on or abused illicit drugs, but not alcohol;
suffering from an emotional disorder or drug and 14.9 million were dependent on or
problem? In this country, in any given year, abused alcohol, but not illicit drugs
about 5–7 percent of adults have a serious (SAMHSA, 2002). An estimated 3.5 million

people aged 12 or older (1.5 percent of the counseling for those showing evidence of
population) received some kind of treatment high-risk or early-stage behavioral illness.
for a problem related to the use of alcohol or Then, either the primary care provider or a
illicit drugs in the 12 months prior to being specialized mental health professional
interviewed for the 2002 National Survey on provides follow-up management. These
Drug Use and Health (SAMHSA, 2002). interventions require skill, consistency, and
Why try to prevent these disabling special training of the primary care providers
disorders? While the social and psychological as well as the capacity of the health care
effects are enormous, the economic costs to delivery system to connect selected patients
society to treat these illnesses are staggering. with specialized mental health professionals.
National expenditures for mental health and There is little value to such screening
substance abuse in 1997 were estimated to procedures if the health care delivery system
be $82.2 billion (Coffey et al., 2000). Mental lacks the means to follow up with definitive
health care is the largest component of that diagnoses and management. Some health
estimate, as 86 percent ($70.8 billion) was care systems opt for increased training of
for treatment of mental illness and 14 primary care practitioners to reduce reliance
percent ($11.4 billion) was for treatment of on mental health professionals.
substance abuse (Coffey et al., 2000). Most clinical preventive services require
Compared with other spending on retail the same infrastructure elements as those
trade, Americans spent more on mental commonly used for quality assurance,
health and substance abuse treatment in accreditation, and in some States, licensure
1997 than they did on computer software. In and Medicaid reimbursement:
1995, they spent more for these disorders
than the amount for treatment of most other ■ Policies and procedures, with committee
types of disease, including cancer, injuries, oversight and annual review
respiratory diseases, and musculoskeletal ■ Provider training
diseases, respectively (Coffey et al., 2000). ■ Patient outreach and communications
The following information addresses ■ Data systems—often including dummy
screening procedures for emotional billing codes (codes for services that are
disorders, depression, tobacco, alcohol, and not individually reimbursed), chart
illicit drugs. It also identifies behavioral review, and/or limited patient and
health services that may prevent or provider surveys
ameliorate mental (behavioral) illness or
otherwise reduce health care costs. These preventive services differ from those
usually classified as “disease management”
Clinical Preventive Behavioral or “demand management” in that patients
Services needing these preventive services usually are
Clinical preventive services for behavioral identified through clinical screening, not
disorders usually start with the primary care through review of the claims database.
provider taking 30 seconds to 2 minutes to
screen for depression and the various
substance-use topics. This screening is
followed by a diagnostic interview and
4 Special Report
Models of Preventive Services through effective treatment of hypertension
Two well-known models of preventive is an example of tertiary prevention. Much
services are used when referring to of disease management is tertiary prevention.
behavioral programming for public health or In the public health model, the three levels of
mental health promotion and substance use prevention are separate and distinct.
prevention. They are reviewed briefly here.
The Continuum of Health Care Model
The Public Health Model According to the Institute of Medicine (IOM)
Public health traditionally defines preventive When dealing with substance use and other
services as “primary,” “secondary,” or behavioral disorders in clinical settings, the
“tertiary.” Primary preventive services, such levels of prevention are less distinct than
as immunizations and programs related to with physical illnesses. The tasks of
tobacco, diet, and exercise, are intended to identifying risk factors and detecting early-
intervene before the onset of illness to stage disease are usually accomplished by
prevent biologic onset of illness. Secondary patient or family interview. Initial
preventive services include screening to management of both risk and early stage
detect disease before it becomes disease is often conducted via patient and
symptomatic, coupled with follow-up to family counseling by the primary care
arrest or eliminate the disease. The Pap test provider. Thus, the continuum of the health
and mammography are medical examples of care model is more practical than the public
secondary prevention. Tertiary prevention health model when dealing with preventive
refers to prevention of complications in behavioral health services.
persons known to be ill. Prevention of stroke The continuum of health care model is
Figure 1. Continuum of Health Care
Source: Reprinted with permission from Reducing Risks for Mental Disorders. Copyright 1994 by the National Academy of Sciences, Courtesy of the
National Academy Press, Washington, DC.

drawn from a 1994 report of the Institute of depression in all adult patients at all primary
Medicine (IOM) (Mrazek & Haggerty, eds., care visits.
1994), as originally proposed by Gordon Selective interventions are more intensive
(1983). It differs from the public health services offered to subpopulations identified
model in that it covers the full range of as having more risk factors than the general
preventive, treatment, and maintenance population, based on their age, gender,
services. There are three types of preventive genetic history, condition, or situation. For
services in the IOM model—universal, example, more intensive breast cancer
selective, and indicated. These do not screening is provided for women with a
correspond to the primary, secondary, and family history of breast cancer. A behavioral
tertiary services in the public health model. health example would be offering smoking
Screening and follow-up preventive cessation programming to all smokers.
behavioral services correspond to secondary Indicated interventions are based on higher
prevention within the public health model. probability of developing a disease. They
Other preventive behavioral services, provide an intensive level of service to
including most community-based services, persons at extremely high risk or who
correspond to primary or tertiary prevention. already show asymptomatic, clinical, or
In the IOM model, a “universal” demonstrable abnormality, but do not meet
preventive measure is an intervention that is diagnostic criteria levels yet. Case
applicable to or useful for everyone in the management and intensive in-home
general population, such as all enrollees in a assessment, health education, and counseling
managed care organization. A “selective” are examples of indicated interventions
preventive measure is desirable only when an (Mrazek & Haggerty, eds., 1994).
individual is a member of a subgroup with Sometimes a universal service is a
above-average risk. An “indicated” screening procedure provided to all, or a
preventive measure applies to persons who primary prevention procedure such as
are found to manifest a risk factor that puts vaccinations for children. The selective
them at high risk (Mrazek & Haggerty, eds., service involves diagnostic procedures to
1994). All these categories describe confirm or deny a diagnosis, and the
individuals who have not been diagnosed indicated service involves much more
with a disease. intensive, individualized services for those at
Universal interventions, on a per-client highest risk.
basis, are relatively inexpensive services The efficacy and cost-efficiency of
offered to the entire population of a life- preventive services depend on the entire
stage group. They are conducted as a array of universal, selective, and indicated
primary prevention or screening to identify service components. They also depend on the
sub-populations and individuals who need ability of the health care system to target
more intensive screening, preventive, or and limit the more costly indicated
therapeutic services. A clinical example interventions to those who could most
would be the provision of prenatal care as a benefit from them.
universal service for all pregnant women. A Appendix C to this report provides a more
behavioral health example would be the use detailed presentation of the following policy,
of a simple screening protocol to identify management, planning, and evaluation issues:
6 Special Report
■ Translation of preventive behavioral This report has been prepared to
research into health care practice summarize and analyze the most promising
■ Assessment of the need for preventive preventive interventions (based on rigorous
services research studies) for consideration by health
■ Assessment of the efficacy of preventive care organizations. Only interventions
services deliverable by health care systems are
■ Infrastructure and service components reviewed in this report. Most community
for preventive services preventive services are oriented toward
school-age children, adolescents, and young
“General” vs. “Targeted” Services adults—age groups with relatively low
Within this monograph, services are also exposure to health care delivery settings.
classified into one of two categories, Such services generally are provided by and
“general” and “targeted,” depending on the through schools and community
evidence base and the nature of the service. organizations.
Those designated as “general” are supported Health care settings, however, are effective
by the evidence base as being appropriate for in reaching pregnant women, infants, adults
universal implementation by all health care with major chronic medical illnesses, and
systems. Services that are classified here as those in need of surgical procedures. For
“targeted” appear to be appropriate for example, these settings provide a place to
selected populations (e.g., selective or address the behavioral needs of these
indicated populations if applying the IOM patients through behavioral screening and
model), or they have a developing research preventive services, with follow-up in
base that is promising. “Targeted” services prescribed regimens of care. In this way,
might also be social or educational clinical preventive services for depression
interventions that could be provided by and substance abuse can reduce emergency
nonmedical staff to secure educational and room use and hospitalization (Olfson, Sing,
social benefits. & Schlesinger, 1999). Psychoeducational
services also can speed recovery of
Clinical vs. Community Preventive postsurgical patients (Egbert, Battit, Welch,
Services & Bartlett, 1964; Mumford, Schlesinger, &
Most preventive behavioral services are Glass, 1982).
delivered in school and community settings, It may not be incumbent upon health care
not health care settings (Schinke, Brounstein, delivery systems to provide highly specialized
& Gardner, 2002; DHHS, 1999). In a 1998 social and educational support services
review of indicated preventive behavioral (Devine, O’Connor, Cook, Wenk, & Curtin,
services for children and adolescents, Durlak 1988), but health care delivery systems do
and Wells (1997) used meta-analysis to have a role to play. Through their mental
review 177 programs—73 percent were in a health and social work staff, they maintain
school setting, compared with 23 percent working relationships with community-
that were mainly in medical settings. In a based, social service, educational, and even
similar review published 1 year later by the correctional agencies to ensure they meet the
same authors (Durlak & Wells, 1998), none needs of members of the health care delivery
of the programs was in a medical setting. system.

Health Care Delivery System Provision physically ill patients (comorbidity
of Preventive Behavioral Services prevention)
The need for behavioral services is 5. Prevention of conduct disorders in young
substantial. Many who could benefit from children
treatment for these disorders do not receive
care (Woodward et al., 1997; Harwood, The 1999 Surgeon General Report was
Sullivan, & Malhorta, 2001). titled Mental Health: A Report of the
Some of the lack of development of Surgeon General (DHHS, 1999). Although
behavioral health services within health care the major focus of this report was care and
delivery systems may be owing to the management of mental disorders, all major
perception that mental health and substance preventive services were included.
use disorder services may be “softer” and SAMHSA published two recent
therefore less effective than conventional prevention-related health care reports. The
medical therapy. However, the efficacy and 2000 literature review titled Preventive
cost-efficiency of these services is well Interventions Under Managed Care
established and has been recommended by (Dorfman, 2000) used broader definitions of
multiple national organizations since at least “prevention” and “mental health services”
the early 1990s (U.S. Preventive Services and recommended six interventions for
Task Force [USPSTF], 1996, 2002a, 2003). managed care plans:
The 1994 IOM report was titled Reducing
Risks for Mental Disorders—Frontiers for 1. Prenatal and infancy home visits
Preventive Intervention Research (Mrazek & 2. Targeted cessation education and
Haggerty, eds., 1994). A 1998 follow-up counseling for smokers—especially those
report, Preventing Mental Health and who are pregnant
Substance Abuse Problems in Managed Care 3. Targeted short-term mental health
Settings (Mrazek, 1998), was completed in therapy
collaboration with the National Mental 4. Self-care education for adults
Health Association (NMHA). This report 5. Presurgical educational intervention with
recommended widespread implementation of adults
primary preventive programming to address 6. Brief counseling and advice to reduce
five problem areas within health care systems: alcohol use
1. Prevention of initial onset of unipolar This new literature review retains four of
major depression across the life span the above services and omits numbers three
2. Prevention of low birthweight and and four on short-term mental health
prevention of child maltreatment in therapy and self-care. The companion
children from birth to 2 years of age document published in 2002 was titled
whose mothers are identified as being at Estimating the Cost of Preventive Services in
high risk Mental Health and Substance Abuse Under
3. Prevention of alcohol or drug abuse in Managed Care (Broskowski & Smith, 2002).
children who have an alcohol- or drug- This report provided cost data for each of
abusing parent the services recommended in the 2000
4. Prevention of mental health problems in literature review. It also featured, for each set
8 Special Report
of recommended services, a range of costs mental health and substance use disorders;
and options based on case mix and private adolescent substance use treatment; mental
versus public insurance coverage. It health promotion; and adult mental health
estimated the cost to managed care treatment. Many programs focus on school
organizations (MCOs) to implement and family, but increasingly, programs from
recommendations for four possible scenarios community coalitions and environmental
ranging from most expensive to least programs are being identified as well
expensive, given drivers such as enrollment implemented, well evaluated, and effective.
mix, staffing, staff salaries, and fixed and NREP evaluates programs for substance
variable expenses. This report did not abuse prevention and treatment, co-occuring
consider savings in other health care disorders, and mental health treatment,
expenses. Even with the most expensive of promotion, and prevention. After receiving
cost profiles, the report did conclude that all published and unpublished program
six services could be fully implemented at a materials from candidates, NREP reviewers,
marginal cost of less than a 1 percent drawn from 80 experts in relevant fields,
increase in cost, per member per month. rate each program according to 18 criteria
During this period, SAMHSA and the for methodological rigor, and they also score
National Committee on Quality Assurance programs for adoptability and usefulness to
(NCQA)–sponsored Health Employer Data communities (Schinke et al., 2002). Based on
Information Set (HEDIS) program have the overall scoring, NREP categorizes
attempted to bring preventive behavioral programs as Model Programs, Effective
services to the attention of the managed care Programs, Promising Programs, or Programs
community. In response to market pressures with Insufficient Current Support. Those
to demonstrate high scores on HEDIS wishing to learn more about Model
measures, the managed care community has Programs can visit
taken giant strides to improve the care of www.modelprograms.samhsa.gov. At this
patients with depression and has taken steps site, there is also a link providing detailed
to enhance member adherence to prescribed information about NREP and the process for
regimens of care for diabetes. submitting a program for NREP review.
In 1998, SAMHSA’s Center for Substance Despite these efforts, behavioral services—
Abuse Prevention created the National both preventive and therapeutic—still are not
Registry of Effective Programs (NREP) as a adequately identified, provided, or arranged
resource to help professionals in the field by primary care practitioners. They also are
become better consumers of prevention not adequately promoted by health care
programs (Schinke et al., 2002). NREP systems. Brief screening instruments for
reviews and screens evidence-based programs alcohol and drug problems, for example,
(conceptually sound and/or theoretically have been available for a number of years but
driven by risk and protective factors) that, are not widely used by practicing physicians
through an expert consensus review of (Duszynski, Nieto, & Vanente, 1995;
research, demonstrate scientifically defensible National Center on Addiction and Substance
evidence. NREP initially focused on Abuse at Columbia University, 2000). In a
substance use prevention but has expanded 2002 review, Garnick et al. (2002) conducted
to include mental health; co-occurring a telephone survey covering 434 MCOs in 60

market areas nationwide and secured useful comparing therapeutic to preventive services.
responses from 92 percent of them. Only This report, titled Medical Necessity in
14.9 percent of MCOs required any alcohol, Private Health Plans: Implications for
drug, or mental health screening by primary Behavioral Health Care (Rosenbaum,
care practitioners. Slightly more than half Kamoie, Mauery, & Walitt, 2003), noted
distributed practice guidelines that addressed that services are covered by health insurance
mental illness, and approximately one third plans only if they are considered a “medical
distributed substance use disorder practice necessity.” The term medical necessity was
guidelines. defined differently for different services
DHHS’s 2003 campaign, Steps to a within each health plan, with due
Healthier U.S., focuses on chronic disease consideration given for each of the following
prevention and health promotion with the five domains:
goals of decreasing both the prevalence of
certain chronic diseases and the risk factors 1. Contractual scope—whether the contract
that allow conditions to develop. This provides any coverage for certain
initiative aims to bring together local procedures and treatments, such as
coalitions to establish model programs and preventive and maintenance treatments
policies that foster health behavior changes, that are not necessary to restore a
encourage healthier lifestyle choices, and patient to “normal functioning.” This
reduce disparities in health care. dimension preempts any other coverage
In early 2003, SAMHSA published a decision.
review of the delivery of behavioral services 2. Standards of practice—whether the
by managed care organizations, based on treatment (as judged by the health plan)
1999 data. This report, The Provision of accords with professional standards of
Mental Health Services in Managed Care practice.
Organizations (Horgan et al., 2003), showed 3. Patient safety and setting—whether the
substantial variability from plan to plan, as treatment will be delivered in the safest
well as substantial variability among health and least intrusive manner.
maintenance organizations (HMOs), point- 4. Medical service—whether the treatment
of-service (POS) plans, and preferred is considered medical as opposed to
provider organizations (PPOs). All MCOs social or nonmedical.
provided behavioral services, but these 5. Cost—whether the treatment is
services usually had limits and copayments considered cost-effective by the insurer
that were more restrictive than for (Rosenbaum et al., 2003).
comparable medical services. Fewer than 10
percent required screening for behavioral The medical necessity report noted that
disorders in primary care settings (Horgan et Federal or State regulation is limited in
al., 2003). covering how health insurance plans define
Another SAMHSA report, also published medical necessity (Rosenbaum et al., 2003).
early in 2003, offers some insight into This SAMHSA update is intended to build
discrepancies in coverage, comparing upon the reports noted above to further
medical to behavioral services and enhance implementation of preventive
discrepancies in policy and coverage, behavioral services in health care settings.
10 Special Report
Organization of This Report intervention’s evidence of need, efficacy, cost-
This report is organized in the following efficiency, data needs, and implementation-
manner: After the Executive Summary and related issues. Summaries of all proposed
Introduction, the Methods follow as Chapter interventions for each life-cycle group are
III. (Additional details about methodology also presented.
and the outcomes of the literature searches Chapter X focuses on a single intervention,
are included in Appendix A.) Chapter IV psychoeducation, for three categories of
provides an overview of interventions. adult patients. Chapter XI presents overall
Chapters V to IX address specific Conclusions, followed by the References
interventions based on age and life-cycle section with more than 530 entries, and four
groups. These chapters include an abstract; a Appendices that provide details of methods,
narrative introduction; a review and management, billing codes, and procedures
synthesis of the literature relating to the for implementation and evaluation.

12 Special Report
III. Methods
T
he purpose of this literature review was to update, increase the rigor,
and supercede a preliminary literature review published by SAMHSA
in 2000 (Dorfman, 2000). This report includes a review of literature
pertinent to the preventive interventions highlighted in the 2000 review, as
well as the addition of other preventive interventions pertinent to health care
delivery systems.
Scope of Review primary prevention AND mental

Articles published between 1964 and 2003 disorders NOT specific topics listed in
were included in three separate searches, using items 2–9 below
different techniques for different time frames: 2. Mass screening and mental disorders
NOT in topics 3–9 below
■ Stage One: 1998–2002: Advanced Search 3. Health education OR health promotion
on PubMed using nine specific search OR patient education AND mental
terms. (See details below.) disorders NOT topics 2, or 4–9
■ Stage Two: 1964–2002: Search PubMed 4. Home care services or home nursing
using articles listed in previous SAMHSA AND mental disorders
literature review (Dorfman, 2000) and 5. Self-care and mental disorders (Note:
PubMed’s “related articles.” (See there was no way to search separately on
Appendix A.) health risk appraisal in PubMed.)
■ Stage Three: July 2002–October 2003: 6. Prenatal care OR perinatal care AND
Ad hoc inclusion of selected recent, mental disorders
highly pertinent articles. 7. Disease management AND managed care
AND mental disorders
Stage One 8. Case management AND mental disorders
First, a PubMed review was conducted for 9. Psychoeducational (any reference where
the period from January 1, 1998, to July 20, this term was used in title, abstract, or
2002, to identify new preventive text; there is no MeSH term on this topic)
interventions not discussed in the 2000
report. The specific terms used in the Because preliminary searching yielded
advanced search for the period from January more than 20,000 references by simple
1998 to July 2002 are listed here: search techniques—with enormous numbers
of duplicates and inappropriate references—
1. Preventive health services OR preventive advanced search techniques with the
medicine OR preventive psychiatry OR following criteria were used:

■ Limits: All fields, 1998–July 20, 2002, were those so recent but so relevant to the
English Human objectives of this review that they were
■ The term “mental disorders” was used to included, although a methodical review of
include all mental and behavioral this time period was not included.
disorder-related topics, including but not The literature review also included an
limited to substance use disorders, extensive set of publications provided by the
tobacco, alcohol, drug dependence, SAMHSA office, various sets of national
depression, schizophrenia, psychosis, recommendations, and an extensive
anxiety state, adjustment reaction, subsidiary set of literature searches,
hysteria, phobic disorder, obsessive- primarily based on the works cited in the
compulsive disorder, neurosis, documents noted above.
hypochondriasis, somatization, More than 3,000 papers, reports,
malingering, personality disorder, recommendations, and Internet sites were
disordered behavior reviewed, including 528 that are included in
■ Management of behavioral disorders to this report. Most represent randomized
prevent onset or complications of major controlled trials, while the remainder provide
medical illnesses was considered in this background information and guidance
literature review, as was psychoeducation relative to planning, implementation, and
to reduce postsurgical convalescence program evaluation.
The results of this advanced search are Exclusions

summarized in Appendix A. This literature review was limited to
preventive behavioral services best provided
Stage Two by health care systems. This excluded
In the second stage, a more focused literature community, social, economic, general-
review was conducted for the period January population education, and school-based and
1964–July 2002 using PubMed to search for criminal justice interventions. Although
potentially omitted neutral or “negative worksite interventions (such as employee
studies” relative to the topics in the 2000 assistance programs) were not addressed in
SAMHSA report and other items that may this monograph, worksite and productivity
have been missed in the original literature gains were included as benefits of some of
search. This was accomplished using an the proposed interventions.
alternative PubMed search technique; that is, Because of the enormity of the literature, a
listing the key studies used by Dorfman in number of topics were excluded from this
the SAMHSA 2000 report, and then review: AIDS-related issues; Alzheimer’s
searching what Pub Med lists as “Related disease; attention deficit hyperactivity
Articles.” The results of this search are listed disorder; autism; delirium; dementia; eating
in Appendix A. disorders; encopresis; gambling; genetic
testing and screening; homelessness; jet lag;
Stage Three mental retardation and developmental
Finally, selected additional references were disorders (other than prenatal services and
added for publications published between early childhood education); prison/jail;
July 2002 and October 2003. These studies sexual issues and problems. Also excluded
14 Special Report
were adult misuse and abuse of prescription delay, and implementation-related issues.
medications, care facilitation, and provision The final step was to format and organize
of support services to caregivers. the material in a manner that will help ease
implementation in health care delivery
PubMed systems.
The literature review conducted for this The national guidance document most
monograph used PubMed, a service of the directly pertinent to this report is the third
National Library of Medicine. PubMed edition of the Guide to Clinical Preventive
includes more than 14 million citations for Services, a report of the U.S. Preventive
biomedical articles, back to 1950. These Services Task Force, as published in 2003
citations are from MEDLINE and additional (USPSTF, 2003). This third edition, which
life science journals. updates the second with newer scientific
PubMed was used to cover the previous studies, is still evolving as new
Grateful Med 11 databases used to prepare recommendations are posted on the Internet.
the 2000 SAMHSA report (Dorfman, 2000). Using literature review procedures more
(The previous 2000 SAMHSA report elaborate and more rigorous than feasible
included 11 databases located on Grateful for this report, the Guide covers many but
Med: MEDLINE, HealthSTAR, not all of the mental or substance abuse
PREMEDLINE, AIDSLINE, AIDSDRUGS, topics reviewed herein. For topics well
AIDSTRIALS, DIRLINE, HISTLINE, covered in both reports, the findings and
HSRPROJ, OLDMEDLINE, and SDILINE recommendations of the Guide are
[Dorfman, 2000].) It should be noted that extensively duplicated, and then
Grateful Med was phased out in 2001 and supplemented with findings in more recent
replaced with PubMed. See literature and pertinent findings from older
www.nlm.nih.gov/pubs/techbull/jf01/jf01_ig literature not included within the Guide. The
m_phaseout.html for details. Questions may newer guideline on depression is used in this
be directed to [email protected], or call SAMHSA report.
888-FIND-NLM.)
Quality and Types of Evidence
Synthesis of Literature Review Findings for The following criteria are based on the 1996
Development of Monograph second edition of the U.S. Preventive Services
The data synthesis was conducted as a Task Force’s Guide to Clinical Preventive
multistep procedure. The first step Services (USPSTF, 1996)—
concentrated on randomized and other
controlled studies, the 2000 SAMHSA report I: Evidence obtained from at least one
(Dorfman, 2000), and the second and third properly designed, randomized
editions of the Guide to Clinical Preventive controlled trial
Services, a report of the U.S. Preventive II-1: Evidence obtained from well-designed
Services Task Force, as published in 1996 controlled trials without randomization
(USPSTF, 1996; USPSTF, 2003). The second II-2: Evidence obtained from well-designed
step was taken to assess the rigor of the cohort or case-control analytic studies,
research studies and to gather as much data preferably from more than one center
as possible to address cost, feasibility, time or research group

II-3: Evidence obtained from multiple time effect of the intervention. The last stage
series with or without the intervention, encompassed about 38 recent articles,
or dramatic results in uncontrolled published in late 2002 through part of 2003,
experiments that were recent and relevant to the
III: Opinions of respected authorities, interventions under consideration.
based on clinical experience, descriptive Intervention topics were considered for
studies, or reports of expert committees inclusion in this report if they were
preventive (i.e., not purely therapeutic;
This literature review focused on category intended to prevent the occurrence or
I and II-1 studies for proof of efficacy. progression of a risk factor or illness), and
Special attention was given to studies behavioral in nature (involving substance
showing no effect to determine whether the misuse or a mental health condition,
strength of these studies is sufficient to intended to impact medical or behavioral
nullify those showing positive results, and to outcome), and appropriate for provision by
studies in other categories for the guidance health care delivery systems. Studies that
they provide relative to program were included for consideration met the
implementation issues. All readily available USPSTF design criteria I through II-2 (see
studies were reviewed, regardless of study definitions above), and in one case, II-3,
design, to identify and address the program explained below.
implementation issues of importance to After analysis of all the peer-reviewed,
translate results of the controlled studies into published studies generated through the
day-to-day health care practice. The search mechanism, most topics selected for
discussion for the evidence base for each “general” interventions to be delivered
guideline addresses the strength of the most universally were required to have at least one
important studies and the strength of the or more RCTs. For interventions where no
overall evidence base. RCT existed, less rigorous literature was
Additional details on the methods used in reviewed for consideration as a suggested
development of this monograph are service, and if used, targeted to selected
presented in Appendix A. patient groups, based on their risk factors.
For example, the inclusion of screening for
Synthesis of Findings illicit drug use by pregnant women was
The first stage of searches yielded more than based on less rigorous observational studies
20,000 articles; advanced searching (classified as II-3) because no RCTs can be
narrowed that number to 3,436. Of those, performed with this group due to ethical
76 studies were randomized controlled trials considerations. Similarly, since there were no
(RCT), and of those RCT, only 49 were RCTs for screening children for behavioral
relevant. The second stage of searching, disorders or screening adolescents for the
based on nine anchor studies from the interventions, other well-designed, peer-
previous SAMHSA report by Dorfman reviewed studies were considered.
(2000), yielded 1,132 references, of which If the literature was strong and the
340 were RCTs or meta-analyses. Analysis of potential benefits outweighed the potential
those 340 articles revealed 58 were positive harmful effects, the intervention was
studies, while 11 were neutral or showed no included as a suggested guideline. Once the
16 Special Report
evidence was established that a screening nonrandomized controlled trials, studies
procedure (for tobacco, alcohol, illicit drugs, with negative or neutral results were
depression, or behavioral disorders) was analyzed. This was followed by
justified for one age-specific life cycle group, consideration of all other available literature
it was also considered for other age groups. on the intervention. These steps were taken
For example, randomized trials exist for to identify determinants of success and
screening adults for depression, but not failure of implementations. While many
adolescents. The established basis for the studies were synthesized into a balanced
service in adults encouraged a review of review of each intervention, only those
intervention literature on screening studies that qualified as a major trial, large
adolescents for depression as well. meta-analysis, or published research that
After consideration of meta-analyses, provided specific guidance about
randomized trials, and well-designed, implementation were included as references.

18 Special Report
IV. Overview of
Interventions
A
health care system could initiate a screening program for one
disorder, or for a single age cohort, or for a life cycle group, and use
the policy, management, and evaluation procedures as templates for
other preventive behavioral services to other age and life-cycle groups. Two
tabular summaries of screening topics based on age and life cycle groups
addressed in this monograph follow:
Table 1: Summary of Universal Preventive Service Guidelines
Child/Adolescent
Tobacco Alcohol Illicit Drugs Depression
Behavioral Disorders
Pregnant Women General General General
Children and
Adolescents Targeted
(5–18 years)
All Adolescents
General General General Targeted
(12–18 years)
Adults (19 years
General General General
and older)
Table 1 summarizes the screening and follow-up guidelines for all patients within the life cycle
group. Those designated as “general” are intended for all patients within that group. Pregnant
women and adolescents should be screened for use of tobacco, alcohol, and illicit drugs. All adults
should be screened for depression, as well as selected adolescents who are at unusually high risk.
The use of the term “targeted,” relative to children and adolescents, reflects literature that shows
the utility of a standardized questionnaire, the Pediatric Symptom Checklist, but the absence of pub-
lished studies that demonstrate improved patient outcomes. All adults aged 19 and older are
grouped into a single life cycle group. For the preventive behavioral services covered in this report,
the guidelines are identical for seniors.
The robust literature search supports vulnerable populations or those with the staff
“general” services for implementation by all expertise to effectively use guidelines and
health care delivery systems. “Targeted” tools. They are either less well documented
services can be considered by health care or are not to be universally applied.
delivery systems, but they will only be Screening pregnant women, adolescents,
appropriate for providers serving highly and adults and providing follow-up for

Table 2: Summary of Selective Preventive Service Guidelines
Pregnant
Women; Targeted: Intensive case management, outreach, and home visitation services for
Children to selected families handicapped by social and economic dependency
Age 5
Targeted: Supplemental educational services for selected infants and preschool
children born to mothers with mental retardation or selected other problems
Adults (19 years
General: Psychoeducation and related services for patients with chronic disease
and older)
General: Psychoeducation for patients scheduled for surgical procedures
Targeted: Psychoeducation for patients with somatization
Table 2 summarizes the preventive behavioral interventions suggested for specific groups of patients.
The first service with home visitation is targeted to high-risk pregnant women and their children
through age 5. The second service is for children born to mothers with mental retardation or other
limitation. The last three interventions on psychoeducation are for adults who fall into one of three
categories.
tobacco use, inappropriate use of alcohol, specific need for physicians and nurses to
illicit drug use, and depression may be screen children for these disorders, as is
regarded as “general” services, supported by suggested for adolescents and adults.
rigorous replicated research studies, as are Screening children and adults for other
psychoeducational services for patients with behavioral disorders may be considered a
chronic diseases and those scheduled for “targeted” service, as noted below.
surgical procedures. ■ Depression is a common and serious
problem in adolescence. The screening
The following are exceptions to the general modalities used in adults appear
guidance above: somewhat less specific for adolescents, and
too few substantive studies exist on
■ There is no evidence that screening screening adolescents for depression to
pregnant women for depression will assert a robust evidence base. The USPSTF
reduce the prevalence or severity of found insufficient evidence in 2002 to
postpartum depression, and the research make a recommendation for universal
is not yet sufficient to demonstrate that depression screening of adolescents,
all adolescents and children should be similar to the one they made for adults.
screened for depression. ■ Adults using illicit drugs should be
■ Community programs that address treated vigorously for both the physical
tobacco, alcohol, illicit drugs, behavioral and psychological aspects of their
disorders, and depression are all addiction. That having been noted, the
important preventive measures. In literature does not support screening all
clinical settings, there appears to be no adults for use of illicit drugs.
20 Special Report
Screening for child and adolescent prescribed regimens of care. The value and
behavioral disorders using the Pediatric efficacy of psychoeducation for chronic
Symptom Checklist (PSC) is widely used in disease patients is well established in the
many medical practices and Medicaid published literature (Spiegel, Kraemer,
programs. The current literature documents Bloom, & Gottheil, 1989; Roter et al., 1998;
the ability of this brief, one-page instrument Hammerlid, Persson, Sullivan, & Westin,
to identify children in need of further 1999; Dusseldorp, van Elderen, Maes,
behavioral evaluation. Unfortunately, there Meulman, & Kraaij, 1999; Von Korff et al.,
are no randomized controlled studies that 1998; Winkler et al., 1989; Parcel et al.,
compare outcomes on screened individuals 1994; Mishel et al., 2002). Similar
with unscreened populations. Despite the psychoeducational services have been shown
fact that no randomized, controlled trials to be of substantial value for both children
have been conducted, PSC screening is still and adults scheduled to undergo surgical
classified here as “general” because of its procedures (Egbert et al., 1964; Mumford et
low burden, ease of use, wide applicability, al., 1982; Devine & Cook, 1983; Devine et
and potential cost-effectiveness. al., 1988; Jay, Elliott, Fitzgibbons, Woody, &
The “targeted” services for pregnant Siegel, 1995).
women and infants handicapped by social As previously defined, somatization
and economic disadvantage can be describes true physical symptoms and true
considered under the general category for physical illnesses that are initially
health care delivery systems serving psychogenic in nature. Those who experience
Medicaid and “safety net” populations, but somatization use substantial medical
this designation may not be appropriate for resources but do not display physical illness
other systems. adequate to explain their high use. Recent
The supplemental educational services for reviews have estimated the prevalence of
infants and preschool children born to somatoform disorders in the range of 10–15
mothers with mental retardation or selected percent of primary care patients (Kroenke,
other problems are nonmedical services Spitzer, deGruy, & Swindle, 1998; Kirmayer
needed by infants and preschool children & Robbins, 1991; Spitzer, Williams, et al.,
whose risk profiles are most obvious to their 1994; Kellner, Lin, Von Korff, et al., 1985)
primary care providers. Health care delivery and documented the impact of these
systems can identify the infants and children disorders on both quality of life and health
in need of these supplemental services and care utilization (Kroenke et al., 1998; Katon,
either provide the services or otherwise Lin, Von Korff, et al., 1991; Smith, Monson,
connect these infants and children to needed & Ray, 1986; Swartz, Landerman, George,
educational programming. et al., 1991; Kroenke, Spitzer, deGruy, et al.,
When dealing with patients who have 1997; Smith, 1994; Escobar, Rubio-Stipec,
heart disease, asthma, diabetes, or other Canino, et al., 1989; Deighton & Nicol,
major chronic illnesses, the term 1985; Hiller, Rief, & Fichter, 1995).
psychoeducation, as defined earlier, refers to Although there are several studies suggesting
counseling integrated with health education that screening for somatization, followed by
to address emotional, perceptual, and psychoeducational interventions is of value
psychological barriers to compliance with (Smith, Rost, & Kashner, 1995; Fifer et al.,

2003), specification of exact screening and
follow-up procedures is insufficient to
suggest implementing psychoeducational
services for somatization as a general clinical
preventive service.
22 Special Report
V. Pregnant Women
T
he literature provides strong evidence that substance use disorder
(tobacco, alcohol, and use of illicit drugs) services for pregnant
women can substantially reduce premature births, neonatal deaths,
birth defects, and the need for neonatal intensive care. Alcohol use that would
not be considered physically problematic for nonpregnant women is medically
contraindicated during pregnancy. Effective interventions to address tobacco
and alcohol use in pregnancy yield benefits in excess of program costs within
12 months of program initiation. Preventing use of illicit drugs during
pregnancy may generate similar benefits, but studies have not been done to
definitively confirm or deny this impression. The health care cost savings
achieved within 12 months of program initiation will be due to reduction in
use of newborn intensive care unit (NICU) services.
The evidence base for the recommended tobacco, alcohol, and illicit drugs during
tobacco-related and alcohol-related universal pregnancy may be considered in the context
interventions for pregnant women is very of similar interventions for all adolescents
strong and includes well-designed, and all adults. Special emphasis is given to
randomized controlled trials. The evidence pregnant women in this section of this
base for services related to illicit drugs does monograph because such screening usually
not include randomized controlled trials can be relied upon to be cost-effective by
because ethical and practical considerations offsetting reductions in health care costs
preclude such studies. (Randomized studies within 12 months of providing the screening
would require purposely denying care for service.
substance abuse to half the women in the Yet another factor is the well-documented
study.) Despite this limitation, the data from increased responsiveness to such screening
currently available nonrandomized studies and counseling during pregnancy, when
fully justify vigorous efforts to identify and women appear more sensitive to such
address illicit drug use by pregnant women. screening. After delivery of the infant, they
The literature specific to depression during are likely to relapse into previously
pregnancy was insufficient to justify established patterns of substance use
pregnancy-specific depression screening disorder. This relapse, although undesirable,
because it does not seem to be of value in does not negate the value of their abstinence
preventing postpartum depression (Hayes, from substance use disorder during
Muller, & Bradley, 2001). pregnancy.
Screening pregnant women for use of

Tobacco pregnancy—for the benefit of the unborn
Robust research suggests that tobacco child. This may be reinforced at every
screening and follow-up be classified as outpatient visit.
essential for all pregnant women in all health Intervention issues specific to tobacco and
care settings. The immediate benefit (direct pregnancy are as follows:
outcome) is reduction of tobacco use for the
duration of pregnancy. The indirect but ■ Research studies indicate that more
definitive benefit is reduction in the intensive smoking cessation
percentage of women delivering low- programming for pregnant women has
birthweight infants who are at high risk of not been shown to be more effective
requiring neonatal intensive care (NICU) than less intense interventions (unlike
services and reduction of infant mortality. studies for nonpregnant adult smokers).
Tobacco-related programming for pregnant ■ Adequate data are not available to
women has a very high probability of being recommend for or against the use of
cost-effective by reducing the need for NICU nicotine-replacement products in
and other hospital services. This is true even pregnant women.
with very low quit rates because of the
extremely high cost of NICU and other Review of Literature
hospital services. A more general review of the tobacco and
Within the doctor-patient interface, health literature is presented in the
tobacco control for pregnant women is discussion of tobacco in the Adults (19 Years
perhaps best delivered in the context of and Older) section of this report. The
tobacco and alcohol screening and related following review is limited to literature
services for pregnant women. The primary specific to pregnant women.
intervention takes place at the first prenatal
visit, when a full history is taken and Evidence of Need
substantial counseling is provided. According to the 1996 Second Edition of the
From the perspective of the health care U.S. Preventive Services Task Force’s Guide
system, the initial screening and follow-up to Clinical Preventive Services (USPSTF,
services are best developed in the context of 1996)—
a well-established array of related services
for all life-cycle groups, with links to … Smoking during pregnancy causes
community-based support services. about 5 percent to 6 percent of
perinatal deaths, 17 percent to 26
percent of low-birthweight births,
Interventions and 7 percent to 10 percent of
General information on screening, follow-up, preterm deliveries (DHHS, 1989;
and data gathering are presented in Centers for Disease Control and
Appendix D of this monograph. Prevention [CDC], 1990), and it
The literature provides evidence that every increases the risk of miscarriage and
pregnant woman should be asked whether fetal growth retardation. It may also
increase the risk for sudden infant
she smokes or uses any other form of
death syndrome (SIDS) (Mitchell,
tobacco. If so, she may be counseled to Ford, Steward, et al., 1993;
quit—at least for the duration of the Schoendorf & Kiely, 1992)… .
24 Special Report
Pregnant women who stop smoking Strong evidence for the efficacy and cost-
by the 30th week of gestation have efficiency of tobacco-related interventions for
infants with higher birthweights than pregnant women can be found in multiple
infants born to women who smoke
randomized controlled trials and meta-
throughout pregnancy (CDC, 1990).
analyses. Four are briefly reviewed below.
Effectiveness: Evidence Base for Intervention The first set of randomized controlled
In two of the earlier randomized clinical trials was published by Ershoff et al., from
trials, tobacco cessation counseling with self- Kaiser Permanente, in Los Angeles (Ershoff
help materials increased mean birthweight et al., 1990; Ershoff, Mullen, & Quinn,
and decreased the incidence of intrauterine 1989). These studies explored the benefits of
growth retardation (Ershoff, Quinn, Mullen, various intensities of smoking cessation
& Lairson, 1990; Sexto & Hebel, 1984). programming for pregnant women in an
Studies indicate that asking pregnant HMO, representing a wide range of
women about tobacco use, combined with socioeconomic classes and racial and ethnic
physician counseling and supplementary diversity. Women who were welfare clientele
smoking cessation programming can increase or who did not speak English were not
tobacco-abstinence rates 5–23 percent, included in these studies.
comparing intervention to control groups The first trial included 126 cases and 116
(Ershoff et al., 1990; Sexto & Hebel, 1984; controls. The experimental intervention
Hjalmarson, Hahn, & Svanberg, 1991; consisted of one-time counseling and a set of
Windsor, Lowe, Perkins, et al., 1993; Mayer, eight short self-help booklets distributed by
Hawkins, & Todd, 1990). mail at weekly intervals, with the women
Since the mid-1980s, every major health- committed to completion of activity
related organization that has addressed this assignments within the booklets. The control
issue has recommended routine clinician group received the initial counseling, a two-
counseling of adults, pregnant women, page brochure, and usual physician
parents, and adolescents to avoid or counseling. No attempt was made to modify
discontinue smoking and use of smokeless the physician counseling or to provide other
tobacco (USPSTF, 1996; American College of health education to the intervention group.
Physicians Health and Public Policy This intervention resulted in a 22.2 percent
Committee, 1986; American Academy of quit rate in the study group, compared with
Family Physicians [AAFP], 1994; American an 8.6 percent quit rate in controls.
Academy of Pediatrics [AAP], 1994, 1988; Compared with the control group, the self-
American College of Obstetricians and help groups were 45 percent less likely to
Gynecologists [ACOG], 1993; Manley, Epps, deliver a low-birthweight infant. Within the
Husten, et al., 1991; American Medical studied population, mean cost per full-term
Association [AMA], 1993, 1994a; American birth, without intrauterine growth
Dental Association [ADA], 1992; Canadian retardation, was $695. Mean cost per
Task Force on the Periodic Health preterm birth was $6,213. Benefit-cost ratio,
Examination, 1994b; National Institutes of based on data limited to the infants’ initial
Health [NIH], 1989, 1994; American hospitalization, was estimated at about 3:1.
Academy of Otolaryngology—Head and In 1995, Ershoff et al. published data from
Neck Surgery, 1992; Green, ed., 1994). 171 pregnant women who quit smoking

prior to pregnancy, then relapsed during smokers into three groups. Group 1, the
pregnancy (Ershoff, Quinn, & Mullen, control, received information in a
1995). These women were provided the nonfocused interaction on smoking and
same interventions noted above pregnancy requiring approximately 5
(simultaneous with the study noted above). minutes at the first prenatal visit. Group 2
In the intervention group, 16 percent received the standard clinic information plus
relapsed, compared with 20 percent in the a copy of Freedom From Smoking in 20
control group—a difference too small to be Days, a self-help manual published by the
of statistical significance. American Lung Association (ALA). They
In 1996 and 1997, the Ershoff team ran also received an ALA informational packet
another smoking cessation trial among entitled “Because You Love Your Baby” and
pregnant women. This study, published in a 10-minute educational session by a
1999 (Ershoff et al., 1999), randomized 390 baccalaureate-trained health education
English-speaking women, 18 years of age and specialist at the initial prenatal visit. The
older, into three groups. The first received third group received the Group 2
usual physician counseling and a self-help intervention, but with a pregnancy-specific
book. The second also was given telephone self-help manual, A Pregnant Woman’s Self-
access to a computerized telephone cessation Help Guide To Quit Smoking. No smoking
program based on interactive voice response cessation interventions were used in any of
technology. The third received the booklet, the three groups after the first prenatal visit.
usual counseling, plus proactive telephone Smoking status was confirmed midpregnancy
counseling from nurse educators using and at the end of pregnancy using patient
motivational interviewing techniques and self-reports and saliva thiocyanate tests. The
strategies. All three groups achieved the quit rates were 2 percent, 6 percent, and 14
approximate 20 percent quit rate achieved in percent for the three groups, respectively.
the earlier study, but the more intensive In the follow-up study, published in 1993
interventions provided no additional benefit. (Windsor et al., 1993), the Windsor team
In all three groups, cessation rates among randomized 814 pregnant smokers from the
initially heavy smokers were strikingly low. same clinic setting to case and control
Within each of the groups, approximately two groups. The control group received an
thirds of the women made at least one serious intervention similar to that of Group 2 from
attempt to quit smoking, at least for the the earlier study. The experimental group
duration of pregnancy. Most were unable to received more extensive written materials
do so. Mean reductions in cigarette smoking and counseling, with follow-up and
among those who continued to smoke were reinforcement at each subsequent clinic visit.
modest, averaging a reduction from 8.3 Quit rates in the two groups were
cigarettes per day to 7.8 cigarettes per day. approximately the same as the quit rates in
Windsor et al. reported on a preliminary the earlier study—8.5 percent and 14.3
and more definitive trial conducted in a percent in the two groups, respectively. Quit
public health clinic population in rates were higher for African Americans than
Birmingham, Alabama (Windsor, Warner, & for Whites in both control and experimental
Cutter, 1988; Windsor et al., 1993). The groups (10.7 percent and 18.7 percent for
initial study randomized 309 pregnant African Americans, compared with 5.2
26 Special Report
percent and 10.0 percent for Whites). consumption during pregnancy.
In a study similar to the second Windsor ■ Available interventions only offer limited
study but conducted in a Women, Infants, quit rates (5–23 percent).
and Children (WIC) clinic in Grand Rapids, ■ Prevalence of smoking is higher and
Michigan, Mayer et al. (1990) demonstrated response to smoking-cessation
quit rates of 11 percent among the programming is less substantial in low-
experimental group and 3 percent among the income and otherwise economically and
controls. When measured 4.7 weeks socially vulnerable women.
postpartum, the quit rates within the two ■ Estimating both current smoking rates
groups were 7 percent and 0 percent, and quit rates in a given population can
respectively. be problematic because smokers who
The strength of this evidence base and know they should not smoke often lie.
benefits of such screening were reaffirmed in The better studies (such as all those
a 2002 meta-analysis by Melvin et al. referenced above) supplement the
(Melvin, Dolan-Mullen, Windsor, Whiteside, women’s statements with laboratory
& Goldenberg, 2000). Another extensive measures of tobacco exposure.
literature review published that same year Laboratory confirmable quit rates tend to
(Lumley, Olver, & Waters, 2000) noted that run much lower than the rates suggested
smoking cessation programs in pregnancy by interviews of smokers. (Editorial note:
appeared to reduce smoking, low-birthweight such laboratory confirmation, measuring
and preterm birth, but no effect was detected cotinine or thiocyanate used in research
for very low birthweight or perinatal studies, is not suggested for routine
mortality. Five trials of (postpartum) smoking clinical practice.)
relapse prevention showed no significant ■ Studies show that pregnant women seem
benefit (Lumley et al., 2000). to respond differently to smoking-
cessation programming, compared with
Efficacy and Program Implementation Issues other adults who smoke. In other adults,
A meta-analysis by Mullen (1999) provides a more intensive programming with more
summary of the available literature and frequent personal contact increases quit
implementation-related issues to be rates, as does use of nicotine replacement
considered by individual managed care products. With pregnant women, basic
plans. Important program implementation physician counseling, supplemented by
points include the following: limited interventions, such as self-help
materials, appears to generate maximal
■ Smoking during pregnancy is a benefit, while more intensive
substantial health hazard to the programming does not increase quit rates.
fetus/infant and mother. ■ High-quality data on the efficacy of
■ These hazards appear to be best avoided nicotine replacement products are not
by having the woman quit smoking prior available for pregnant women.
to pregnancy; but if that has not been
achieved, substantial benefits may be The one issue of greatest concern not
secured by having her quit, or at least addressed by Mullen is the level of benefit,
substantially reduce cigarette according to quit rate, that is needed to

generate cost-effectiveness within 12 months Windsor (Windsor et al., 1988, 1993), and
of program initiation. This issue is addressed Mullen (1999) studies referenced above
in a cost-benefit/cost-effectiveness analysis of provide information on providing effective
such programming published by Marks and and cost-efficient smoking-cessation services
his team at the Centers for Disease Control to pregnant women in conventional HMO
and Prevention (CDC) in 1990 (Marks, settings (Ershoff et al., 1999) and indigent
Koplan, Hogue, & Dalmat, 1990). This care clinics (Windsor et al., 1988, 1993).
analysis, based on the studies referenced The Mullen study (Mullen, 1999) provides
previously in this report and a number of excellent guidance on issues to be addressed
similar studies by other authors, in the design of such programs.
demonstrates an average savings of $3.31 for In the studies where this has been
each dollar spent on effective smoking documented, more than half the women who
cessation programming. This estimate quit smoking during pregnancy resume
assumes a quit rate of approximately 15 smoking after the birth of the infant (CDC,
percent, with the cost calculations limited to 2002). Thus, screening of pregnant women
prenatal care and the initial hospitalization for tobacco use and provision of antismoking
at time of birth of the infant. Considering programming does not eliminate the need for
the cost of care for the infant in subsequent the pediatrician to address these same issues
years, the benefit exceeds $6 per dollar spent after birth of the infant, for the benefit of
on smoking cessation programming for both mother and child.
pregnant women. According to these limited
calculations, a program with a quit rate of Data Needs Specific to Tobacco and Pregnancy
only 5 percent could pay for itself within a Refer to Appendix D, Procedures for
year. These cost-benefit calculations do not Implementation and Evaluation of Preventive
include costs averted relative to respiratory Services, for a discussion of issues related to
illness in mother and infant or any of the screening, follow-up, and data gathering.
other smoking-related costs, some of which
can be substantial. Assessment of Need for Programming and
One other study of note is that of Latts et Assessment of Program Efficacy
al. (Latts, Prochaska, Salas, & Young, 2002) Collecting the following data would help
in a Denver, Colorado, managed care plan. health plans track and evaluate the impact of
In this study, the sponsoring plan staff from tobacco interventions:
participating physician offices were trained
and paid $150 for each pregnant woman ■ Medical records data showing use or
counseled. This study, reported as an suspicion of use of tobacco before and
uncontrolled pilot study, failed to increase during pregnancy
the number of smokers counseled. ■ The number and percentage of these
Program implementation issues deal with women who quit prior to the first
the social and cultural milieu of the pregnant prenatal visit
woman, her educational and socioeconomic ■ Rates of NICU utilization and other
status, and the dedication of both the hospital services during the first 30 days
physician and health care system to tobacco of life
control. The Ershoff (Ershoff et al., 1999), ■ Perinatal death rates (infant death rates
28 Special Report
during the first 30 days of life) women has a very high probability of being
■ Comparison of fetal/infant illness, death, cost-effective by reducing the need for NICU
and health care utilization through the services. This is true even with very low
first 30 days of life, comparing mothers abstinence rates because of the extremely
who quit, those who did not, and high cost of premature births and
nonusers (as ascertained by interview underweight newborns.
and recorded in the medical record) At the doctor-patient interface, alcohol-
control programming for pregnant women is
Summary of Tobacco Use and Pregnancy probably best delivered in the context of
Tobacco use during pregnancy is a major tobacco and illicit drug screening and related
cause of prematurity, low birthweight, and services for pregnant women. The primary
neonatal death. The robust literature indicates intervention takes place at the first prenatal
that all pregnant women—and those visit, when a full history is taken and
comtemplating becoming pregnant—should substantial counseling is provided.
be screened for use of tobacco and advised to From the perspective of the health care
quit. In response to such screening and system, the initial screening and the follow-
follow-up, quit rates from 5 to 30 percent can up services may be best developed in the
be expected. Even a 5 percent quit rate is context of a well-established array of such
likely to pay for itself in reduced utilization of services for all life-cycle groups, with links to
intensive care for premature infants within 12 community-based support services.
months of program initiation.
Interventions
Alcohol A general discussion of factors related to
Screening pregnant women for alcohol use is screening, follow-up, and data gathering
classified as “general.” This means that appears in Appendix D, Procedures for
extensive research suggests programming is Implementation and Evaluation of Preventive
beneficial to all pregnant women in all health Services. The literature provides strong
care settings. The direct outcome is reduced evidence that every pregnant woman should
alcohol use during pregnancy. The immediate be asked about alcohol consumption and
benefit is a dramatic reduction in Fetal should be urged to abstain, at least for the
Alcohol Spectrum Disorders (FASD), including duration of the pregnancy for the benefit of
the most debilitating form, Fetal Alcohol the unborn child. Similarly, research suggests
Syndrome (FAS), and a modest reduction in that those who historically have consumed
prematurity. Given the relative rarity of FAS alcohol would benefit from having this
and FASD in most health care settings, and the message reinforced at every outpatient visit.
nature and quality of the literature available,
the primary measurable benefit to reducing Intervention-Related Issues Specific to Alcohol and
alcohol use in pregnancy relates to the Pregnancy
reduction in prematurity and low birthweight. Information adapted from the 1996 Second
The absence of claims for FAS and FAE does Edition of the U.S. Preventive Services Task
not suggest a lack of need for alcohol control Force’s Guide to Clinical Preventive Services
programming for pregnant women. (USPSTF, 1996) suggests that—
Alcohol-related programming for pregnant ■ All pregnant women be screened for

evidence of problem drinking or risk to complete and is more accurate
drinking (two drinks or more per day or than AUDIT (Alcohol Use Disorder
binge drinking), especially during the Identification Test) for detecting
current alcohol consumption and
first trimester of pregnancy.
risky drinking, as well as history of
■ All pregnant women and all women past alcoholism; however, it is less
contemplating pregnancy be informed of specific (Chang, 2001). The five-item
the harmful effects of alcohol on the TWEAK (Tolerance/Worried/Eye
fetus and be advised to cease drinking. opener/Amnesia/K(c)ut down)
■ Women who both smoke and drink be (Russell, Martier, & Sokol, 1991)
performs similarly to T-ACE (Chang,
advised that their risk of low-birthweight
2001) and can be used to detect a
infants is greatest. range of drinking levels from
■ Patients with evidence of alcohol abuse moderate to high-risk consumption
or hazardous drinking be offered brief (Dawson, Das, Faden, et al., 2001).
advice and counseling.
■ Patients with evidence of alcohol Details on these and other alcohol-related
dependence be referred to appropriate screening tests can be found on the NIAAA
clinical specialists or community Web site at www.niaaa.nih.gov. Additional
programs. information and sample questionnaires for
■ Physician education: Because of the CAGE and AUDIT are provided in the
difficulty in ascertaining alcohol use in discussion about alcohol in this monograph.
many women, use of facilitators, as
suggested later in this report, or use of Literature Review
videotape-augmented training of More substantial reviews of the alcohol-and-
obstetric care practitioners may be health literature can be found in the sections
considered. A group in New Mexico has of this monograph related to selected
demonstrated the value of the videotape- children, adolescents, and adults. The
augmented training in a randomized discussion on adults and alcohol includes
controlled trial (Handmaker, Hester, & presentation and discussion of the most
Delaney, 1999). important alcohol screening questionnaires.
In a 2002 review of alcohol problem- Evidence of Need

related screening questionnaires, the According to further information in the
National Institute on Alcohol Abuse and 1996 Second Edition of the U.S. Preventive
Alcoholism (NIAAA, 2002) stated— Services Task Force’s Guide to Clinical
Preventive Services (USPSTF 1996)—
… Two questionnaires are available
that are appropriate for pregnant The proportion of pregnant women
women, both derived in part from who report drinking has declined
CAGE (Cut steadily in the U.S. (Serdula,
Down/Annoyed/Guilty/Eye opener) Williamson, Kendrick, et al., 1991).
(Chan et al., 1994), T-ACE Recent surveys indicated 12–14
Tolerance-Annoyed/Cut down/Eye percent of pregnant women continue
Opener (Sokol, Martier, & Ager, to consume some alcohol (Goodwin,
1989) takes approximately 1 minute Bruce, Zahniser, et al., 1994; CDC,
30 Special Report
1994b), with most reporting only 1993), but the effects at lower levels
occasional, light drinking (median: have been inconsistent (Russell,
four drinks per month) (Serdula et 1991; Jacobson, Jacobson, Sokol, et
al., 1991). Binge drinking or daily al., 1993; Streissguth, Barr, &
risk drinking (usually defined as two Sampson, 1990). Modest
drinks per day or greater) is reported developmental effects have been
by 1–2 percent of pregnant women attributed to light drinking (seven
(Goodwin et al., 1994; CDC, 1994b, drinks per week) in some studies, but
1995a), but higher rates (4–6 underreporting by heavy drinkers
percent) have been reported in some and confounding effects of other
screening studies (Sokol et al., 1989; important factors (nutrition,
Russell, Martier, Sokol et al., 1994). environment, etc.) make it difficult
to prove or disprove a direct effect of
Excessive use of alcohol during light drinking (NIAAA, 1993;
pregnancy can produce fetal alcohol Russell, 1991; Knupfer, 1991).
syndrome (FAS), a constellation of Timing of exposure and pattern of
growth retardation, facial drinking may be important, with
deformities, and central nervous greater effects proposed for exposure
system dysfunction (microcephaly, early in pregnancy and for frequent
mental retardation, or behavioral binge drinking (NIAAA, 1993).
abnormalities) (Rosett, Weiner, &
Edelin, 1983). Other infants display Effectiveness Evidence Base for Intervention
growth retardation or neurologic According to the 1996 Second Edition of the
involvement in the absence of full U.S. Preventive Services Task Force’s Guide
FAS (i.e., fetal alcohol effects [FAE]) to Clinical Preventive Services (USPSTF,
(NIAAA, 1993). FAS has been
1996)—
estimated to affect approximately
one in 3,000 births in the U.S.
(1,200 children annually), making it There are no definitive controlled
a leading treatable cause of birth trials of treatments for excessive
defects and mental retardation (Abel drinking in pregnancy (Schorling,
& Sokol, 1991; CDC, 1993b). 1993). In several uncontrolled
studies, a majority of heavy-drinking
The level of alcohol consumption pregnant women who received
that poses a risk during pregnancy counseling reduced alcohol
remains controversial (NIAAA, consumption (Rosett et al., 1983;
1993; Russell, 1991). FAS has only Larson, 1983; Halmesmaki, 1988)
been reported in infants born to and reductions in drinking were
alcoholic mothers, but the variable associated with lower rates of FAS
incidence of FAS among alcoholic (Rosett et al., 1983; Halmesmaki,
women (from 3 to 40 percent) (Abel 1988). Many women spontaneously
& Sokol, 1991) suggests that other reduce their drinking while pregnant,
factors … may influence the however, and women who continue
expression of FAS (NIAAA, 1993)…. to drink differ in many respects from
Most studies report an increased women who cut down (e.g., heavier
incidence of FAE among mothers drinking, poorer prenatal care, and
who consume 14 drinks per week or nutrition). As a result, it is difficult
more (Russell, 1991; Virji, 1991; to determine precisely the benefit of
Forrest, Florey, et al., 1991; Verkerk, screening and counseling during
Noord-Zaadstra, Florey, et al., pregnancy. In two trials that

employed a control group, the Chasnoff, Neuman, Thornton, & Callaghan,
proportions of women abstaining or 2001).
reducing consumption were similar Another part of the problem is the limited
in intervention and control groups
utility of interventions, especially in heavier
(Waterson & Murray-Lyon, 1990;
Meberg, Halvorsen, Holter, et al., drinkers and those who do not access early
1986). prenatal care. As noted below, results are
mixed and not well documented in
The U.S. Surgeon General (Surgeon controlled studies. The better controlled
General, 1981) and the American studies did not address the cost-benefit or
Academy of Pediatrics (AAP) and
cost-efficiency of treatment options.
American College of Obstetricians
and Gynecologists (ACOG) Despite this lack of firm evidence, the
(AAP/ACOG, 1992; American hazard posed by alcohol consumption during
Academy of Pediatrics Committee on pregnancy and the apparent ease by which
Substance Abuse and Committee on alcohol consumption can be reduced in
Children with Disabilities, 1993) many pregnant women would seem to
advise counseling all women who are indicate that all health care providers should
pregnant or planning pregnancy that
address this issue.
drinking can be harmful to the fetus
and that abstinence is the safest Although they did not provide new
policy. The Canadian Task Force findings or evidence, two recent reviews
(CTF) recommends that all women nicely summarized literature more recent
be screened for problem drinking and than the USPSTF Guide (USPSTF, 1996).
advised to reduce tobacco use during These are a 1999 review in the Milbank
pregnancy (CTF on the Periodic
Quarterly (Frohna, Lantz, & Pollack, 1999)
Health Examination, 1994a).
and a 2000 review from a group at Wayne
Efficacy and Program Implementation Issues State University in Detroit (Hankin, McCaul,
In the case of alcohol control during & Heussner, 2000).
pregnancy, the major program
implementation issue will relate to the Data Needs Specific to Pregnancy and
sociodemographic profile of the membership Alcohol
and issues that will need to be addressed Collecting the following data would help
relative to cultural sensitivity. The overall health plans track the impact of their
community tolerance for alcohol alcohol- screening intervention. Refer to
consumption, use, and abuse will be a Appendix D.
significant factor.
A major part of the problem is identifying ■ Numbers of cases of FAS and FASD
alcohol use in pregnant women, since many diagnosed in prior year
will not admit such use. Several studies have ■ Evidence of alcohol-related problems in
demonstrated the value of structured other members of the managed care plan
questionnaires as an effective means of that might suggest a community-wide
ascertaining alcohol use (Chang et al., 1998; alcohol problem
Chang, Goetz, Wilkins-Haug, & Berman, ■ Medical records data showing use or
1999; Midanik, Zahnd, & Klein, 1998; Bull, suspicion of use of alcohol before and
Kvigne, Leonardson, Lacina, & Welty, 1999; during pregnancy
32 Special Report
■ The number and percentage of these elimination of maternal, fetal, and infant
women who quit prior to the first complications of such use. At the doctor-
prenatal visit patient interface, programming for pregnant
■ Rates of NICU utilization and other women using illicit drugs is probably best
hospital services during the first 30 days delivered in the context of tobacco and
of life alcohol screening and related services for
■ Perinatal death rates (infant death rates pregnant women. The primary intervention
during the first 30 days of life) takes place at the first prenatal visit, when a
■ Comparison of fetal/infant illness, death, full history is taken and substantial
and health care utilization through the counseling is provided. From the perspective
first 30 days of life, comparing mothers of the health care system, the services are
who quit, those who did not, and non- best developed within the context of
users (as ascertained by interview and established services for all life-cycle groups
documented in the medical record) with links to community-based support
services.
Summary of Alcohol Use and Pregnancy
The robust literature indicates that all Intervention
pregnant women—and those contemplating Robust research supports asking every
becoming pregnant—should be screened for pregnant woman about use of illicit drugs
the use of alcohol and advised to abstain and urging pregnant women to abstain, at
while pregnant. least for the duration of the pregnancy, for
the benefit of the unborn child. Similarly, the
Illicit Drugs literature provides strong evidence that this
Screening pregnant women for use of illicit message should be reinforced at every
drugs is classified as “general.” This means outpatient visit for those who historically
that strong research supports this for all have used such drugs.
pregnant women in all managed care and
other health care settings. With the exception Service-Related Issues Specific
of withdrawal symptoms at time of delivery, to Illicit Drugs and Pregnancy
no studies have successfully separated the Information adapted from the
effects of the illicit drugs on the fetus/infant recommendation in the 1996 Second Edition
from the effects of concurrent tobacco and of the U.S. Preventive Services Task Force’s
alcohol use and lack of prenatal care. The Guide to Clinical Preventive Services
literature clearly indicates that pregnant (USPSTF, 1996) suggests that—
women using illicit drugs have poor pregnancy
outcomes, but separating the influence of the ■ Every managed care organization has
drug itself from these other risk factors has access to psychiatrists and/or other
proven practically impossible (USPSTF, 1996). professional staff who are expert in the
There are no published studies in which the diagnosis and management of women
woman has been given drug treatment without who engage in the use of illicit drugs
concurrent prenatal care. (marijuana, cocaine, heroin, and others)
The benefits to be pursued are reduction of during pregnancy.
illicit drug use during pregnancy and ■ All clinicians in managed care settings

that participate in the provision of and cocaine (1.1 percent) (National
prenatal care be trained to recognize Institute on Drug Abuse [NIDA],
signs and symptoms that suggest use of 1994c). Anonymous urine testing of
nearly 30,000 women giving birth in
illicit drugs during pregnancy and how
California in 1992 detected illicit
best to interview such patients. drugs in 5.2 percent: marijuana (1.9
■ All pregnant women be advised of the percent), opiates (1.5 percent), and
potentially adverse effects of drug use on cocaine (1.1 percent) were the most
the development of the fetus. frequently detected substances (Vega,
■ Routine (blood and urine) screening of Kolodny, Hwang, & Noble, 1993).
Prevalence of drug use generally is
pregnant women for illicit drug use is
higher among mothers who smoke
only justified when dealing with or drink, are unmarried, are not
populations known to have a high working, have public or no
prevalence of use of such drugs (more insurance, live in urban areas, or
than 2 percent of pregnant women as receive late or no prenatal care
ascertained by record review and/or (NIDA, 1994c; Vega et al., 1993;
claims data). There is no need for such a Moser, Jones, & Kuthy, 1993).
Anonymous urine testing detected
screening program in most managed care
cocaine use in 7–15 percent of
organizations. pregnant women from high-risk,
■ Organizations dealing with a high urban communities (Schulman,
prevalence of use of illicit drugs or an Morel, Karmen, et al., 1993) and in
otherwise exceptionally high-risk 0.2 percent to 1.5 percent of mothers
population for such substance abuse are in private clinics and rural areas
(Sloan, Gay, & Snyder, 1992; Burke
virtually assured of encountering high
& Roth, 1993).
rates of tobacco use and alcohol abuse.
Such organizations can consider their Drug use during pregnancy has been
options for screening through associated with a variety of adverse
modification of one of the alcohol- outcomes, but problems associated
related screening instruments, and with drug use (e.g., use of alcohol or
cigarettes, poverty, poor nutrition,
adoption of follow-up of such screenings inadequate prenatal care) may be
patterned after their alcohol-control more important than the direct
programming. effects of drugs (Mayes, Granger,
Borstein, et al., 1992; Robins &
Review of Literature Mills, eds., 1993). Regular use of
cocaine and opiates is associated
Evidence of Need with poor weight gain among
According to the 1996 Second Edition of the pregnant women, impaired fetal
U.S. Preventive Services Task Force’s Guide to growth, and increased risk of
Clinical Preventive Services (USPSTF, 1996)— premature birth; cocaine appears to
increase the risk of abruptio
placentae (Volpe, 1992). The effects
A national probability sample of
of social use of cocaine in the first
2,613 women giving birth in
trimester are uncertain (Graham,
1992–93 estimated that 5.5 percent
Dimitrakoudis, Pellegrini, et al.,
used some illicit drug during
1989; Chasnoff, Griffith,
pregnancy: the most frequently used MacGregor, et al., 1989). Cocaine
drugs were marijuana (2.9 percent)
34 Special Report
has been blamed for some congenital et al., 1998) to 658 (Eisen et al., 2000).
defects (Robins et al., 1993), but the Taken together, these studies reaffirm
teratogenic potential of cocaine has
previously established impressions that
not been definitively established.
Infants exposed to drugs in utero aggressive provision of basic prenatal care is
may exhibit withdrawal symptoms of substantial value for these women, but
due to opiates, or increased tremors, supplementary programs for illicit drug use
hyperexcitability, and hypertonicity in pregnant women are of only marginal
due to cocaine (Robins et al., 1993;
value. In the only one of these studies to
Hutchings, 1982). Possible long-term
neurologic effects of drug exposure address this issue (Eisen, et al., 2000), it was
are difficult to separate from the noted that none of the reductions in use of
effects of other factors that influence alcohol or illicit drugs was maintained
development among vulnerable through 6 months postpartum.
children (Robins et al., 1993; Frank,
Given this circumstance, the
Bresnahan, & Zuckerman, 1993;
Chasnoff, Griffith, Freier, & Murray, recommendation of the American College of
1992). The effects of marijuana on Obstetricians and Gynecologists is limited to
the fetus remain controversial “a thorough history of substance use and
(Zuckerman, Frank, Hingson, et al., abuse in all obstetric patients, and remain
1989; Day & Richardson, 1991; Bell
alert to signs of substance use disorder in all
& Lau, 1995).
women” (USPSTF, 1996; ACOG, 1994).
Effectiveness: Evidence Base for Intervention
Although the risk of drug use to the mother Efficacy: Program Implementation Issues
and fetus is clear, the evidence base for According to the 1996 Second Edition of the
effective interventions during pregnancy is U.S. Preventive Services Task Force’s Guide to
largely limited to observational studies Clinical Preventive Services (USPSTF, 1996)—
showing a decrease in the risk of low
birthweight with increasing numbers of The diagnostic standard for drug
prenatal visits (Chasnoff et al., 1989; abuse and dependence is the careful
diagnostic interview (USPSTF, 1996;
Zuckerman et al., 1989).
APA, 1994). … There are few data
Two studies published since the 1996 to determine whether or not the use
Guide reaffirmed that substance abuse in of standardized screening
pregnancy continues to be a significant questionnaires can increase the
problem (Butz, Lears, O’Neil, & Lukk, detection of potential drug problems
1998; Richardson, Hamel, Goldschmidt, & among patients. Brief alcohol
Day, 1999). Our literature search also screening instruments such as the
CAGE or MAST [Michigan
identified five clinical trials relating to
Alcoholism Screening Test] can be
treatment to secure discontinuation of illicit modified to assess the consequences
drug use in pregnancy (Elk, Mangus, of drug use in a standardized manner
Rhoades, Andres, & Grabowski, 1998; (Trachtenberg & Fleming, 1994;
Eisen, Keyser-Smith, Dampeer, Sambrano, Skinner, 1982), but these instruments
2000; Schuler, Nair, Black, & Kettinger, have not been compared with
routine history of clinician
2000; Jansson et al., 1996; Svikis et al.,
assessment. Questionnaires … [that]
1997). All were controlled to some degree, identify adolescents at increased risk
with study populations ranging from 12 (Elk for drug use … have not been

validated in prospective studies denied their use of tobacco, alcohol, and
(Schwartz & Wirtz, 1990). Other cocaine. Interviews detected only about half
instruments such as the Addiction of the women whose urine tests were
Severity Index (McLellan, Luborsky,
positive for one or more of these substances
Woody, et al., 1980) are useful for
evaluating treatment needs but are (Markovic et al., 2000).
too long for screening. There are few controlled trials of
interventions for pregnant women who use
… Drug testing is frequently illicit drugs (USPSTF, 1996). The lack of
performed without informed consent randomized and controlled studies is not
in the clinical setting on the grounds
accidental. It is due to the perception by
that it is a diagnostic test intended to
improve the care of the patient. investigators that it would be unethical to
Because of the significance of a deny pregnant women treatment believed to
positive drug screen for the patient, be beneficial (Burkett, Gomez-Martin, Yasin,
however, the rights of patients to & Martinez, 1998). As a result, there is a
autonomy and privacy have
continuing flow of observational studies
important implications for screening
of asymptomatic persons (Merrick, (Kukko & Halmesmaki, 1999; Newschaffer,
1993). If confidentiality is not Cocroft, Hauck, Fanning, & Turner, 1998;
ensured, test results may affect a Berkowitz, Brindis, & Peterson, 1998; Clark,
patient’s employment, insurance Dee, Bale, & Martin, 2001; Corse & Smith,
coverage, or personal relationships 1998) and one controlled but not
(Rosenstock, 1987). Testing during
randomized study (Burkett et al., 1998) that
pregnancy is especially problematic
because clinicians may be required showed substantial benefit to mother and
by State laws to report evidence of fetus/infant. These studies suggest, but do
potential harmful drug or alcohol not confirm, that detection of substance use
use in pregnant patients. disorder in pregnant women should be cost-
There is a single recent paper suggesting effective within 12 months of program
that primary care clinicians can ask three initiation through reduction in need for
questions in the context of a prenatal health NICU services.
evaluation to target women for referral to a The AMA and most other medical
full clinical assessment for drug and alcohol organizations endorse urine testing when
use (Chasnoff et al., 2001). The three there is reasonable suspicion of substance
questions are— use disorder, but none of these groups
recommends routine drug screening in the
1. Have you ever drunk alcohol? absence of clinical indications (USPSTF,
2. How much alcohol did you drink in the 1996).
month before pregnancy?
3. How many cigarettes did you smoke in Program Implementation Issues:
the month before pregnancy? How To Manage the Intervention So That
The screen is intended for use by primary It Succeeds in Securing Desired Benefits
practitioners to sort women by risk category. In most health care settings, issues relative to
In at least one high-prevalence population substance use disorders among pregnant
where this issue was addressed in a recent members will be limited to assurance that
study in Pittsburgh, women commonly clinicians engaged in prenatal care have the
36 Special Report
capacity to recognize such cases and have the ■ Data from the local criminal justice
capacity to refer such members to system that might suggest a community-
appropriate specialists. In those few plans wide drug problem or specific problems
with a prevalence of use of illicit drugs likely within geographically or
to be more than 2 percent of pregnant demographically defined subpopulations
women, substance use disorder screening and ■ Use of NICU services for infants
follow-up can be managed in a manner
patterned after what should already be well- Summary: Use of Illicit Drugs During
developed alcohol control programming in Pregnancy
those managed care plans. All pregnant women should be asked
about their use of illicit drugs and advised
Data Needs Specific to Illicit Drugs and to abstain. Those who report using drugs
Pregnancy during pregnancy need follow-up,
The following data should help health plans supplementary case management, and
track and assess the impact of their counseling to receive optimal medical care.
intervention. Refer to Appendix D.
■ Numbers of cases of illicit drug use

diagnosed in prior year in pregnant
women and newborn infants

38 Special Report
VI. High-Risk Pregnant
Women and Children
to Age 5
P
reventive services during pregnancy, infancy, and early childhood can
reduce the prevalence and severity of future medical, behavioral, and
social problems. Risk is highest in low-income and socially
disadvantaged family units. The term “high risk” in the literature refers to
those low-income, first-time mothers at risk for poverty, welfare dependency,
and involvement with the criminal justice system. The term also refers to
babies with low birthweight, prematurity, or mental deficits such as
retardation. Medicaid and public sector health care systems see large numbers
of such families. As poverty is not the only determinant of risk, there are
likely to be small numbers of high-risk individuals in every health care system,
whether public or private.
Two sets of services are presented. The first more of the following risk characteristics:
is a program of home visitation for family low-income, adolescent pregnant woman or
units characterized by social and economic mother, unemployed, fewer than 12 years of
vulnerability. The second is the need for education, or membership in a socially
supplemental educational services for the vulnerable ethnic, racial, or non-English-
infants and preschool children from these speaking group. Individuals with these risk
families, plus selective low-birthweight factors tend to depend on Medicaid-oriented
infants; those exposed to substance use managed care plans, public systems of care,
disorder during pregnancy; and those born or do without routine care altogether. Two
to mothers with mental retardation. sets of services and benefits may be best for
Although the provision of the supplemental these high-risk family units. The first set,
educational services might not be the role of focusing on early and comprehensive
the health care delivery system, if pediatric prenatal care, can reduce prematurity and
staff does not identify the infants in need of infant mortality, and by reducing the need
service, it is unlikely that the infants will for intensive hospital services during the first
receive the needed services. 30 days of life, reduce health care costs. The
second set—addressed here—is primarily
Social and Economic Dependency nonmedical. This second set, for families
Family units at highest risk of social and that could benefit from these interventions,
economic dependency are those with one or can yield substantial social, educational,

economic, and behavioral benefits—but is services in preventing future mother and
unlikely to generate immediate reductions in child illness, handicap, social dependency,
health care costs. and behavioral problems.
Prenatal and infant home visitation to Issues and problems addressed include the
reduce family dependence on welfare is following:
classified as “targeted” in this report. This is
an intervention with a strong evidence base, ■ Outcomes of pregnancy—low
but with social, economic, educational, and birthweight and infant mortality
other nonmedical goals. The home visit ■ Spacing between pregnancies
intervention involves nurses visiting homes to ■ Welfare dependency
deliver education and emotional coaching to ■ Use of tobacco, alcohol, and illicit drugs
low-income, first-time, disadvantaged ■ Nutritional status
pregnant women. The intervention consists of ■ Various measures of child development
prenatal and infancy home visits by nurses ■ Child abuse
every 2 weeks for an average of nine prenatal ■ Criminal behavior
visits lasting over an hour each. The nurses ■ Infant/child intelligence
also screen infants for sensory and ■ Maternal scholastic achievement
developmental problems. There is provision
of free transportation to prenatal and well Women who may benefit from the addition
child visits to local clinics, and in some cases, of home visitation services—in addition to
continued home visits for up to 2 years after already comprehensive medical, financial,
the birth of the child. While in the home, and social-support services—are women with
nurses promote health-related behaviors multiple sociodemographic risk factors such
during pregnancy, appropriate care for as being an adolescent, being unmarried,
infants by parents, and maternal life-course having fewer than 12 years of education,
family planning and educational achievement and/or being unemployed. The primary
(Olds et al., 1993; 1997). benefits relate to welfare dependency. Other
Home visitation primarily relates to health benefits included a wide range of health,
care organizations that serve socially and social, and financial domains. The concept
economically vulnerable populations. As of offsetting savings in other health care
noted above, however, every health care costs was not pursued.
system is likely to have small numbers of These services are not inexpensive. The
family units that could benefit from such benefits are unlikely to include substantial
services. Since the benefits are substantial, short-term reductions in health care costs.
these services might be implemented by health This creates a situation where supplemental
care systems serving high-risk populations. funding might be pursued to cover the costs
Other health care systems may choose to be of these services. One would expect such
aware of such services and develop the funding to be tied to supplemental guidelines
capacity to connect selected families to these and standardized reporting procedures to
outreach and educational programs. document the efficacy and efficiency of these
The literature, reviewed below, attests to services.
the benefits of home visitation in the context
of a comprehensive program of preventive
40 Special Report
Intervention 2000; Olds et al., 1998; Olds, Henderson,
Possible intervention has two major Tatelbaum, & Chamberlin, 1988; Olds,
elements. The first is an institutional Chamberlin, & Tatelbaum, 1986; Olds,
infrastructure with a complete array of Henderson, Tatelbaum, & Chamberlin,
health and social services, including all 1986; Kitzman et al., 1997; Olds et al.,
needed outpatient and inpatient care 1997; Olds, Henderson, Kitzman, & Cole,
modalities, social, financial and 1995; Olds, 1994; Olds, Henderson, Phelps,
psychological support services, health Kitzman, & Hanks, 1993; Olds, 1992).
education, and case management. The Women in the control groups received free
second element is a highly structured nurse transportation to the clinics and an array of
home visitation program for adolescent screening and referral services, in addition to
and/or unmarried and/or otherwise socially routine prenatal and pediatric care. This
or economically vulnerable pregnant women high level of service to the control
and their infants—to deal with the full array population has probably reduced what
of medical, social, economic, and behavioral otherwise might have been even more
issues and problems that reflect the profile of substantial differences between case and
unmet needs of each of the women/infants control groups.
served. Olds and Kitzman published six papers
To be effective and cost-efficient, these between 1986 and 1994 on their Elmira
services might be best delivered by specially study, dealing with parental care-giving at 25
trained staff and in accordance with strictly to 40 months of age (Olds, 1994); effect of
defined protocols. Training requirements and the nurse visitation program on government
protocols can be accessed at the Internet site spending (AFDC, food stamps, Medicaid and
of the National Center for Children Families Child Protective minus tax revenues from
and Communities (NCCFC) at the University maternal employment (Olds et al., 1993)
of Colorado Health Sciences Center, (AFDC is Aid for Families with Dependent
www.nccfc.org. Children, since renamed TANF, Temporary
Aid to Needy Families); adverse maternal
Review of Literature health behavior, dysfunctional infant care
Olds and Kitzman and stressful environmental conditions
A substantial body of literature relating to (Olds, 1992); maternal life course vis-a-vis
prenatal and infant home visits for socially completion of high school and employment
and economically vulnerable families has (Olds et al., 1988); prenatal care and
been generated by Drs. Olds and Kitzman. outcomes of pregnancy (Olds, et al., 1986);
They have explored this intervention in a and prevention of child abuse during infancy
predominantly White population in (Olds et al., 1986). In 1995, Olds et al.
semirural Elmira, New York, and in an (1995) reported interim strongly favorable
urban, predominantly African American results relative to child abuse and neglect in
population in Memphis, Tennessee. They Elmira.
have published long-term follow-up studies In 1997, Kitzman et al. (1997) published
to demonstrate continuation of benefit up to the results of their Memphis trial on a
15 years after initial delivery of the service number of maternal and infant health
(Eckenrode et al., 2000; Kitzman et al., measures. Dramatic and highly statistically

significant benefits were shown for et al., 2000)—published yet another 15-year
pregnancy-induced hypertension, visits and follow-up of the Elmira study. The group
hospitalizations for infant injuries and successfully reached 315 of the 400 families
ingestions, and second pregnancies. There visited during pregnancy and up to 2 years
were no program effects on preterm delivery, postpartum. The women had been adolescent,
low birthweight, children’s immunization unmarried, and/or low-income at the time of
rates, mental development, or behavioral initial enrollment. This publication showed a
problems or mother’s education and substantial and highly statistically significant
employment. reduction in a number of measures of child
In 1997, Olds et al. (1997) also published abuse and neglect, but only among the
a 15-year follow-up on the Elmira study, families that had received postnatal visits, and
showing dramatic and highly statistically only among family units with 28 or fewer
significant benefits in areas of welfare incidents of domestic violence.
dependency, child abuse and neglect, arrests,
and behavioral impairments related to Other Investigators
alcohol and other drugs. In 1994, Marcenko and Spence (1994)
In 1998, Olds et al. (1998) published reported on a home visitation program for
another 15-year follow-up of the Elmira women considered to be at risk for out-of-
study. The case families showed substantial home placement for their newborns. The
clinical benefits and statistically significant study included 125 cases and 100 controls,
differences from the control families in the with home visits provided weekly or
incidence of running away, arrests, biweekly from initiation of prenatal care
convictions, number of lifetime sex partners, through the first birthday. The authors
tobacco use, alcohol use, and problems considered the intervention successful on the
related to alcohol and drugs. basis of greater social support, greater access
In 2000, Kitzman et al. (2000) published a to services, and less psychological distress
3-year follow-up of their trial of home visits among the intervention families, even though
to a cohort of 743 mainly African American more case children were placed out of home
women in Memphis, Tennessee. These than controls.
women had no previous live births and at In 1996, Margolis et al. did a randomized
least two of three sociodemographic risk trial involving 93 Medicaid eligible pregnant
factors (unmarried, fewer than 12 years of women in two North Carolina counties to
education, or unemployed). Modest but see whether home visitation would do a
strongly statistically significant outcomes better job of accessing prenatal care. Results
were noted, all in favor of the intervention were strongly positive (Margolis et al., 1996).
group, for intervals between pregnancies and In 1998, Ramey et al. published the
months of dependence on AFDC and food combined results from three trials intended
stamps. This study showed persistence of to demonstrate prevention of intellectual
benefit over the 3-year period with findings disability in low-birthweight and
consistent with their prior studies of White economically vulnerable newborns (Ramey
women in a rural area. & Ramey, 1998). These early intervention
In 2000, the Olds/Kitzman group—this time programs were multidisciplinary in that they
with Eckenrode as prime author (Eckenrode included early childhood education, family
42 Special Report
counseling and home visits, health services, visitation for the prevention of child abuse
medical services, nursing services, nutrition and neglect (Task Force on Community
services, service coordination, special Preventive Services, 2003). This was based on
instruction, speech-language services, and a highly structured review of the literature.
transportation. The study relative to the low-
birthweight infants (Ramey et al., 1992) is Program Implementation Issues: How To
reported in the next section of this report. Manage the Intervention So That It Succeeds
The Abecedarian and Carolina Approach to in Securing Desired Benefits
Responsive Education (Project CARE) The primary program implementation issue
studies were randomized controlled trials of would appear to be the already well-
an educational intervention using a 36- developed system of medical, social, and
month program known as Partners for financial support services, with home
Learning. These two trials showed consistent visitation added as an extra benefit. The
and substantial improvements in IQ, as number of home visits is dependent on the
measured in cognitive assessments at 6, 12, judgment of the nurse and study protocols
18, 24, and 36 months of age. and will vary considerably from family to
In 1999, Armstrong et al. published results family. This enables the program to secure
of a randomized controlled trial of nurse maximum benefits without excess
home visits to “vulnerable” families with expenditures for home care services.
newborns to see whether they could reduce
maternal depression and improve maternal- Data Needs Specific to Home Visitation
infant bonding. This study, conducted in
Australia with 180 participants and 6 weeks ■ As the level of service is fairly intense, it
of follow-up measurement, showed strong would probably be best to maintain a
and highly significant improvement in line listing of cases, with quarterly
measures of emotion and maternal-child updates for discussion and presentation
interaction. quarterly at pediatric quality assurance
In 2001, Margolis et al. in North Carolina meetings.
reported on the results of a validation study ■ Program planning, quality assurance, and
expanding this approach to a systematic evaluation should be in accordance with
community-wide intervention involving the guidelines available through the
teams of nursing staff working with both National Center for Children, Families and
private practitioners and community health Communities Web site at www.nccfc.org.
centers. Levels of participation by both
physician offices and eligible women were Educational Services To Improve the
very high. Multiple outcome measures very Intelligence of Selective Infants and
strongly favored the intervention women in Preschool Children
this randomized trial (Margolis et al., 2001). The following groups of infants and
In October of 2003, an independent, preschool children are at high risk of
nonfederal task force with support from subnormal intellectual development—a risk
CDC—the task force developing the Guide to that can be identified by the health care
Community Preventive Services—issued a provider, and then addressed through the
report recommending early childhood home delivery of specialized educational services:

■ Social and economic vulnerability fully consistent with the larger and more
■ Low birthweight definitive studies presented in the prior
■ Exposure to alcohol or illicit drugs section that demonstrate the value of
during pregnancy intensified services to economically and
■ Offspring of a mentally retarded mother socially vulnerable mother/infant dyads. The
benefits to be secured from these services are
Research indicates that health care delivery primarily social rather than medical in
systems should be alerted to the need for nature. The literature demonstrating the
supplemental educational services for these value of such services for improving infant
infants. Although it may not be incumbent and child intelligence does not address the
upon the health care system to provide the possibility that such services might reduce
needed education, these infants are likely to health care costs. As a result, these services
be missed unless detected and brought to the are not expected to generate a health care
attention of social service agencies by cost-related return on investment.
pediatric staff.
The need for supplemental educational Intervention
services will be most apparent to the The literature indicates that the services to
pediatric medical and nursing staff if they be provided are educational in nature. They
have been alerted to this problem. Awareness may include infant stimulation, home
of the problem through in-service education visitation and special classes in health care,
would seem reasonable for all health plans, and educational or social service settings.
especially those serving large numbers of at- These services can be coordinated with the
risk families. Whether or not the needed home visitation and other preventive services
supplemental educational services are paid provided by the health care delivery system.
for by the health plan or provided by the The health care system case managers can
health care delivery systems will depend on also oversee them.
plan-specific scope-of-contract decisions, and Such services could be dismissed easily as
plan and health-care-delivery-system social and educational in nature and not the
definition as to whether such services are concern of health care delivery systems.
considered medical, rather than social or However, if they are not addressed by
nonmedical (Rosenbaum et al., 2003). If pediatric staff, it is unlikely that the families
deemed outside the scope-of-contract or in need of such services will connect with
nonmedical, research would indicate it is them, regardless of who pays for them.
incumbent upon the health care system to Provision of such supplemental educational
refer such cases to appropriate educational services can be seen as having three distinct
and social service programs, and to assist the stages. The first is detection of the need for
family in securing the needed service. For such services. The second is delivery of the
these reasons, the provision of the services. The third is follow-up to determine
supplemental educational services are if the services were provided and whether
classified as “targeted/social and they were effective in enhancing infant and
educational” in this report. child intelligence. The decision to pay for or
These interventions have a moderate provide the educational service is one to be
evidence base, as reviewed below, and are made by each health care delivery system on
44 Special Report
the basis of its scope of coverage and specialized child development centers. There
conceptualization of whether such services were 377 intervention families and 608
are medical in nature. However, the research control families. Both cases and controls
indicates that a good case can be made for received all indicated pediatric care. Both
all health care systems having the capacity to cases and controls showed similar profiles of
identify the need for such services and to prematurity.
follow up to help assure that they have been The results showed statistically significant
provided effectively. increases in mean Stanford-Binet IQ scores,
At the health care system level, the comparing cases to controls, and a dose-
following will be beneficial, based on the response relationship within the case
literature: population showing increases in IQ with
increasing participation in the program, with
■ Periodic educational programming for the low participation group showing a mean
medical and nursing staff caring for IQ about five points higher than controls,
infants and small children as to the and the highest participation group showing
conditions suggesting a special need for a mean IQ almost 15 points higher.
supplemental educational services, plus Although the factors determining levels of
how such services are arranged and program participation among the cases were
provided for within or through the not randomly distributed and probably
health care system reflected important confounding variables, it
■ Policies and procedures by which family seems reasonable to conclude that the three-
units that may have the need for such part intervention did have a significant
supplemental educational services are impact on the child’s IQ score at age 36
individually assessed to confirm or deny months (Ramey et al., 1992).
the impression that such services might In 1997, McCarton et al. published an 8-
be needed, and to ascertain the package year follow-up on a randomized controlled
of services for that family trial of educational services, home-based
■ Periodic follow-up to include assessment family support, and pediatric follow-up to
of infant and child intelligence on low-birthweight infants. The results showed
subsequent “well baby” visits small, but favorable differences, comparing
■ Occasional special quality assurance the intervention to control groups, with most
studies to document that infants at risk of the benefit in the heavier infants
have been properly identified and that (McCarton et al., 1997).
follow-through has been appropriate In 1999, Bao et al. published the results of
a randomized controlled trial conducted in
Review of Literature Beijing, China (Bao, Sun, & Wei, 1999).
Services to Low-Birthweight Infants To Improve Enrollees were all low-birthweight infants.
Infant/Child Intelligence The intervention consisted of an educational
In 1992, Ramey et al. published the results program that taught mothers techniques of
of an eight-site randomized controlled trial infant stimulation to be used in the home. At
of a 3-year intervention consisting of home the end of the 2-year intervention, the
visitation, parent support groups, and a Mental Development Index scores for the
systematic educational program provided in intervention infants were approximately 14

points higher than for the low-birthweight for children of low-IQ mothers to compensate
controls, and approximately six points for the mother’s inability to provide adequate
higher than the small group of normal infant stimulation and education. They
birthweight control infants. reported on two similar randomized trials of
infants born to mentally retarded mothers and
Services to Economically and Socially one trial of low-birthweight infants. The
Vulnerable Families To Improve Infant/Child sample sizes in the two studies with mentally
Intelligence retarded mothers were small. The Abecedarian
Olds and Kitzman also considered the study had 41 cases and 45 controls. The Care
impact of their home visitation program on study had 24 cases and 15 cases, respectively,
infant/child intelligence, but only as one of in two intervention groups and 23 controls.
many outcome parameters being considered. The impact of the supplemental education was
There were no statistically significant dramatic, in most cases moving the child from
treatment effects on infant/child intelligence an IQ of approximately 90 to an IQ of
in either their Elmira (Olds, 1994) or approximately 110. In addition to education,
Memphis (Kitzman et al., 1997) studies. the interventions also provided medical and
In 1998, Ramey and Ramey published the nutritional support. The benefits, although
combined results from three trials intended substantial, did not appear likely to reduce
to demonstrate prevention of intellectual other health care costs. The studies on this
disability in low-birthweight and topic did not address the issue of health care
economically vulnerable newborns (Ramey cost.
& Ramey, 1998). The study relative to the Securing the participation of enough
low-birthweight infants (Ramey et al., 1992) infants of mentally retarded mothers to do
is reported in the next section of this reasonably rigorous randomized controlled
monograph. The Abecedarian and CARE trials is a difficult task. Given the magnitude
studies were randomized controlled trials of of the benefit documented in this study, and
an educational intervention of a 36-month the consistency of these results with the
program known as Partners for Learning. results of other studies of intensive support
These two trials showed consistent and services provided to vulnerable mother/infant
substantial improvements in IQ, as measured dyads, it seems reasonable to accept the
in cognitive assessments at 6, 12, 18, 24, and results of these studies as strong evidence
36 months of age. that intensive educational support services
Based on this research, it appears that provided as a supplement to reasonably
generalized home visitation programs are comprehensive medical care can be effective
likely to have a minimal impact on infant/child in dramatically improving the intellectual
intelligence, but intensive educational performance of infants born to mentally
programs can have a significant effect. retarded mothers.
Services to Infants Born to Mentally Retarded Other

or Otherwise Challenged Mothers In 1994, Olds published data from the
Two studies published 6 years apart by Ramey Elmira trial (White, semirural, low-income),
and Ramey (Ramey & Ramey, 1992, 1998) which compared intellectual development of
provided intensive educational interventions infants whose mothers smoke more than 10
46 Special Report
cigarettes a day. The study population Program Implementation Issues: How To
provided 64 cases and 57 controls. The data Manage the Intervention So That It Succeeds
showed that the generalized Olds/Kitzman in Securing Desired Benefits
home visitation intervention was effective in Management of these interventions will
preventing intellectual impairment related to probably best be done using collaboration
smoking in the infants receiving the home with external agencies than has traditionally
visitation intervention (Olds, Henderson, & been experienced within the managed care
Tatelbaum, 1994). community.
In 1994, Black et al. (1994) published
results of a small randomized clinical trial, Data To Be Gathered
including 31 cases and 29 controls, of home As the level of service is fairly intense, it
visitation for newborn infants of drug- would probably be best to maintain a line
abusing women. This program of generalized listing of cases, with quarterly updates for
support through biweekly home visits by discussion and presentation quarterly at
nurses during the first 18 months of life pediatric quality assurance meetings.
showed modest improvements in maternal
drug-related behavior, improvements in Summary: High-Risk Women and Children
parenting, and improvements in child Targeted interventions, including home visits
development. Although this study is weak to at-risk, low-income, pregnant women and
and far from definitive (it is the only one developmental/sensory screening of their
covering this issue from the perspective of infants, may yield short-term benefits to the
drug-abusing pregnant women), its findings health plan of healthier babies wih fewer
suggest that these women and their infants problems, and long-term benefits to the
respond to infant visitation programs mother and child.
offering comprehensive maternal and
pediatric care in a manner similar to other
vulnerable women and their infants.

48 Special Report
VII. Screening Children
and Adolescents
(5–18 Years)
S
creening for child and adolescent behavioral disorders using the Pediatric
Symptom Checklist (PSC) is widely used in many medical practices and
Medicaid programs. The current literature documents the ability of this
brief, one-page instrument to identify children in need of further behavioral
evaluation. Unfortunately, there are no randomized, controlled studies that
document outcomes on screened individuals or groups, compared with
populations not screened. PSC screening is classified “targeted” rather than
“general” because the studies needed to provide a firmer evidence base have
not been done.
Screening for Evidence of Behavioral psychosocial problems (Jellinek & Murphy,

Disorder 1988; Walker, LaGrone, & Atkinson, 1989;
The PSC is a brief, one-page, 35-question Murphy, Arnett, Bishop, Jellinek, & Reede,
instrument designed for use by parents in the 1992; Jellinek & Murphy, 1999, Gardner,
doctor’s waiting room. The questionnaire is 2002; Jellinek et al., 1999). In use since the
designed to detect behavioral and 1970s, the PSC has been tested and used in
psychosocial problems in children from 2 to tens of thousands of children; scored well in
16 years of age, and it has been used a test of its usefulness to the Medicaid-
effectively in persons up to 18 years of age sponsored Early and Periodic Screening,
(Bernal et al., 2000). Each of the questions Diagnosis, and Treatment (EPSDT) program
can be answered with a “never,” (Murphy et al., 1996); and is used in several
sometimes,” or “often,” with scores of 0, 1, States in the context of their EPSDT
or 2, respectively, attributed to each answer. programming (Jellinek & Murphy, 1999;
Scores of 24, 28, or higher, depending on the Bernal et al., 2000; Gardner, Kelleher, &
age of the child, are considered indicative of Pajer, 2002).
a possible behavioral or psychosocial The PSC has been found to be acceptable
problem and will warrant further to parents, regardless of socioeconomic
exploration by the clinician (Jellinek & status or ethnicity, and to clinicians and
Murphy, 1999). clinic office staff (Murphy et al., 1992;
The PSC has been suggested as a tool for Murphy, Reede, Jellinek, & Bishop 1992;
universal use with children 2 to 16 years of Jellinek et al., 1999; Navon, Nelson, Pagano,
age to screen for behavioral and & Murphy, 2001). It has been validated

against more elaborate classification costs of $1,138 per year. Psychosocial
instruments—the Child Behavior Checklist dysfunction was associated with higher costs.
(CBCL) and the Clinician’s Global Unfortunately, this study did not explore
Assessment Scale (CGAS (Walker et al., whether detection and treatment of the
1989; Jellinek & Murphy, 1999). It also psychosocial dysfunction could lower these
routinely generates prevalence rates for costs. With a documented minimum
pediatric psychosocial and behavioral sensitivity (accurately detecting true
disorders of approximately 12 percent, “positives” or those with the illness) of 80
which is consistent with other estimates of percent, and a specificity (detecting those
pediatric behavioral and psychosocial without disease) of 68 percent or better
disorders (Jellinek & Murphy, 1999; (Jellinek et al., 1988; Jellinek & Murphy,
Jellinek, 1999). The expected increase in 1999), this screening instrument may miss
psychosocial dysfunction with lower up to 20 percent of children who have
socioeconomic class (Jellinek, Little, Murphy, serious problems, and refer up to 32 percent
& Pagano, 1995) and the expected of well children to diagnostic interviews that
correlation with maternal psychological prove negative for any treatable behavioral
distress and marital adjustment (Sanger, or psychosocial behavior. Although these
MacLean, & Van Slyke, 1992) have been efficacy statistics are within acceptable
clearly documented. ranges for screening instruments, they do
The primary outcome measure noted in the speak to costs of program implementation
PSC literature has been the percentage of that need to be considered. Like virtually all
children referred for behavioral or other screening programs, little or no benefit
psychosocial evaluation and treatment. This will accrue without follow-up treatment for
rate of referral has dramatically increased those found to be in need of such treatment.
with the introduction of the PSC in every Owing to the research findings, the PSC may
study where this measure has been reported be considered a “targeted” service for use in
(Navon et al., 2001). In one study, the health care delivery settings with providers
referral rate increased from 1.5 percent and health care systems wishing to use it.
before implementation of the PSC to 12 The available literature leaves unanswered
percent, then dropped back to 2 percent the possible use of the PSC when the
after the PSC screening was discontinued primary care practitioner suspects a
(Murphy et al., 1992). This review found no significant behavioral problem but does not
studies that address the behavioral and have enough information to confirm or deny
psychosocial benefits to the children screened this impression. For such cases, health care
or costs associated with referral of false- systems may wish to make this instrument
positive cases. available to providers for selective use, at
One study published in 2000 (Bernal et al., their discretion.
2000) reported average log costs for health The PSC, along with articles describing its
and psychiatric care for all children studied proper use on the Pediatric Development and
at $393 per year, and costs of those with Behavior Web site, is available at
anxious, depressed symptoms at $805 per www.dbpeds.org/handouts/ (Jellinek &
year. Chronically ill children showed the Murphy, 1999) under “screening.” It should
highest health care costs, with average log be used without modification, other than for
50 Special Report
translation when working with non- Summary: Children and Adolescents 5–18
English-speaking families. Years
The PSC consists of 35 very brief Screening for potential child and adolescent
statements to which the parent responds behavioral disorders using the PSC is widely
“never,” “sometimes,” or “often.” Presented used in medical practices and Medicaid
on a single page with check-off boxes, programs. Because of its low burden (brief),
sample statements include: “Complains of ease of use, wide applicability, and validity,
aches/pains; tires easily, little energy; has the literature supports its use by health plans
trouble with a teacher; acts as if driven by a with all children in a health care system. In
motor … .” The responses are graded on a this report, such screening is classified as a
zero-to-two scale. Depending on age, a score “targeted” service rather than “general”
of 24, 28, or greater is considered indicative because no randomized controlled trials that
of significant psychosocial impairment could document outcomes have been
(Jellinek & Murphy, 1999). attempted.

52 Special Report
VIII. Adolescents
(12–18 Years)
T
here is a substantial body of behavioral literature dealing with
adolescents. Most commonly, adolescence is considered to begin
within puberty and continue through 18 or 19 years of age. Individual
differences in the onset of puberty and full achievement of sexual maturity
create a situation in which biological adolescence for some individuals begins
as early as 6 years of age and extends into the early 20s. For program
planning and evaluation, adolescence can be defined as extending from the
11th or 12th birthday to the 19th birthday. Research supports screening
interviews for tobacco, alcohol, and illicit drug use for all adolescents aged
12–18 years, and suggests screening for depression as a “targeted” service.
Adolescence is a period of rapid change and specific or sensitive for adolescents. This
development that offers unique opportunities means that there will be more false-positives
for interventions that could have substantial and more false-negatives. Furthermore, no
impact on future health and quality of life. studies have examined treatment outcomes
Addictions and lifelong habits related to for children or adolescents identified by
tobacco, alcohol, illicit drugs, and high-risk primary care clinicians through screening
behaviors frequently are formed in (USPSTF, 2003). This lack of adolescent-
adolescence. Most of the literature and most specific, primary-care–specific research
guidelines relating to these issues focus on makes it difficult to suggest screening of all
the adolescent age group and address adolescents for depression as a “general”
community, social agency, and educational service. Preventive behavioral services to
interventions. Since the vast majority of adolescent pregnant women are the same for
adolescents use relatively little medical care, adolescents and adults.
screening of adolescents in health care According to the 1996 Second Edition of
settings has not been a cornerstone of most the U.S. Preventive Services Task Force’s
adolescent-related preventive behavioral Guide to Clinical Preventive Services (US-
programming. Almost all preventive PSTF, 1996), the following is suggested for
behavioral programming is conducted in male adolescents and nonpregnant female
school and community settings, and adolescents:
occasionally in correctional settings (Schinke
et al., 2002). Organizations developing clinical re-
Depression and suicide are major concerns commendations recommend
universal (interview) screening of
in adolescence. Unfortunately, the adult
adolescents for tobacco, alcohol, and
screening tests for depression are not as illicit drug use—with follow-up on

positive findings to confirm the products cause. This classification also takes
impression from screening and into account the lack of substantial evidence
provide needed counseling and other to show the value of clinician interventions
services. These include the American
in either preventing tobacco use or in getting
College of Physicians (American
College of Physicians Health and adolescents to quit. These recommendations
Public Policy Committee, 1986), the are not limited to cigarettes and cigars
American Academy of Family because a substantial number of teens use
Practice, the American Academy of snuff or chewing tobacco (DHHS, 1994).
Family Physicians (1994), the There are two major reasons to address
American Academy of Pediatrics
tobacco control in adolescents. The first and
(AAP, 1994), the American College
of Obstetrics and Gynecology most significant reason is to prevent future
(ACOG, 1993), the American illness and death. Most smokers start during
Medical Association (AMA , 1994), adolescence, and if someone does not begin to
and others (ADA, 1992; CTF on the smoke until after the age of 21, it is very
Periodic Health Examination, 1994b; unlikely that smoking will become a lifelong
NIH, 1989, 1994); American addiction (DHHS, 1988; Henningfield, Cohen,
Academy of Otolaryngology—Head
& Pickworth, 1994). The second and less
and Neck Surgery, 1992; Green, ed.,
1994; USPSTF, 1996). Although important reason relates to immediate
available interventions are limited in prevention of physical deterioration and illness.
efficacy, these services appear to be Tobacco-related interventions have proven
of enough value to the adolescents effective enough in practice to be universally
reachable by these means to be implemented. This is backed up by the fact
recommended as universal services
that all major health care organizations and
for all adolescents being seen in all
health care systems (USPSTF, 1996). authorities recommend routine clinician
counseling of adults, pregnant women,
With the exception of adolescents who are parents, and adolescents to avoid or
pregnant or suffering from a major chronic discontinue smoking and use of smokeless
disease, it is unlikely that health care systems tobacco (USPSTF, 1996; American College of
can anticipate a significant immediate Physicians Health and Public Policy
reduction in other health care costs that Committee, 1986; American Academy of
result from providing behavioral screening Family Physicians, 1994; AAP, 1994, 1988;
and follow-up services. The universality of ACOG, 1993; Manley et al., 1991; AMA,
these guidelines for health care systems is 1993; American Dental Association [ADA],
based on the perception that attitudes and 1992; CTF on the Periodic Health
habits developed during adolescence will Examination, 1994b; NIH, 1989, 1994;
have a lifetime impact on health risk profiles AMA, 1994a; American Academy of
and quality of life. Otolaryngology—Head and Neck Surgery,
1992; Green, ed., 1994).
Tobacco Intervention
Tobacco screening and follow-up for The primary care physician or nurse may
adolescents is classified as “general” because inquire about the use of tobacco products at
of the addictive nature of tobacco products every visit, counsel not to initiate tobacco
and because of the severe harm tobacco use, and reinforce this message at every visit.
54 Special Report
A primary focus of adolescent tobacco- (DHHS, 1989), bladder (CDC, 1990;
related programming (as opposed to Hartge, Silverman, Schairer et al.,
pregnant women and adults) is the initiation 1993), and cervix (CDC, 1990;
Coker, Rosenberg, McCann, et al.,
of tobacco use.
1992; Sood, 1991; Gram, Austin, &
Stalsberg, 1992); … 100,000 deaths
Review of Literature from coronary heart disease … [and]
A more substantial review of the tobacco 85,000 deaths from pulmonary
and health literature is presented in the diseases … . Children and
discussion of tobacco in the Adults (19 Years adolescents who are active smokers
have an increased prevalence and
and Older) section of this report.
severity of respiratory symptoms and
illnesses, decreased physical fitness,
Evidence Base for Intervention and potential retardation of lung
According to the 1996 Second Edition of the growth (DHHS, 1994)… the nicotine
U.S. Preventive Services Task Force’s Guide to in tobacco is an addictive drug …
Clinical Preventive Services (USPSTF, 1996)— initiation of tobacco use at an early
age is associated with more severe
The scope of this report does not addiction as an adult.
permit an examination of each study
of the health effects of smoking or There is a large body of evidence
the nature of the risk relationship from prospective cohort and case-
(e.g., relative risk, dose-response controlled studies showing that many
relationship) between smoking and of these health risks can be reduced
each disease. Detailed reviews of this by smoking cessation (CDC, 1990).
extensive literature have been
published elsewhere (CDC, 1990, There have been no published trials
1993a; DHHS, 1986, 1989; U.S. that have adequately evaluated
Environmental Protection Agency interventions by clinicians in
[EPA], 1992; National Cancer preventing tobacco use initiation.
Institute [NCI], 1993). A number of Since the mid-1970s, however, more
consistent findings from this body of than 90 controlled trials of school-
evidence are well established. First, based tobacco use prevention
tobacco is one of the most potent of interventions have been published
human carcinogens, causing an (DHHS, 1994). School-based
estimated 148,000 deaths among programs reduce the incidence
smokers annually due to smoking- (Hansen, Johnson, Flay, et al. 1988;
related cancers (CDC, 1993a). The Abernathy & Bertrand, 1992) and
majority of all cancers of the lung, prevalence (Elder, Wildey, de Moor,
trachea, bronchus, larynx, pharynx, et al., 1993; Botvin, Dusenbury,
oral cavity, and esophagus are Tortu, et al., 1990) of tobacco use in
attributable to the use of smoked or adolescents at 2 to 4 years follow-up.
smokeless tobacco (DHHS, 1986, However, longer follow-up has
1989). Smoking also accounts for a shown little long-term benefit …
significant, but smaller proportion of suggesting that program effects need
cancers of the pancreas (CDC, 1990; to be reinforced (Flay, Koepke,
Howe, Jain, Burch et al., 1991; Thomson, et al., 1989; Murray, Pirie,
Bueno de Mesquita, Miasonneuve, Luepker, et al., 1989). All major
Moerman, et al., 1991), kidney health care organizations and
authorities recommend routine

clinician counseling of adults, ■ Office reminders to the physician
pregnant women, parents, and ■ Self-help materials
adolescents to avoid or discontinue ■ Community programs for additional help
smoking and use of smokeless
in quitting
tobacco (USPSTF, 1996; American
College of Physicians Health and
■ Drug therapy (nicotine patch or gum and
Public Policy Committee, 1986; related products)
AAFP, 1994; AAP, 1994, 1988;
ACOG, 1993; Manley, et al., 1991; Data To Be Tracked For Surveillance, Member
AMA, 1993; ADA, 1992; CTF on Selection, Feasibility Assessment, and
the Periodic Health Examination,
Program Evaluation
1994b; NIH, 1989, 1994; AMA,
1994a; American Academy of Data To Be Gathered
Otolaryngology—Head and Neck Refer to Appendix D, Procedures for
Surgery, 1992; Green, ed., 1994). Implementation and Evaluation of Preventive
Services, and the sections on tobacco use in
This literature search failed to yield pregnant women and adults.
significant new literature on the topics noted
above since publication of the Guide. The Alcohol
problem is not negative literature, but an Alcohol screening and follow-up for
absence of literature on clinician adolescents are classified as “general”
interventions for adolescents. because of the severe immediate harm caused
For adolescents other than pregnant by alcohol use by adolescents, including auto
women, the evidence base for the accidents and problems in school. This
recommended interventions (clinician classification was established in the face of
counseling to prevent tobacco use or to no substantial evidence base from
encourage cessation of tobacco) is weak, but randomized controlled trials to show the
the health-status cost of becoming addicted value of clinician interventions in either
to tobacco products or continuing an preventing alcohol use or getting adolescents
established addiction is so extreme, that to quit.
programming of even minimal effectiveness
is considered standard practice. Intervention
The primary care physician or nurse may
Program Implementation Issues choose to inquire as to use of alcohol at
According to the 1996 Second Edition of the every visit, counsel abstention or
U.S. Preventive Services Task Force’s Guide moderation, and reinforce this message at
to Clinical Preventive Services (USPSTF, every visit.
1996), certain strategies can increase the
effectiveness of counseling to end tobacco Service-Related Issues Specific to Alcohol
use (NIH, 1986, 1989, 1994; AMA, 1994a; and Adolescents
AAFP, 1987; Kenford, Fiore, Jorenby, 1994):
■ As with tobacco and illicit drugs,
■ Direct, face-to-face advice and practitioners seeing adolescents may
suggestions choose to address the topic of alcohol,
■ Reinforcement urge abstinence or no more than very
56 Special Report
moderate use, and explore whether there report. The adult alcohol discussion includes
is a problem in need of additional the most important alcohol screening
discussion. questionnaires. Literature specific to use of
■ High-quality, validated screening alcohol during pregnancy is presented in the
questionnaires that are brief enough to be section called Pregnant Women.
practical in primary care settings are
available for screening adolescents and Evidence Base for Intervention
adults for problem drinking. Adults may According to the 1996 Second Edition of the
be periodically screened for problem U.S. Preventive Services Task Force’s Guide to
drinking or alcohol dependence. In most Clinical Preventive Services (USPSTF, 1996)—
primary care settings, the two-question,
two-item conjoint screen (TICS) or four- … Use of alcohol by adolescents and
question CAGE (Chan, 1994) or CUGE young adults has declined over the
past decade but remains a serious
(Cut down/Under the influence
problem (NIDA, 1993). Among
driving/Guilty/Eye opener) (Aertgeerts et 12–17 year-olds surveyed in 1993,
al., 2000) screening instruments may be 18 percent had used alcohol in the
most useful. In emergency room and last month, and 35 percent in the
psychiatric inpatient settings, the CAGE last year (SAMHSA, 1994). In a
(four yes/no questions), Audit (10 separate 1993 survey, 45 percent and
multiple-choice questions), or Michigan 33 percent, respectively, of male and
female 12th graders reported binge
Alcoholism Screening Test (MAST)
drinking (five or more drinks on one
(Selzer, 1971) (25 questions) may be occasion) within the previous month
considered. These are all described below. (CDC, 1995b). The leading causes of
In community health centers and facility- death in adolescents and young
based primary care outpatient settings adults—motor vehicle and other
with provision for nurses or social unintentional injuries, homicides, and
suicides—are each associated with
workers to conduct initial patient
alcohol or other drug intoxication in
settings, use of the 10-question Adult Use approximately half of the cases.
Disorders Identification Test (AUDIT) Driving under the influence of
instrument may be very helpful. alcohol is more than twice as
■ Special studies may be needed to identify common in adolescents than in adults
whether the health care system has a (CDC, 1987). Binge drinking is
high enough incidence of car crashes, especially prevalent among college
students: half of all men and roughly
injuries, homicides, or suicides within
one third of all women report heavy
any segment of its adolescent population drinking within the previous 2 weeks
to warrant partnering with appropriate (NIDA, 1993; Wechsler, Davenport,
community agencies to address possibly Dowdall, et al., 1994). Most binge
severe alcohol-related problems. drinkers report numerous alcohol-
related problems, including problems
with school work, unplanned or
Review of Literature
unsafe sex, and trouble with police
A more substantial review of the alcohol and (Wechsler et al., 1994).
health literature can be found in the section
on Adults (19 Years and Older) in this The American Academy of Pediatrics

(AAP), AMA Guidelines for Numerous studies demonstrate that
Adolescent Preventive Services clinicians frequently are unaware of
(GAPS), the Bright Futures problem drinking by their patients
Guidelines, and the American (USPSTF, 1996; NIAAA, 1993).
Academy of Family Physicians Early detection and intervention may
(AAFP) all recommend careful alleviate ongoing medical and social
discussion with all adolescents problems due to drinking and reduce
regarding alcohol use and regular future risks from alcohol abuse.
advice to abstain from alcohol
(American Academy of Pediatrics A 1990 Institute of Medicine (IOM)
Committee on Adolescence, 1995; report concluded that specific
AMA, 1994b; Green, ed., 1994; recommendations for the treatment
AAFP, 1994). of alcohol problems in young
persons were impossible, due to
Program Implementation Issues From disagreement over what constitutes a
the Published Literature drinking problem in adolescents, the
In a 2002 review of alcohol-problem related wide variety of interventions
screening questionnaires (NIAAA, 2002), the employed, and the absence of any
rigorous evaluation of different
National Institute on Alcohol Abuse and
treatments (IOM, 1990). Recent
Alcoholism (NIAAA) stated: “The Alcohol reviews of school-based programs
Use Disorders Identification Test (AUDIT) is found that most effects were
relatively free of gender and cultural bias inconsistent, small, and short-lived;
(Cherpitel, 1999; Reinert & Allen, 2002; programs that sought to develop
Volk, Steinbauer, Cantor, & Holtzer, 1997). In social skills to resist drug use seem to
be more effective than programs that
addition, it shows promise for screening
emphasize factual knowledge
adolescents and older people—populations in (Ennett, Tobler, Ringwalt, et al.,
which standard screening instruments produce 1994; Hansen, 1992).
inconsistent results (Steinbauer, Canton,
Holzer, & Volk, 1998; Reinert & Allen, 2002; All the data available regarding the
Clay, 1997; Chung, Colby, Barnett, et al., efficacy of clinical interventions at
2000; Chung, Colby, Barnett, & Monti, the time of the 1996 report are from
studies in adults, not adolescents. The
2002). The major disadvantage of AUDIT is
studies needed to document the
its length (10 questions) and relative efficacy of such interventions in
complexity (multiple choice); clinicians adolescents simply have not been
require training to score and interpret the test done, leaving us with a situation
results (Allen & Columbus, 1995).” where we either ignore alcohol
According to the 1996 Second Edition of problems in adolescents or
extrapolate the results from adults to
the U.S. Preventive Services Task Force’s
adolescents until such time as the
Guide to Clinical Preventive Services needed studies can be conducted,
(USPSTF, 1996)— peer-reviewed, and published. As
noted above, AMA, AAP, and AAFP
Laboratory tests generally are all have opted to recommend
insensitive and nonspecific for intervention in adolescents despite
problem drinking in both adolescents the lack of adolescent-specific studies.
and adults.
58 Special Report
According to the 1996 Second Edition of NIAAA, 1993). The IOM review
the U.S. Preventive Services Task Force’s concluded that treatment of other life
Guide to Clinical Preventive Services (US- problems (e.g., with antidepressant
medication, family or marital
PSTF, 1996)—
therapy, stress management) and
[counsel with] empathetic therapists
Typical of the results for were [factors] likely to improve
nondependent drinkers, a meta- treatment outcomes (IOM, 1989).
analysis of six brief intervention
trials (5–15 minutes of clinical
counseling) showed an average Data To Be Gathered
reduction in alcohol consumption of Refer to Appendix D. There are no specific
24 percent, comparing cases to supplemental data needs relative to alcohol
controls. Although self-reported and adolescents.
consumption may be subject to bias,
reported changes in drinking Illicit Drugs
correlated with measures of GTT
Programming to control use of illicit drugs
[glucose tolerance test] and blood
pressure in most studies (Babor & by adolescents is classified as “general”
Grant, eds., 1992). It is important to because of the severe immediate harm caused
note that this and most other such by drug use by adolescents—including auto
studies suffered from important accidents and problems in school. A number
methodological limitations. of studies demonstrate the efficacy of clinical
interventions in reducing or eliminating drug
For adults with alcohol-dependence,
completing either inpatient treatment use among symptomatic adolescents.
or 12 weeks of outpatient treatment, Although community interventions have
some studies have shown demonstrated value in preventing adolescent
approximately 60 percent long-term drug use, there is no substantial evidence
abstinence rates. These data are that stand-alone clinical interventions can
difficult to interpret, however, prevent drug experimentation and use. There
because of inadequate control
is no substantial evidence base to show the
groups, insufficient or selective
follow-up, and selection bias due to value of clinician interventions in getting
the characteristics of patients who asymptomatic adolescent drug users to quit.
successfully complete voluntary In each instance, the needed adolescent-
treatment programs (IOM, 1989; specific studies have not been done. Given
Thurstin, Alfano, & Sherer, 1986; these circumstances, the severe harm caused
Emrick, 1987). Since spontaneous
by drugs in adolescents, and the difficulty in
remission occurs in as many as 30
percent of alcoholics (Smart, ascertaining which adolescents are using
1975/76; Saunders & Kershaw, illicit drugs (because many parents do not
1979), reduced consumption may be know and many adolescents are unlikely to
inappropriately attributed to be forthright on this issue with adult
treatment. Successful treatment is authority figures), the most prudent course
likely to represent a complex appears to be brief universal screening of
interaction of patient motivation,
adolescents for drug use (by interview at
treatment characteristics, and the
post-treatment environment (family each primary care visit), with follow-up as
support, stress, etc.) (IOM, 1990; appropriate.

Intervention establish and maintain the desired
The primary care physician or nurse may trusting relationships with adolescents.
wish to inquire as to the use of illicit drugs Such reimbursement mechanisms would
at every visit, counsel abstention, and eliminate current financial disincentives
reinforce this message at every visit. to longer clinic visits.
Service-related issues specific to illicit drugs
and adolescents are as follows: Review of Literature
Evidence Base for Intervention
■ To approach discussion of use of illicit According to the 1996 Second Edition of the
drugs in a nonjudgmental manner, U.S. Preventive Services Task Force’s Guide to
clinicians should consider establishing a Clinical Preventive Services (USPSTF, 1996)—
trusting relationship with patients and
properly respect their concerns about the In a national household survey in
confidentiality of disclosed information. 1993, 14 percent of adults ages 18–25
years and 3 percent of those over 35
This would mean that physicians and
reported using illicit drugs within the
other clinicians would need to spend last month (SAMHSA, 1994).
much more time with their adolescent
patients so they can get to know each Among high school seniors in 1994,
other and begin to establish the trusting 22 percent reported using an illicit
relationships needed. Although common drug in the past month: marijuana
sense suggests these steps to be taken to (19 percent), stimulants (4 percent),
inhalants (3 percent), and
enhance the ability of health care
hallucinogens (3 percent) were more
delivery systems to deal with alcohol and common than cocaine (1.5 percent)
related issues in adolescent populations, or heroin (0.3 percent) (NIDA,
we know of no randomized controlled 1994b). Abuse of inhalants is a
trials that demonstrate their efficacy. leading drug problem in younger
Here, again, the needed studies have not adolescents (NIDA, 1994b) and can
cause asphyxiation or neurologic
been done.
damage with chronic abuse (Sharp,
■ Clinician inquiry as to use of illicit drugs at 1992). Abuse of anabolic steroids in
every visit with clinician counseling at adolescent boys and young men can
every visit not to initiate use of illicit drugs. cause psychiatric symptoms and has
■ Health care systems may wish to been associated with hepatitis,
consider the need to develop and endocrine, and cardiovascular
maintain special training programming problems.
to educate and assist clinicians in
Drug use is more common among
establishing relationships with men, unemployed adults who have
adolescents and in communicating with not completed high school, and
them about illicit drugs and related urban residents. The overall
topics. prevalence of drug use does not
■ Health care systems may wish to differ greatly among White, African
American, and Hispanic/Latino
consider the need for reimbursement and
populations, but patterns of drug use
payment systems that will enable may differ (NIDA, 1994a).
clinicians to spend the time required to Adverse effects of drug use are
60 Special Report
greatest in heavy users and those Faruque, et al., 1994)… . Drugs play
dependent on drugs, but some can a role in many homicides, suicides,
occur from even occasional drug use. and motor vehicle injuries… . Nearly
Cocaine can produce acute half of all users of cocaine or
cardiovascular complications (e.g., marijuana reported having driven a
arrhythmias, myocardial infarction, car shortly after using drugs
cerebral hemorrhage, and seizures), (Schwartz, 1987; Keer et al., 1994).
nasal and sinus disease, and
respiratory problems (when smoked) Early intervention has the potential
(Perper & Van Thiel, 1992; Warner, to avert some of the serious
1993). Dependence on cocaine consequences of drug abuse,
produces diminished motivation, including injuries, legal problems,
psychomotor retardation, irregular and medical complications. Although
sleep patterns, and other symptoms various treatments have been proven
of depression (Gold, Washton, & effective in persons with drug
Dackis, 1985). “Crack,” a popular dependence, they have largely been
and cheaper smokeable form of studies in patients who have already
cocaine, is also highly addictive. developed medical, social, or legal
Mortality among injection drug users problems due to their drug use.
(IDUs) is high from overdose, There is much less evidence that
suicide, violence, and medical systematic screening and earlier
complications from injecting intervention is effective in improving
contaminated materials (e.g., human clinical outcomes among
immunodeficiency virus [HIV]) asymptomatic persons, who may be
infection, hepatitis, bacterial less motivated to undergo treatment
endocarditis, chronic than more severely impaired drug
glomerulonephritis, and pulmonary users. Here, again, the needed studies
emboli); in some cities, up to 40 have not been done.
percent of IDUs are infected with
HIV (National Center for Infectious Treatment of adolescent substance
Diseases, 1993). Although the extent use disorders has been recently
of adverse effects of marijuana use is reviewed for nearly 1,500 primary
controversial, chronic use may be middle-class adolescents aged 12–19
associated with respiratory years who entered inpatient or
complications or amotivational residential treatment programs
syndrome (Schwartz, 1987; Jones, (Bergmann, Smith, & Hoffman,
1984). In a 1991 survey, 8 percent of 1995). Compared to use before
cocaine users and 21 percent of treatment, there was a significant
marijuana users reported daily use reduction in regular drug use (weekly
for 2 weeks or more (Keer, Colliver, or more) 1 year after treatment (85
& Kopstein, 1994). percent versus 29 percent), and 50
percent of teens had been abstinent
The indirect medical and social for 6 months. Increasing parental
consequences of drug use are equally participation in treatment was
important: criminal activities related associated with greater levels of
to illicit drugs take a tremendous toll abstinence.
in many communities. Use of
injection drugs and crack are major High school primary prevention
factors in the spread of HIV programs that emphasize “life skills”
infection (CDC, 1994; Edlin, Irwin, have reduced tobacco or alcohol use

over the short term (1 year) (Botvin The diagnostic standard for drug
& Botvin, 1992), but long-term abuse and dependence is the careful
effects on illicit drug use have not diagnostic interview (APA, 1994)… .
been well studied. In a 6-year
randomized trial among 3,597 high There are few data to determine
school students, a prevention whether the use of standardized
curriculum delivered in grades 7–9 screening questionnaires can increase
significantly reduced smoking and the detection of potential drug
alcohol use, but not marijuana use, problems among patients. Brief
in high school seniors; a subgroup of alcohol screening instruments such as
students who received a more the CAGE or MAST can be modified
complete intervention were less likely to assess the consequences of drug
to use marijuana regularly (5 percent use in a standardized manner
versus 9 percent) (Botvin, Baker, (Trachtenberg & Fleming, 1994;
Dusenbury, et al., 1995). Skinner, 1982), but these instruments
have not been compared with
The American Medical Association routine history of clinician
(AMA, 1988) and the American assessment. Questionnaires to
Academy of Family Physicians (AAFP, identify adolescents at increased risk
1994) advise physicians to include an for drug use have not been validated
in-depth history of substance use in prospective studies (Schwartz &
disorder as part of a complete health Wirtz, 1990). Other instruments,
examination for all patients. The … such as the Addiction Severity Index
AAFP (1994), AMA Guidelines for (McLellan et al., 1980), are useful
Adolescent Preventive Services (GAPS) for evaluating treatment needs but
(AMA, 1994b), Bright Futures are too long for screening.
recommendations (Green, ed., 1994),
and American Academy of Pediatrics Toxicological tests can provide
(AAP, 1989; AAP Committee on objective evidence of drug use… .
Substance Abuse, 1993) suggest that Sensitivity of these tests generally is
clinicians discuss the dangers of drug above 99 percent compared with
use with all children and adolescents reference standards (Armbruster,
and include questions about substance Schwartzoff, Hubster, et al., 1993);
use disorder as part of routine sensitivity for detecting drug use in
adolescent visits. individuals, however, depends directly
on timing of drug use and the urinary
The AMA and most other medical excretion of drug metabolites.
organizations endorse urine testing Marijuana may be detected for up to
(for drugs) when there is reasonable 14 days after repeated use, but
suspicion of substance use disorder, evidence of cocaine, opiates,
but none of these groups amphetamines, and barbiturates is
recommends routine drug screening present for only 2 to 4 days after use.
in the absence of clinical indications. Various techniques may be employed
by drug users who wish to avoid
Program Implementation Issues detection that further reduces the
From the Literature sensitivity of urine testing: water
According to the 1996 Second Edition of the loading, diuretic use, ingestion of
U.S. Preventive Services Task Force’s Guide to interfering substances, or adulterating
urine samples. Most importantly,
Clinical Preventive Services (USPSTF, 1996)—
toxicologic tests do not distinguish
62 Special Report
between occasional users and pregnancy is especially problematic,
individuals who are dependent on or because State law may require
otherwise impaired by drug use. physicians to report evidence of
potential harmful drug or alcohol
False-positive results from urine drug use in pregnant patients.
screening are possible due to cross-
reaction with other medications or
naturally occurring compounds in Data To Be Gathered
foods (ElSohly & ElSohly, 1990). To See Appendix D. Because optimal two-way
prevent falsely implicating persons as communication with adolescents, especially
users of illicit drugs, screen-positive
regarding use of illicit drugs, requires longer
samples are usually confirmed with
more specific (and expensive) clinic visits, health care systems may wish to
techniques, such as gas establish some means by which they can
chromatography-mass spectroscopy track time spent by primary care staff and
(GC-MS). These procedures reduce, time spent by those specializing in adolescent
but do not eliminate, the possibility health in clinic visits.
of false-positive results due to cross-
reactions, contamination, or
mislabeled specimens. Proficiency
Depression
testing of nearly 1,500 urine Depression in adolescents presents risk of
specimens sent to 31 U.S. suicide, risks relative to substance use
laboratories produced no false- disorder, inhibition of development of
positive results and three percent scholastic and emotional skills, and for those
false-negative results (Frings, with a chronic illness (such as asthma,
Bataglia, & White, 1989). A similar
diabetes, or even severe obesity), risk of non-
study of 120 clinical laboratories in
the U.K. demonstrated higher error adherence to prescribed regimens of care.
rates (4 percent false-positive, 8 The incidence of documented suicides by
percent false-negative), largely due to adolescents and young adults has
laboratories that did not use dramatically increased in recent decades,
confirmatory tests (Burnett, Lader, & with 5,000 youths committing suicide each
Richens, 1990). year and perhaps as many as
500,000–1,000,000 making an attempt
Drug testing is frequently performed
without informed consent in the (Greydanus, 1986; USPSTF, 1996).
clinical setting on the grounds that it In 2002, the U.S. Preventive Services Task
is a diagnostic test intended to Force issued the recommendation that all
improve the care of the patient. adults should be screened for depression in
Because of the significance of a health care settings, but concluded that
positive drug screen for the patient,
evidence was insufficient to extend this
however, the rights of patients to
autonomy and privacy have recommendation to children and adolescents
important implications for screening because of the limited number and quality of
of asymptomatic persons (Merrick, available studies specific to children and
1993). If confidentiality is not adolescents (USPSTF, 2002b, 2003; Pignone
ensured, test results may affect a et al., 2002). The problem here is that few
patient’s employment, insurance adolescent-specific studies have been done,
coverage, or personal relationships
and none has been done in primary care
(Rosenstock, 1987). Testing during

settings (USPSTF, 2003). The studies that screen adolescents for depression as a
have been done in other settings suggest that “targeted” service. The case for screening of
available screening procedures are less preadolescent children is much less clear; it
reliable in adolescents than adults, but that may be advisable to alert clinicians to signs
treatment is comparable in efficacy. and symptoms of depression in such children
A discussion of the adult literature and rather than having them apply universal
screening procedures that may be considered screening.
are both presented in the discussion about
depression in the section of this report called Intervention
Adults (19 Years and Older). Primary care practitioners can use their
The available literature on depression in clinical judgment in deciding which
adolescents clearly shows an increase in risk adolescents to screen for depression, and the
and severity of depression among children screening procedures that should be used.
and adolescents with a depressed parent, as The health care delivery system should
well as adolescents who have economic, assure that practitioners seeing large
social, and educational vulnerabilities. As a numbers of adolescents are familiar with the
matter of practicality, it will probably be research on this topic. All such practitioners
easier for primary care practitioners to should be alert to signs and symptoms of
directly screen the adolescent for depression depression in both children and adolescents.
with a brief screening instrument than it
would be to explore whether or not one or Review of Literature
both parents might be depressed and explore A more substantial review of the literature
possible sociodemographic risk factors. on depression appears in the section of this
Preventive interventions aimed at such report called Adults (19 Years and Older).
children, when they are showing
“subsyndromal” depressive symptoms can be Evidence Base for Intervention
very effective in preventing future episodes Depression is common among adolescents,
of major depression (Clarke et al., 2001). with a point prevalence estimated at 3–8
Depression and suicide are major concerns percent (Clarke et al., 2001; Birmaher et al.,
in adolescence. Unfortunately, the adult 1996). By 18 years of age, as many as 25
screening tests for depression, although fairly percent of adolescents have had at least one
good, are not as specific or sensitive for depressive episode (Lewinsohn, Hops,
adolescents. This means that there will be Roberts, Seeley, & Andrews, 1993). Children
more false-positives and more false- and adolescents with a depressed parent are
negatives. Furthermore, no studies have up to six times more likely to develop
examined treatment outcomes for children or depression than other children (Downey &
adolescents identified by primary care Coyne, 1990; Beardslee, Versage, &
clinicians through screening (USPSTF, 2003). Gladstone, 1998).
This lack of adolescent-specific, primary- Evidence now exists that psychosocial
care–specific research creates a situation interventions may prevent depression
where screening of all adolescents for (Beardslee et al., 1993; Clarke et al., 1995;
depression cannot be suggested as a Jaycox, Reivich, Gillham, & Seligman,
“general” service. It may be advisable to 1994). A frequently studied group consists of
64 Special Report
individuals who do not meet full DSM–IV experiencing major depression at time of
criteria for an affective episode, but who intake showed no net benefit from the
report significant “subsyndromal” depressive cognitive therapy intervention (Clarke et al.,
symptoms. Full-blown depression is more 2002).
likely to develop in these individuals In an earlier study (Clarke et al., 1995),
(Roberts, 1987; Horwath, Johnson, the Clarke team tested 1,625 high school
Klerman, & Weissman, 1992; Weissman, students with the CES-D (depression
Fendrich, Warner, & Wickramaratne, 1992). questionnaire) and then conducted a
Such individuals have been the subject of randomized controlled trial of 150 students
several targeted prevention interventions with “subsyndromal” depressive symptoms
(Clarke et al., 1995; Jaycox et al., 1994). who agreed to participate in the study. After
Clarke et al. (2001) published such a study randomizing them and providing the same
in a managed care population in Oregon. 15-session cognitive therapy intervention,
The Clarke team enrolled 45 cases and 49 cases showed a 14.5 percent rate of
controls, including adolescent children depressive episodes over the next 12 months,
showing “subsyndromal” depressive compared with 25.7 percent of the
symptoms who had at least one depressed controls—a level of risk and benefit similar
parent. Those offspring who met the to the children of depressed parents noted
diagnostic criteria for full-blown depression above. This high school study did not
were treated and studied separately. Those explore parental mental health conditions or
with no depressive symptoms were not other potential risk factors.
subsequently followed up. Those offspring In a thought-provoking ecological study
with subdiagnostic levels of depressive published in 2001, Podorefsky et al.
symptoms insufficient for a diagnosis were (Podorefsky, McDonald-Dowdell, &
invited to receive the experimental Beardslee, 2001) interviewed low-income
intervention, and adolescents who chose to families with parental depression and
participate were randomly assigned to the explored alliance-building as an intervention
experimental intervention versus the usual- to reduce both parental and child depression.
care group. In this small but well-designed Sixteen families participated in the study.
randomized controlled trial, the intervention Without exception, mothers described
was a 15-session group cognitive therapy depression as a reaction to traumatic or
prevention program. In the year after intake, chronic stressful conditions. The research
cases experienced 11 days of depression, team felt that at least some of these families
compared with 44 days for controls. Over a were living under conditions of
mean follow-up period of 15 months, 9.3 overwhelming adversity. The intervention
percent of the cases experienced one or more involved alliance-building at the community
depressive episodes, compared with 28.8 level, as well as with caregivers and family. It
percent of the controls. Much but not all of focused on family resilience and immediate
this preventive benefit persisted through the daily concerns—with promising preliminary
24-month follow-up, suggesting a durable results. This study suggests, but does not
but fading level of protection. prove, that for at least some families with
A parallel study by the Clarke team, of depression under certain circumstances,
children and adolescents who were already assistance with dealing with environmental

causes of the depression might be of value— tobacco, alcohol, and illicit drug use for all
and might be within reach of agency social adolescents aged 12–18 and suggests
work staff and community partners. screening adolescents for depression as a
The literature on the prevalence of “targeted” service. The literature supporting
depression in adults and the efficacy of screening adolescents for depression is less
screening and follow-up procedures is robust than its counterpart in adults because
reviewed in the section of this report on adult the randomized, adolescent-specific studies
depression and will not be duplicated here. have not been done.
Summary: Adolescents 12–18 Years

Research supports screening interviews for
66 Special Report
IX. Adults
(19 Years and Older)
S
creening and follow-up for tobacco and alcohol use disorders and for
depression/anxiety are the primary topics here that are addressed for
adults. Each topic is associated with a few brief questions, followed by
various low-cost interventions.
In persons without major medical or abuse in adults. Depression-related disorders

behavioral comorbidities, the medical are presented in detail, with a separate
benefits of screening and follow-up are discussion of depression screening, follow-
substantial but are spread out over too many up, and cost-effectiveness related to heavy
years to generate immediate health care cost users of health care services and those with
savings. The literature shows tobacco and major chronic diseases.
alcohol quit rates in the range of 5–30 Separate analyses were done for adults
percent (comparing cases to controls) and older and younger than 65 years of age.
frequent relapse, but even with these Problems related to use and misuse of
relatively modest quit rates, the benefits are multiple prescription drugs in persons over
substantial enough to suggest universal 65 years of age were considered to be
implementation. Adult guidelines differ from outside the scope of this report. Otherwise,
the adolescent and pregnancy guidelines in preventive guidelines and projected benefits
that preventing use of illicit drugs is not as for tobacco, alcohol, and depression
urgent an issue. screening were so similar for adults older
With depression and anxiety, the short- and younger than 65 years of age that the
term benefit of cost savings depends on the guidelines for all adults are presented in a
presence or absence of other medical and single section of this monograph for adults
behavioral comorbidities. In persons without 19 years of age and older.
such comorbidities, the benefits are
substantial but primarily related to quality of Tobacco
life and workplace productivity. In persons After reaching 21 years of age, initiation of
with such comorbidities, reductions in health tobacco use is rarely a problem. For those
care costs can be substantial and immediate. who already smoke, the issue to be
Detailed guidelines and literature reviews addressed is prevention of future tobacco-
are presented for tobacco, alcohol, related medical illness through reduction or
depression, and anxiety. These guidelines elimination of current tobacco use. In
include the specific screening questions to be randomized trials, inexpensive clinical
used, and guidelines for follow-up. A brief interventions for cessation of tobacco use
discussion is provided relative to substance have shown increases in abstinence rates in

the range of 3–25 percent at one year, reductions in health care costs attributable to
compared with controls (Wilson, Taylor, addressing alcohol use, use of illicit
Gilbert, et al., 1988; Okene, Kristeller, substances, and depression do not appear to
Goldberg, et al., 1991; Bronson, Flynn, be a benefit of tobacco cessation
Solomon, et al., 1989; Hollis, Lichtenstein, programming. As a result, from a health-
Vogt, Stevens, & Biglan, 1993; Cohen, care–cost perspective, smoking cessation will
Stookey, Katz, et al., 1989; Curry, Marlatt, have little or no immediate impact on
Gordon, et al., 1988; Stevens & Hollis, aggregate health care costs.
1989). The key to success is consistent As tobacco use becomes less and less
reinforcement by clinicians. socially acceptable, fewer people will smoke,
Tobacco-related disease is prevalent and those who do smoke will smoke less.
enough and serious enough that even with One suggested way to pursue this objective,
limited efficacy of clinical interventions, such on a societal basis, is to have every adult and
interventions have been deemed worthy of senior asked about tobacco use at every
universal implementation. In fact, all major primary care visit, and to have every tobacco
health organizations that have addressed this user briefly counseled to quit. Although this
topic have supported this recommendation. approach is not amenable to randomized
As a result of these findings, tobacco controlled trials, it seems reasonable to
cessation programming for adults and presume that action along this line could
seniors is classified as “general.” play a significant role in reducing adult and
This literature search uncovered no senior tobacco use.
literature dealing directly with the issue of
cost-effectiveness for tobacco control Interventions
programming for adults and seniors. The The literature suggests that the topic of
problem here is two-fold. First, the benefits tobacco use should be brought up at every
for adults and seniors without major chronic outpatient visit. Those who smoke or
diseases are too far in the future, and their otherwise use tobacco products may be
health care service utilization is too small for counseled to cease such use. If immediate
smoking cessation to substantially reduce cessation seems out of reach, smokers may
other health care costs within 12 months. be counseled to reduce the amount of
Second, for those with major chronic tobacco they use and to consider enrollment
diseases, the major impact is likely to be a in tobacco cessation programming.
reduction in short-term mortality. This If not already accomplished, steps can be
reduction in mortality is a substantial patient taken to assure that all health and medical
benefit, but it may increase health care costs facilities are totally smoke-free. This is
by keeping these sick patients alive longer, important for a number of reasons, the most
thereby nullifying the savings from marginal important of which may be communicating
reductions in health care use by these same to staff and patients that smoking is simply
persons with chronic diseases. not acceptable because of its extreme hazard
This literature review found no direct to the health of both smokers and persons
evidence that tobacco use influenced a exposed to secondhand tobacco smoke.
patient’s ability and willingness to follow
prescribed regimens of care. The near-term
68 Special Report
Review of Literature (Wilson et al., 1988; Okene et al.,
Evidence Base for Intervention 1991; Bronson et al., 1989; Hollis et
According to the 1996 Second Edition of the al., 1993; Kottke, Battista, DeFriese,
et al., 1988; Cohen et al., 1989) and
U.S. Preventive Services Task Force’s Guide
group (Kottke et al., 1988; Curry et
to Clinical Preventive Services (USPSTF, al., 1988; Stevens & Hollis, 1989) in
1996)— changing the smoking behavior of
patients… . A meta-analysis of 39
… Detailed reviews of the extensive clinical trials in nonpregnant adults
literature on the health effects of examined different types of clinical
smoking, dose-response smoking cessation techniques
relationships, and nicotine addiction involving various combinations of
have been published elsewhere counseling, distribution of literature,
(CDC, 1993a; DHHS, 1986, 1989, and nicotine replacement therapy. It
1990b; EPA, 1992; NCI, 1993). A found higher cessation rates in the
number of consistent findings from intervention group compared with
this body of evidence are well the control groups, with differences
established. First, tobacco is one of averaging 6 percent after 1 year
the most potent of human (Kottke et al., 1988). Subsequent
carcinogens, causing an estimated published trials have demonstrated
148,000 deaths among smokers increases in abstinence rates of 3–7
annually due to smoking-related percent in patients receiving clinician
cancers (CDC, 1993a). The majority counseling (Wilson et al., 1988;
of all cancers of the lung, trachea, Okene et al., 1991; Bronson et al.,
bronchus, larynx, pharynx, oral 1989; Hollis et al., 1993; Cohen et
cavity, and esophagus are al., 1989) and 8–25 percent with
attributable to the use of smoked or group counseling, compared with
smokeless tobacco (DHHS, 1986, controls (Curry et al., 1988; Stevens
1989). Smoking also accounts for a & Hollis, 1989). The key elements of
significant but smaller proportion of effective counseling seem to be
cancers of the pancreas (CDC, 1990; providing reinforcement through
Ghadirian, Simard, & Baillargeon, consistent and repeated advice from
1991; Howe et al., 1991; Bueno de a team of providers to stop smoking,
Mesquita et al., 1991), kidney setting a specific “quit date,” and
(DHHS, 1989), bladder (CDC, 1990; scheduling follow-up contacts or
Hartge et al., 1993), and cervix visits. Using additional modalities,
(CDC, 1990; Coker et al., 1992; such as self-help materials, referral to
Sood, 1991; Gram et al., 1992)… . group counseling, advice from more
100,000 deaths from coronary heart than one clinician, or chart
disease … [and] 85,000 deaths from reminders identifying patients who
pulmonary diseases … . smoke, seems to further enhance
effectiveness (Kottke et al., 1988;
There is a large body of evidence Cohen et al., 1989; Russell, Wilson,
from prospective cohort and case- Taylor, et al., 1979; Janz, Becker,
controlled studies showing that many Kirscht, et al., 1987; Sanders,
of these health risks can be reduced Fowler, Mant, et al., 1989).
by smoking cessation (CDC, 1990).
A number of clinical trials have As adjuncts to counseling, the
demonstrated the effectiveness of prescription of nicotine products can
certain forms of clinician counseling facilitate smoking cessation (Lam,

Sze, Sacks, et al., 1987; Jarvis, Raw, toxicity (Johnson, Steven, Hollis, et
Russell, et al., 1982; Jackson, al., 1992; Orleans, Resch, Noll, et
Stapleton, Russell, et al., 1986; al., 1994).
Tonnesen, Fryd, Hansen, et al.,
1988; Hughes, Gust, Kennan, et al., All major health care organizations
1989; Tonnesen, Norregaard, and authorities recommend routine
Simonsen, et al., 1991; Stapleton, clinician counseling of adults,
Russell, Feyerabend, et al., 1995; pregnant women, parents, and
Transdermal Nicotine Study Group, adolescents to avoid or discontinue
1991; Daughton, Heatly, smoking and use of smokeless
Prendergast, et al., 1991; Muller, tobacco (USPSTF, 1996; American
Abelin, Ehrsam, et al., 1990; Sachs, College of Physicians Health and
Sawe, & Leischow, 1993; Fiore, Public Policy Committee, 1986;
Kenford, Jorenby, et al., 1994; Hurt, AAFP, 1994; AAP, 1988, 1994;
Dale, Fredrickson, et al., 1994; ACOG, 1993; Manley et al., 1991;
Fiore, Smith, Jorenby, et al., 1994). AMA, 1993, 1994a; ADA, 1992;
Randomized controlled trials have CTF on the Periodic Health
found that 12-month cessation rates Examination, 1994b; NIH, 1989,
after brief clinician counseling and 1994; American Academy of
multiple follow-up visits double from Otolaryngology—Head and Neck
4 percent to 9 percent with placebo Surgery, 1992; Green, ed., 1994).
to 9 percent to 25 percent with the
nicotine patch (Tonnesen et al., The effects on patients with coronary heart
1991; Stapleton et al., 1995; Sachs et disease quitting smoking was reviewed by
al., 1993; Hurt et al., 1994). When Critchley and Capewell (Critchley &
used correctly and in combination
Capewell, 2003). In this 2003 literature
with clinician advice to stop
smoking, nicotine gum increases review, they concluded that “quitting
long-term smoking cessation rates by smoking is associated with a substantial
approximately one third (Oster, reduction in risk of all-cause mortality
Huse, Delea, & Colditz, 1986; Tang, among patients with coronary heart disease.
Law, & Wald, 1994)… . Two meta- This risk reduction appears to be consistent
analyses of controlled trials of regardless of age, sex, index cardiac event,
nicotine replacement therapies found
country, and year of study commencement.”
a significant benefit for all modalities
with no modality being significantly Thus there is a strong evidence base for a
better than another (Tang et al., modest reduction in tobacco use through
1994; Silagy, Mant, Fowler, et al., clinician counseling to encourage cessation.
1994)… . The evidence suggests that The evidence suggests that the health risks of
nicotine products are most effective continuing an established tobacco addiction
as adjuncts to ongoing smoking
are so extreme, however, that programming
cessation counseling (Silagy et al.,
1994; Fiore, Jorenby, Baker, et al., of even minimal effectiveness would reap
1992). Furthermore, patients need considerable benefits when offered as routine
proper instruction on how to use the clinical practice.
nicotine replacement therapies. Nurse-assisted counseling for smokers may
Patients have been reported to use be considered by health care systems that
nicotine patches and gum without provide primary care services in large clinic
discontinuing smoking, thus
settings. In 1993, Kaiser Permanente
increasing the risk of nicotine
70 Special Report
(Portland, Oregon) published a randomized Although the significant health hazard
controlled trial (Hollis et al., 1993) showing of tobacco use and the benefits of
86 percent physician participation in cessation are well established, studies
suggest that many clinicians fail to
delivering brief advice, and quit rates of
counsel patients who smoke to stop
approximately 7 percent in nurse-counseled tobacco use (CDC, 1993c; Anda,
patients, compared with approximately 3.9 Remington, Sienko, et al., 1987;
percent for physician advice alone at one Frankowski & Secker-Walker, 1989;
year. Prior to the study, physicians USPSTF, 1996). This reluctance to
participated in a 1-hour training session to intervene may be the result of a
number of variables, including lack of
encourage them to use their own words to
confidence in the ability to provide
deliver a basic message lasting no more than adequate counseling, lack of patient
30 seconds: interest, lack of financial
reimbursement or personal reward,
The best thing you can do for your insufficient time, and inadequate staff
health is to stop smoking, and I support (Kottke, Willms, Solberg, et
want to advise you to stop as soon al., 1994). As described above,
as possible. I know it can be very however, a number of studies have
hard; many people try several times shown that clinician counseling can
before they finally make it. You may change behavior, even when the
or may not want to stop now, but I intervention is relatively brief. Nearly
want you to talk briefly with our 50 percent of all living individuals
health counselor, who has some tips who have ever smoked have stopped
to make stopping easier when you (CDC, 1994a), and 30 percent of
decide the time is right. quitters report being urged to quit by
a physician (Fiore, Novotny, Peirce, et
The nurse counseling session included a al., 1990). Approximately 90 percent
10-minute video and an assortment of aids of successful quitters have quit
and stop-smoking literature. There were without intensive counseling but by
three different study interventions— stopping abruptly or with the help of
individual, group, and combination—all quitting manuals (Fiore et al., 1990).
with similar quit rates (Hollis et al., 1993). A cost-effectiveness study supports
the clinical value of offering smoking
The study was limited, given that only about
cessation counseling during the
half of the participating cases and controls routine office visit of patients who
provided saliva samples for the follow-up smoke (Cummings, Rubin, & Oster,
testing. Those results were still highly 1989).
statistically significant, but with results
30–50 percent lower than noted above, if all Certain strategies can increase the
those who did not submit saliva samples effectiveness of counseling against tobacco
were counted as continuing smokers. use (NIH, 1986, 1989, 1994; AMA, 1994a;
AAFP, 1987; Kenford et al., 1994):
Program Implementation Issues
According to the 1996 Second Edition of the ■ Direct, face-to-face advice and
U.S. Preventive Services Task Force’s Guide to suggestions
Clinical Preventive Services (USPSTF, 1996)— ■ Reinforcement
■ Office reminders to the physician

■ Self-help materials tobacco and illicit drugs, any use is harmful.
■ Community programs for additional help With alcohol, however, moderate use can
in quitting have a favorable effect on all-cause death
■ Drug therapy (nicotine patch or gum and rates, and on death rates from coronary
related products) heart disease (Bradley, Donovan, & Larson,
1993; Stampfer, Rimm, & Walsh, 1993;
One recent study (McAfee, Grossman, Maclure, 1993; Klatsky, Armstrong, &
Dacey, & McClure, 2002) suggested that in a Friedman, 1990; Stampfer, Golditz, Willett,
managed care setting (Group Health et al., 1988; Gaziano, Buring, Breslow, et al.,
Cooperative, Tukwila, Washington), a quality 1993).
improvement initiative using an automated There is relatively little clinicians can do to
billing system with performance feedback prevent initial excessive use of alcohol, but
and senior-level incentives could dramatically available, reasonably inexpensive interventions
increase tobacco-related counseling and can significantly reduce future excessive use
frequency of intervention, as well as secure and the behavioral, social, and injury-related
the data through the billing system. complications of such use. In persons with one
or more chronic diseases, reducing excessive
Data To Be Gathered alcohol use may be of value in improving
Refer to the section in this monograph called patient adherence to prescribed regimens of
Procedures for Implemention and Evaluation care and avoiding medical complications of
of Preventive Services. Special data issues excessive alcohol use.
relative to tobacco and adults are limited to From a primary care perspective, alcohol-
special attention to tobacco use in patients related problems can be divided into two
with major chronic diseases. Although not major categories: alcohol
caused by tobacco use, diabetes carries a much dependence/addiction and nondependent
higher rate of major complications in smokers. problem drinking. The research suggests that
those with addiction/dependence should be
Alcohol referred for specialized care. The primary
Alcohol screening for all adults, including care physician, however, often can
college students, is classified as “general” successfully manage the nondependent
because of the severity of both immediate problem drinkers. Separate sections of this
and long-term harms caused by alcohol use report address use of alcohol by pregnant
by adults. Since both acute use and women and by adolescents.
immediate problems are most severe among
college students and other college-age young Suggested Interventions
adults, special attention is directed to this As with tobacco use, the topic of alcohol use
age group (18–29 years of age). The efficacy may be brought up at every outpatient visit,
of clinical interventions to reduce harmful with follow-up counseling as needed. Unlike
alcohol use is modest, but the severity of the tobacco, there appears to be no harm, and
harm—both short-term and long-term— some benefit, from one or two drinks per
mandates that health care providers and day. This benefit, however, is not substantial
health care delivery systems do what they enough to recommend that nondrinkers
can to reduce such harmful use. With begin to consume alcohol. Practitioners may
72 Special Report
be careful not to communicate the benefits research suggests that the most effective
of moderate use as an excuse for more and most well-documented primary care
substantial consumption of alcohol. intervention is the Trial for Early
Alcohol Treatment (TrEAT) protocol.
Special Service-Related Issues Specific to This involves a defined set of materials
Adults and Alcohol and two physician-patient sessions of 10
to 20 minutes apiece. The evidence for
■ High-quality, validated screening this protocol and against single-visit and
questionnaires that are brief enough to shorter protocols is described below.
be practical in primary care settings are ■ Unlike tobacco and illicit drugs, modest
available for screening adolescents and use of alcohol can have health benefits,
adults for problem drinking. Adults such as reducing the risk of heart disease.
should be periodically screened for
problem drinking or alcohol dependence. Review of Literature
In most primary care settings, the two- Additional alcohol-and-health literature is
question/two-item conjoint screen (TICS) presented in the sections of this report
or four-question CAGE or CUGE addressing the needs of pregnant women and
screening instruments may be most adolescents.
useful. In emergency room and
psychiatric inpatient settings, the CAGE Evidence Base for Intervention
(four yes/no questions), Audit (10 Burden of Suffering
multiple-choice questions), or Michigan According to the 2003 National Institute on
Alcoholism Screening Test (MAST) Alcohol Abuse and Alcoholism (NIAAA)
(Selzer, 1971) (25 questions) may be health practitioner’s guide to helping patients
considered. These are all described with alcohol problems (NIAAA, 2003)—
below. In community health centers and
facility-based primary care outpatient Alcohol problems are common: 14
settings that allow nurses or social million American adults suffer from
alcohol abuse or alcoholism (Grant,
workers to conduct initial patient
Harford, Dawson, et al., 1994), and
settings, use of the 10-question Adult more than 100,000 people die from
Use Disorders Identification Test alcohol-related diseases and injuries
(AUDIT) instrument may be considered each year (Stinson, Nephew, Dufour,
seriously. & Grant, 1996). About a third of all
■ Clinicians must be able to differentiate adults engage in some kind of risky
problem drinking from alcohol drinking behavior, ranging from
occasional to daily heavy drinking
dependence. Problem drinking usually
(NIAAA, 2002). Over the past few
can be successfully managed by the generations, patterns of alcohol
primary care practitioner. Alcohol consumption have changed notably:
dependence requires much more people start drinking at increasingly
intensive intervention, and either earlier ages, the likelihood of
specialized programming or specialized dependence has risen in drinkers, and
women’s drinking patterns and rates of
health care staff.
dependence have become increasingly
■ For nondependent problem drinkers, similar to men’s (Grant, 1997).

According to the 1996 Second Edition of withdrawal syndrome, psychosis,
the U.S. Preventive Services Task Force’s hepatitis, cirrhosis, pancreatitis,
Guide to Clinical Preventive Services thiamine deficiency, neuropathy,
dementia, and cardiomyopathy
(USPSTF, 1996)—
(NIAAA, 1993). Nondependent
heavy drinkers, however, account for
Over half a million Americans are the majority of alcohol-related
under treatment for alcoholism, but morbidity and mortality in the
there is growing recognition that general population (IOM, 1990).
alcoholism (i.e., alcohol dependence) There is a dose-response relationship
represents only one end of the between daily alcohol consumption
spectrum of “problem drinking” and elevations in blood pressure and
(IOM, 1990). Many problem risk of cirrhosis, hemorrhagic stroke,
drinkers have medical or social and cancers of the oropharynx,
problems attributable to alcohol (i.e., larynx, esophagus, and liver
alcohol abuse or “harmful (Klatsky, Armstrong, & Friedman,
drinking”) without typical signs of 1992; Boffetta & Garfinkel, 1990;
dependence (APA, 1994; WHO, Anderson, Cremona, Paton, et al.,
1992), and other asymptomatic 1993). A number of studies have
drinkers are at risk for future reported a modest increase in breast
problems due to chronic heavy cancer among women drinking two
alcohol consumption or frequent drinks per day or more, but a causal
binges (i.e., “hazardous drinking”). connection has not yet been proven
Heavy drinking (more than five (Rosenberg, Metzger, & Palmer,
drinks per day, five times per week) 1993). Three large cohort studies,
is reported by 10 percent of adult involving more than 500,000 men
men and 2 percent of women and women, observed increasing all-
(SAMHSA, 1994). In large cause mortality beginning at four
community surveys using detailed drinks per day in men (Klatsky et al.,
interviews (Helzer & McEvoy, 1991; 1992; Boffetta & Garfinkel, 1990)
Grant et al., 1994; Kessler et al., and above two drinks per day in
1994), the prevalence of alcohol women (Fuchs, Stampfer, Colditz, et
abuse and dependence in the al., 1995). Women achieve higher
previous year among men was 17–24 blood alcohol levels than do men,
percent among 18–29 year-olds, due to their smaller size and slower
11–14 percent among 30–44 year- metabolism (Klatsky et al., 1992;
olds, 6–8 percent among 45–64 year- Fuchs et al., 1995). Compared to
olds, and 1–3 percent for men over nondrinkers and light drinkers,
65; among women in the overall mortality was 30 percent to
corresponding age groups, 38 percent higher among men, and
prevalence of abuse or dependence more than doubled among women
was 4–10 percent, 2–4 percent, 1–2 who drank six or more drinks per
percent, and less than 1 percent, day (Klatsky, et al., 1992; Boffetta
respectively. Problem drinking is & Garfinkel, 1990). Of the more
even more common among patients than 100,000 deaths attributed to
seen in the primary care setting alcohol annually, nearly half are due
(8–20 percent) (Bradley, 1994). to unintentional and intentional
injuries (CDC, 1990), including 44
Medical problems due to alcohol percent of all traffic fatalities in 1993
dependence include alcohol (National Highway Traffic Safety
74 Special Report
Administration, 1994) and a In an update published in 2002, Naimi et al.
substantial proportion of deaths (2002) noted that nationwide, binge drinking
from fires, drownings, homicides, increased from 1993 to 2001. Binge drinking
and suicides …
episodes among U.S. adults increased from
The social consequences of problem 1.2 billion to 1.5 billion (25 percent
drinking are often as damaging as the increase), while binge-drinking episodes per
direct medical consequences. Nearly person increased by 17 percent, from 6.3
20 percent of drinkers report percent to 7.4 percent. Men accounted for
problems with friends, family, work, 81 percent of binge drinking episodes. Rates
or police due to drinking (NIAAA,
of binge drinking episodes were highest
1993). Persons who abuse alcohol
have a higher risk of divorce, among those aged 18–25 years. Binge
depression, suicide, domestic violence, drinkers were 14 times more likely to drive
unemployment, and poverty (NIAAA, while impaired by alcohol compared with
1993). Intoxication may lead to nonbinge drinkers. There were substantial
unsafe sexual behavior that increases State and regional differences in per capita
the risk of sexually transmitted binge drinking.
diseases, including human
immunodeficiency virus (HIV).
Finally, an estimated 27 million Brief Summary of Available Alcohol Screening
American children are at risk for Tests for Use in Primary Care Settings
abnormal psychosocial development There are a number of screening tests
due to the abuse of alcohol by their available, ranging from 1 to 25 questions in
parents (Sher, ed., 1991). length, and with substantial variation in
sensitivity, specificity, and staff training
Moderate alcohol consumption has
favorable effects on the risk of required for optimal use. None is perfect,
coronary heart disease (CHD) but all are better than no screening at all. All
(Bradley et al., 1993; Stampfer et al., of these questionnaire instruments are for
1988, 1993; Maclure, 1993; Klatsky screening, not diagnosis. Positive responses
et al., 1990; Gaziano et al., 1993). appear best when followed up with more
CHD incidence and mortality rates extensive interview to confirm or deny the
are 20 percent to 40 percent lower in
presence of an alcohol-related problem and
men and women who drink one to
two drinks/day than in nondrinkers to differentiate between alcoholism and
(Fuchs et al., 1995; Klatsky et al., nondependent problem drinking. These are
1990; Stampfer et al., 1988). A all described in greater detail in the
meta-analysis of epidemiologic following section, with sample questions
studies suggests little additional provided.
benefit of drinking more than 0.5
drinks per day (Maclure, 1993). The
exact mechanism for the protective Single Question: “On any single occasion
effect of alcohol is not known but during the past 3 months, have you had
may involve increases in high-density more than five drinks containing alcohol?”
lipoprotein (Gaziano et al., 1993)
and/or fibrinolytic mediators (Ridker, Two-Question: “In the last year, have you
Vaughan, Stampfer, et al., 1994). ever drank or used drugs more than you
meant to?” and “Have you felt you wanted

or needed to cut down on your drinking or morning to get yourself going after a
drug use in the last year?” heavy drinking session?
7. How often during the last year have
Four-Question: “CAGE” you had a feeling of guilt or remorse
C: “Have your ever felt you ought to Cut after drinking?
down on drinking?” 8. How often during the last year have
A: “Have people Annoyed you by criticizing you been unable to remember what
your drinking?” happened the night before because
G: “Have you ever felt bad or Guilty about you had been drinking?
your drinking?” 9. Have you or someone else been
E: “Have you ever had a drink first thing in injured as a result of your drinking?
the morning to steady your nerves or get 10. Has a relative, or friend, or doctor,
rid of a hangover (Eye opener)?” or another health worker been
concerned about your drinking, or
Four-Question: “CUGE” The CUGE suggested you cut down?
questionnaire replaces the “annoyed you by
criticizing your drinking” question with 25-Question: “MAST” The 25-question
“Have you often driven under the Michigan Alcoholism Screening Test (MAST)
influence?” is relatively sensitive and specific, but it
generally is considered too lengthy for
Ten-Question: “AUDIT” (Alcohol Use routine screening in primary care settings. It
Disorders Identification Test) is commonly used in psychiatric outpatient
1. How often do you have a drink and inpatient settings.
containing alcohol? Most studies seem to recommend the four-
2. How many drinks containing alcohol question CAGE and CUGE questionnaires
do you have on a typical day when for primary care settings, with a minimum of
you are drinking? paraprofessional support and use of the 10-
3. How often do you have six or more question AUDIT questionnaire where non-
drinks on one occasion? physician staff are available to administer
(Interviewers are then instructed to and score the questionnaire. The CAGE and
skip to questions 9 and 10 if the CUGE questionnaires require only yes/no
answer to question 2 is fewer than answers and are easily memorized by
three drinks, and if the answer to primary care practitioners. The 10-question
question 3 is “never.”) AUDIT questionnaire has multiple choice
4. How often during the last year have questions and a formalized scoring
you found that you were not able to procedure.
stop drinking once you had started?
5. How often during the last year have More Detailed Discussion of the Accuracy
you failed to do what was normally and Utility of Alcohol Screening Tests
expected from you because of According to the 1996 Second Edition of the
drinking? U.S. Preventive Services Task Force’s Guide to
6. How often during the last year have Clinical Preventive Services (USPSTF, 1996)—
you needed a first drink in the
76 Special Report
Laboratory tests generally are Kaplan, 1972), but it is too lengthy
insensitive and nonspecific for for routine screening. . . . The four-
problem drinking in both adolescents question CAGE instrument is the
and adults. most popular screening test for use
in primary care (Ewing, 1984), and
Accurately assessing patients for has good sensitivity and specificity
drinking problems during the routine for alcohol abuse or dependence (74
clinical encounter is difficult. The percent to 89 percent and 79 percent
diagnostic standard for alcohol to 95 percent, respectively) in both
dependence or abuse (Diagnostic and inpatients (Bernadt, Mumford,
Statistical Manual of Mental Taylor, et al., 1982; Bush, Shaw,
Disorders [DSM] IV) (APA, 1994) Cleary, et al., 1987) and outpatients
requires a detailed interview and is (King, 1986; Buchsbaum, Buchanan,
not feasible for routine screening. Centor, et al., 1991; Chan, Pristach,
Physical findings … are only late & Welte, 1994).
manifestations of prolonged, heavy
alcohol abuse (Glaze & Coggan, The CAGE is less sensitive for early
1987). Asking the patient about the problem drinking or heavy drinking
quantity and frequency of alcohol (Chan et al., 1994; Hays &
use is an essential component of Spickard, 1987). Both the CAGE and
assessing drinking problems, but it is MAST questionnaires share
not sufficiently sensitive or specific important limitations as screening
by itself for screening. In one study, instruments in the primary care
drinking 12 or more drinks a week setting: an emphasis on symptoms of
was specific (92 percent) but dependence rather than early
insensitive (50 percent) for patients drinking problems, lack of
meeting DSM criteria for an active information on level and pattern of
drinking disorder (Buchsbaum, alcohol use, and failure to
Welsh, Buchanan, et al., 1995). The distinguish current from lifetime
reliability of patient report is highly problems (Chan, Pristach, Welte, et
variable and dependent on the al., 1993).
patient, the clinician, and individual
circumstances. Heavy drinkers may Some of these weaknesses are
underestimate the amount they drink addressed by . . . AUDIT, a 10-item
because of denial, forgetfulness, or screening instrument developed by
fear of the consequences of being the World Health Organization
diagnosed with a drinking problem. (WHO) in conjunction with an
international intervention trial. The
A variety of screening questionnaires AUDIT incorporates questions about
have been developed which focus on drinking quantity, frequency, and
consequences of drinking and binge behavior along with questions
perceptions of drinking behavior. about consequences of drinking
The 25-question Michigan (Saunders, Aasland, Babor, et al.,
Alcoholism Screening Test (MAST) 1993). . . . AUDIT had high
(Selzer, 1971) is relatively sensitive sensitivity and specificity for
and specific for DSM-diagnosed “harmful and hazardous drinking”
alcohol abuse or dependence (84 (92 percent and 94 percent,
percent to 100 percent and 87 respectively) as assessed by more
percent to 95 percent, respectively) extensive interview (Saunders et al.,
(Selzer, 1971; Pokorny, Miller, & 1993). . . . Because it focuses on

drinking in the previous year, alcohol-related problems in the emergency
however, AUDIT is less sensitive for department setting. The Task Force asserted
past drinking problems (Schmidt, that early detection of alcohol problems
Barry, & Fleming, 1995).
would provide an opportunity for early
The World Health Organization (WHO) intervention, which in turn might reduce
recommends use of the AUDIT questionnaire subsequent morbidity and mortality
in all primary care settings. A guidelines (D’Ononfrio et al., 1998).
document for use with AUDIT is available In a review of the quality of health care
free of charge from WHO (Babor TF, provided to adults in the United States,
Higgins-Biddle, & Monterio, 2001). The published in the New England Journal of
questionnaire consists of 10 questions Medicine in 2003, McGlynn et al. reported
dealing with consumption of alcohol, that, of all quality measures explored,
symptoms of dependence, and social and adherence to quality measures for alcohol
behavioral evidence of harm. Each of the dependence was documented in only 10.5
questions is scored on a scale of 0–4, with percent of records reviewed. This compares
scores of 16–19 warranting supplemental with approximately 40 percent to 78 percent
counseling and continued monitoring. Scores for most other quality measures in this study
in the range of 20–40 suggest referral to a (McGlynn et al., 2003). This study gathered
specialist for diagnostic evaluation and data from adult surveys and medical record
treatment. reviews in 12 metropolitan areas of the
The AUDIT and MAST questionnaires United States for the most recent 2-year
require written forms and formal scoring period.
procedures, which in turn require more staff Several recent papers urged screening of
training. These are not problems with the patients with depression (Abraham & Fava,
shorter and simpler TICS, CAGE, and 1999), schizophrenia (Agelink, Ullrich,
CUGE, which are short enough to be easily Lemmer, Dirkes-Kersting, & Zeit T, 1999)
memorized by the primary care physicians and/or mood, anxiety, and substance use
and nurses and elicit yes/no answers. disorder (DeGraff, Bijl, Smit, Vollenbergh, &
Spijker, 2002) for alcohol-related problems,
Use of Screening Tests for Alcohol Problems given the high prevalence of comorbid
Numerous studies demonstrate that clinicians alcohol problems in these patients as well as
frequently are unaware of problem drinking self-medication with alcohol.
by their patients (USPSTF, 1996; NIAAA, A brief overview of screening tests for
1993; Weisner & Matzger, 2003). Early alcohol problems can be found on the Web
detection and intervention may alleviate site of the National Institute on Alcohol
ongoing medical and social problems Abuse and Alcoholism (NIAAA) at
resulting from drinking and reduce future www.niaaa.nih.gov/publications/aa56.htm.
risks from alcohol abuse (USPSTF, 1996). This April 2002 review (NIAAA, 2002)
In 1998, the Substance Abuse Task Force makes the following major points:
of the Society for Academic Emergency
Medicine issued a statement urging ■ Both questionnaires and blood tests are
emergency room physicians to use screening available. The blood tests (GGT
questionnaires to improve their detection of [Gamma-glutamyl transferase]; CDT
78 Special Report
[Carbohydrate Deficient Transferrin]; population sample (Dawson, 2000) and
MCV [Mean Corpuscular Volume]; and did better than CAGE alone among
possibly FAEEs [Fatty Acid Ethel African Americans in an urban
Ethers]) probably are of little value in emergency room (Friedman, Saitz,
screening for chronic alcohol problems, Gogineni, Zhang, & Stein, 2001).
but may be of significant value in ■ The Alcohol Use Disorders Identification
tracking the progress of alcoholics and Test (AUDIT) (Saunders et al., 1993)
problem drinkers under care. also incorporates questions about
■ The screening tests are not diagnostic. quantity and frequency of alcohol use. In
They identify individuals who may be contrast to CAGE, AUDIT compares
interviewed more carefully to confirm or favorably with other instruments in
deny the impression of an alcohol-related detecting risky drinking but is less
problem, before establishing the need for effective in identifying alcohol use and
further investigation, treatment, or alcoholism (Fiellin et al., 2000; Reinert
referral. & Allen, 2002). AUDIT has proven
■ Use of screening tests is very effective useful among medical and psychiatric
both in identifying individuals with inpatients, in emergency rooms (Reinert
alcohol-related problems, and getting & Allen, 2002), and in the workplace
them the appropriate therapy (Fiellin, (Reinert & Allen, 2002; Hermansson,
Reid, & O’Connor, 2000). Helander, Huss, Brandt, & Ronnberg,
■ The CAGE questionnaire (Ewing, 1984) 2000; Hermansson, Helander, Brandt,
has been verified extensively, with Huss, & Ronnberg, 2002). AUDIT is
sensitivities for detecting alcohol abuse relatively free of gender and cultural bias
and alcoholism (Fiellin et al., 2000) (Cherpitel, 1999; Reinert & Allen, 2002;
ranging from 43 to 94 percent. It is well Volk et al., 1997). In addition, it shows
suited to primary care practice because it promise for screening adolescents and
poses four straightforward yes/no older people, populations in which
questions that the clinician can easily standard screening instruments produce
remember, and it requires less than a inconsistent results (Steinbauer et al.,
minute to complete. This test, however, 1998; Reinert & Allen, 2002; Clay,
may fail to detect low but risky levels of 1997; Chung et al., 2000; 2002). The
drinking (Fiellin et al., 2000), and often major disadvantages of AUDIT are its
performs less well among women and length (10 questions) and relative
socially vulnerable populations complexity (multiple choice); clinicians
(Cherpitel, 1999; Steinbauer et al., require training to score and interpret
1998). the test results (Allen & Columbus,
■ The performance of CAGE can be 1995).
improved by incorporating questions ■ Alcohol consumption puts people at
about the quantity and frequency of greater risk of injury. It plays a role in a
drinking, as recommended by NIAAA in large percentage of trauma incidents,
The Physicians Guide to Helping Patients including motor vehicle crashes. RAPS4
With Alcohol Problems (NIAAA, 1995). is a four-item questionnaire derived in
This approach worked well in a general part from TWEAK and AUDIT. In both

primary care and emergency room Saunders, & Papasouliotis, 2001) presented
settings, RAPS4 showed consistently high promising, but as yet unverified results for a
sensitivity for detecting alcoholism across two-question questionnaire—the two-item
gender and ethnic subgroups, although conjoint screen (TICS) for alcohol and other
its utility for screening for risky drinking drug abuse that can be incorporated easily
or alcohol abuse has yet to be proven into routine clinical practice. The two
(Cherpitel, 2000; Borges & Cherpitel, questions are: “In the last year, have you
2001). ever drunk or used drugs more than you
meant to?” and “Have you felt you wanted
More information on these and other or needed to cut down on your drinking or
alcohol-related screening tests also can be drug abuse in the last year?”
found on the NIAAA Web site at Of all studies considered, the four-item
www.niaaa.nih.gov. CAGE and CUGE questionnaires are
In a study published in 2000, Aertgeerts probably the most appropriate for most
(Aertgeerts et al., 2000), working from primary care settings. They are detailed
Catholic University in Belgium, compared earlier in this chapter.
several screening questionnaires in a
population of 3,564 consecutive college Alcohol Abuse Diagnostic Criteria
freshman and concluded that a modified The following criteria have been adapted
CAGE questionnaire, which is called from the Diagnostic and Statistical Manual
“CUGE,” may improve screening in college of Mental Disorders, Fourth Edition
students. The CUGE questionnaire replaces (DSM–IV), published by the American
the “annoyed you by criticizing your Psychiatric Association. This is as published
drinking” question with “often driving under in the NIAAA Health Practitioner’s Guide
the influence.” (NIAAA, 2003). The criteria are as follows,
A series of four recent papers (Williams & with one or more of these situations
Vinson, 2001; Taj, Devera-Sales, & Vinson, occurring at any time in the past 12 months:
1998; Aertgeerts, Buntinx, Ansoms, &
Fevery, 2001; Seppa, Lepisto, & Sillanaukee, ■ Failure to fulfill major role obligations at
1998) reported that variants on the theme of work, school, or home because of
a single “five-shot” question generated recurrent drinking
results comparable to CAGE and AUDIT in ■ Recurrent drinking in hazardous
adult male and female patients. The basic situations
question was: “On any single occasion ■ Recurrent legal problems related to alcohol
during the past 3 months, have you had ■ Continued use despite recurrent
more than five drinks containing alcohol?” interpersonal or social problems
Perhaps the most reasonable interpretation is
that of Taj et al. (1998): “A single question Alcohol Dependence Diagnostic Criteria
about alcohol can detect at-risk drinking and The following criteria have been adapted
current alcohol-use disorders with clinically from the Diagnostic and Statistical Manual
useful positive and negative predictive of Mental Disorders, Fourth Edition
values.” (DSM–IV), published by the American
Another recent study (Brown, Leonard, Psychiatric Association. This is as published
80 Special Report
in the NIAA Health Practitioner’s Guide Brief Intervention Study Group, 1996). The
(NIAAA, 2003). The criteria are follows, subjects were selected to be nondependent,
with three or more of these situations heavy drinkers. The two interventions tested
occurring at any time in the past 12 months: were a single, 5-minute “simple advice”
session and a 20-minute “brief counseling”
■ Tolerance (need to drink more to get the session, both supported with various written
same effect) educational materials. Each intervention was
■ Withdrawal syndrome or drinking to delivered in a single session, with patients
relieve withdrawal followed up 9 months later. On interview 9
■ Impaired control (unable to stop months later, men reported 17 percent lower
drinking) average daily alcohol consumption, and
■ Drank more or longer than intended women reported a 10 percent decrease.
■ Neglect of activities There was no difference between those
■ Time spent related to drinking or getting the 5-minute “simple advice” and
recovering those receiving the more intensive 20-minute
■ Continued use despite recurrent “brief counseling” session. Although
psychological or physical problems promising, weaknesses in the study design
raise questions about the firmness of the
Effectiveness of “Brief Interventions” for findings. This WHO study frequently is
Nondependent Problem Drinkers referenced in newspapers and other
Typical of the results for nondependent nonresearch publications as proof that even
drinkers, a meta-analysis of six brief the briefest of interventions are of value;
intervention trials (5–15 minutes of clinical however, this conclusion has not been borne
counseling) showed an average reduction in out in other studies.
alcohol consumption of 24 percent, In 1999, Poikolainen published a meta-
comparing cases to controls. Although self- analysis of brief interventions in problem
reported consumption may be subject to drinkers comparing single-session “brief
bias, reported changes in drinking correlated interventions” with multi-session “extended
with measures of GTT and blood pressure in brief interventions” (Poikolainen, 1999). His
most studies (USPSTF, 1996; Babor et al., review of the literature did not include the
1992). It is important to note, however, that WHO study referenced above because it
this and most other such studies suffered apparently did not meet his criteria for
from important methodological limitations inclusion in the review on methodological
(USPSTF, 1996). Since publication of the grounds. His review of multiple other
1996 Guide (as quoted above), there have publications, including 14 separate datasets,
been several publications, which among concluded that the single-session brief
them appear to bring this issue into clearer interventions were of little or no value, and
focus for nondependent problem drinkers. that the multiple-session interventions were
In mid-1996, WHO published the results clearly beneficial in women, and sometimes
of a randomized, controlled trial of two brief but not always beneficial in men.
interventions in 1,260 men and 299 women The best documented and
in study centers scattered across 10 methodologically strongest recent trial is the
countries, including the United States (WHO Project TrEAT (Trial for Early Alcohol

Treatment) published by Fleming et al. in a have shown long-term abstinence rates of
series of papers from 1997 to 2000 (Fleming, approximately 60 percent. These data are
Mundt, French, Manwell, Stauffacher, & difficult to interpret, however, because of
Barry, 2000; Fleming, Manwell, Barry, inadequate control groups, insufficient or
Adams, & Stauffacher, 1999; Fleming, Barry, selective follow-up, and selection bias due to
Manwell, Johnson, & London, 1997). This the characteristics of patients who
series of papers looked at nondependent successfully complete voluntary treatment
problem drinkers in 17 primary care and programs (USPSTF, 1996; IOM, 1989;
managed care sites in Wisconsin. There were Thurstin et al., 1986; Emrick, 1987). Since
382 controls and 392 intervention patients. spontaneous remission occurs in as many as
The intervention consisted of two 10–15 30 percent of alcoholics (USPSTF, 1996;
minute counseling sessions by the primary Smart, 1975/1976; Saunders & Kershaw,
care physician, with written support 1979), reduced consumption may be
materials. Patients were followed up at 6 inappropriately attributed to treatment.
months and 12 months. Depending on the Successful treatment is likely to represent a
measure, differences in alcohol consumption complex interaction of patient motivation,
between cases and controls were in the range treatment characteristics, and the
of 20–50 percent at 12 months. This posttreatment environment (family support,
difference was significant enough to reduce stress, etc.) (USPSTF, 1996; IOM, 1990;
emergency room and hospital bed use within NIAAA, 1993). The IOM review concluded
the first 12 months to more than cover the that treatment of other life problems (e.g.,
$205 estimated average per-case cost of the with antidepressant medication, family or
intervention. Considering only health care marital therapy, or stress management) and
costs, the benefit-cost ratio was about 2.5:1. counseling with empathetic therapists were
If avoided costs of crime and motor vehicle likely to improve treatment outcomes (US-
accidents are included, the benefit-cost ratio PSTF, 1996; IOM, 1989).
increases to 5.6:1.
Yet another controlled clinical trial Program Implementation Issues: How To
demonstrating the lack of efficacy of single- Manage the Intervention So That It Succeeds
session counseling sessions was published in in Securing Desired Benefits
2000 (Freeborn, Polin, Hollis, & Senft, 2000).
This trial, with 514 participants in a managed ■ Based on the research, the primary
care setting (Kaiser Permanente, Portland, program implementation issue relative to
Oregon) showed a nonsignificant reduction in alcohol-related screening and
alcohol consumption at 6 months, but no intervention appears to be strict
reduction in health care utilization when adherence to the details of screening and
comparing cases with controls. intervention protocols, especially if the
TrEAT protocol is to be used. Given the
Effectiveness of “Brief Interventions” for nature of the protocol, it is all too easy
Dependent/Addicted Drinkers to defer the counseling sessions from the
For adults with alcohol-dependency primary care physicians to other staff, or
completing either inpatient treatment or 12 to reduce the content length of the
weeks of outpatient treatment, some studies sessions. The literature shows, however,
82 Special Report
that doing so may substantially reduce, if with the issue of prevention of adult use of
not eliminate, the benefit to be secured illicit drugs. The conventional wisdom
from the intervention. appears to be that initiation of illicit drug
■ The second program implementation issue use is relatively uncommon beyond young
relative to alcohol-related screening has to adulthood unless such use is self-medication
do with the structure and staffing of the for stress, depression, or another behavioral
primary care setting. In settings without disorder. There seems to be no need for
adequate nursing and/or health education health care systems to initiate specific
support staff, the research indicates that it programming to prevent initiation of illicit
may be better to proceed with one of the drug use by adults.
simpler one to four question screening Treating adults, especially younger adults,
instruments than to attempt to use the 10- for use of illicit substances is an important
question AUDIT instrument on a selective therapeutic issue and generally is handled in
or inconsistent basis. the emergency room and by mental health
■ Finally, special attention can be paid to professionals, rather than by primary care
policies and procedures and staff and practitioners. Preventive issues generally are
physician education to ensure adequate limited to those noted in the following
screening and follow-up, and to enable review of pertinent literature.
the staff to better differentiate between A related topic is misuse and abuse of
alcohol dependence/addiction and prescription medications among adults,
nondependent problem drinking. especially older adults who have minor
depression and/or who use multiple
Data To Be Gathered medications to control multiple chronic
Refer to Appendix D. Supplemental data diseases. This is a serious problem, but
needs relative to alcohol and adults include because it is more therapeutic than
the following: preventive, it is considered beyond the scope
of this current literature review.
■ Prevalence of alcoholism, cirrhosis, and
other specific alcohol-related disorders Intervention
■ Incidence of alcohol-related injury, Although clinical management of adult use
suicide, and homicide within the enrolled of illicit drugs is appropriate, no screening or
population other preventive services are suggested for
■ Alcohol-related utilization of outpatient, adults concerning illicit drugs. A partial
inpatient, and emergency services exception may be the need to counsel older
■ Separate tracking of services to address adults about possible abuse of prescription
problem drinking and alcohol dependence, medication. Further discussion of this topic
with follow-up to prevent and address is beyond the scope of this report.
relapse, and to document the success (or
lack thereof) of the programming Review of Pertinent Literature
Although none of the studies noted below is
Adult Use/Abuse of Illicit Drugs a randomized clinical trial, the studies do
There is remarkably little in the way of provide background information on the issue
published, peer-reviewed literature dealing of adult use/abuse of illicit drugs for health

care policymakers who wish to further Comerford, & McCoy, 2001), noted that
explore this issue. injection drug users, other sustained drug
In a 1998 literature review, Drake et al. users, and “heavy” alcohol users were less
(Drake, Mercer-McFadden, Mueser, likely to avail themselves of preventive
McHugo, & Bond, 1998) noted that patients services than other patients being seen in
with severe mental disorders, such as their Miami, Florida, center.
schizophrenia and co-occurring substance Bennet and Beaudin, in an opinion piece
use disorders, frequently receive treatment published in 2000 (Bennett & Beaudin,
for their disorders from multiple clinicians in 2000), provided a guide to facilitate
parallel treatment systems. Their review collaboration between employers and
provides promising evidence that integrating managed care plans to address substance use
the treatment of these patients through a disorder in the workplace.
single set of clinicians can yield promising
results in terms of remission of the Data To Be Gathered
underlying mental disorder, reduction in Since there are no suggested screening or
substance use disorder, and use of health other preventive services, there are no data
care resources. needs specific to preventive services, illicit
Frankin and Hendrix, in an uncontrolled drugs, and adults.
study published in 2001 (Franken &
Hendriks, 2001), noted that screening Depression and Anxiety
persons with substance use disorder for Depression-related disorders (generalized
underlying anxiety and mood disorders using anxiety disorder, minor depression, major
the SCL-90 (Symptom Checklist 90) depression, and bipolar disorder) are
questionnaire (Franken & Hendricks, 2001) common, serious, readily treatable, and more
could be of significant value in controlling often than not either missed or ignored in
both disorders and reducing the need for primary care settings. Effective and cost-
more extensive psychiatric diagnostic efficient screening procedures are readily
evaluation. available, but they should be used with
Schermer and Wisner, in a record review of caution because of the importance of
patients suffering from major trauma, differentiating between the depression-
published in 1999 (Schermer & Wisner, related disorders noted above.
1999), urged screening of patients suffering From a preventive perspective, it is
from major trauma for methamphetamines important to differentiate major depression
and cocaine. This California study noted a from the other listed disorders, and to
doubling of methamphetamine rates from consider separately the consequences of
7.4 percent to 13.4 percent in patients depression in otherwise healthy adults as
suffering from major trauma from 1989 to compared with adults who have major
1994; minimal increases in cocaine positivity, medical and/or psychiatric comorbidities. In
from 5.8 percent to 6.2 percent; and a both populations, depression dramatically
decrease in alcohol positivity, from 43 increases the risk of suicide, dramatically
percent to 35 percent. reduces the quality of life, and unfavorably
In a record review published in 2001, affects workplace productivity. Among those
Chitwood et al. (Chitwood, Sanchez, with major chronic diseases, however,
84 Special Report
depression dramatically reduces the ability to mental health professionals for the more
and willingness of the patient to adhere to difficult cases, and to properly differentiate
prescribed regimens of care. In this chronic anxiety disorders and minor depression from
disease group, detection and skilled major depression, as well as unipolar
management of the depression has been depression from bipolar (manic-depressive)
shown in research to be cost-effective in disorder.
terms of other health care costs.
Routine screening for depression among all Summary of 2002 U.S. Preventive Services
adult outpatients was given a universal Task Force Recommendations: Depression
rating by the U.S. Preventive Services Task In April 2002, the U.S. Preventive Services
Force in 2002 (USPSTF, 2002b, 2003). There Task Force (USPSTF) issued an updated
are no medical means to prevent depression report on depression (Pignone et al., 2002;
(Munoz, 1993). There are, however, effective USPSTF, 2003). The USPSTF is an
means to screen and then manage the independent panel of experts in primary care
depression in a cost-efficient way to improve and prevention that systematically reviews
the quality of life of the patient, reduce other the evidence of effectiveness and develops
health care costs, and substantially reduce recommendations for clinical preventive
the risk of suicide. services (USPSTF, 2003). These new
recommendations have been incorporated
Intervention into the newly developing Guide to Clinical
Rigorous research demonstrates that all Preventive Services, 3rd Edition, 2000–2003.
adults should be screened for depression at This update guide is not yet available in
every outpatient visit. A simple two-question book form, but it is readily accessible on the
screen is likely to be as effective as longer Internet site of the Agency for Healthcare
screening instruments. The two questions Quality Research (AHRQ) at www.ahrq.gov.
are: “Over the past 2 weeks, have you felt The best way to access the depression
down, depressed, or hopeless?” and “Over recommendation and evidence base is to: 1)
the past 2 weeks, have you felt little interest go to the Web site; 2) click on “Clinical
or pleasure in doing things?” (USPSTF, Information: Preventive Services,” 3) click on
2002b, 2003). These questions are not “U.S. Preventive Services Task Force
diagnostic, but they do serve as a starting (USPSTF),” 4) click on “Mental Disorders
point for further exploration of depressive and Substance Abuse,” and 5) click on
symptoms to determine the need for referral “Depression: Screening.” This will lead to
to mental health specialists and/or the summary and full text of the April 2002
prescription of antidepressant medications. literature review. The site and all its reports
The literature supports every health care are available to the public, free of charge,
delivery system developing and maintaining with no requirement for a password or any
the capacity to follow up with more form of registration.
definitive diagnostic interviews and The following provides a series of
appropriate patient management. Although quotations from the summary and the
much of this can be managed with literature review, which have been selected to
supplemental training of primary care meet the needs of health care system
practitioners, it is important to have access administrators, benefit managers, and fiscal

officers. Those desiring more detailed depression (an episodic, less severe
information are urged to access the full illness). These two illnesses are as
recommendations and full literature review common as major depression in
primary care settings.
on the AHRQ Web site.
Diagnosis of Major Depression
Summary of Recommendations The prevailing standard of the
The U.S. Preventive Services Task American Psychiatric Association for
Force (USPSTF) recommends the diagnosis of depression is the
screening adults for depression in opinion of an examining clinician
clinical practices that have systems in that a patient’s symptoms meet the
place to assure accurate diagnosis, criteria described in the fourth
effective treatment, and follow-up. edition of the Diagnostic and
[The USPSTF] gave a “B” Statistical Manual of Mental
recommendation [which means] Disorders (DSM–IV) (APA, 1994).
clinicians should routinely provide This creates a situation in which,
the service to eligible patients; [there following the initial screening, there
is] at least fair evidence that the must be further questioning by the
service improves important health primary care practitioner to confirm
outcomes and [USPSTF] concludes or deny the impression of possible
that benefits outweigh harms. depression, and differentiate minor
from major depression.
. . . Trials that have directly The diagnosis of major depression is
evaluated the effect of screening on based upon the daily presence of
clinical outcomes have shown mixed four or more of the following
results. Small benefits have been symptoms, along with sadness or
observed in studies that simply feed apathy, for at least 2 weeks
back screening results to clinicians. (Dornbrand, Hoole, & Pickard,
Larger benefits have been observed 1992):
in studies in which the
communication of screening results is
1. Decreased or increased appetite,
coordinated with effective follow-up
weight change
and treatment.
2. Insomnia or increased sleeping
The USPSTF concludes that the 3. Observable change in psychomotor
amount and rigor of research to date activity, either agitation or
are insufficient to recommend for or retardation
against routine screening of children 4. Persistent inability to enjoy usually
or adolescents for depression.
pleasurable activities, including sex
Epidemiology and Clinical Consequences 5. Fatigue
… In primary care settings, the point 6. Feelings of worthlessness or guilt
prevalence of major depression 7. Slowed thinking or decreased
ranges from 5 to 9 percent among concentration
adults, and up to 50 percent of
8. Recurrent thoughts of death or suicide
depressed patients are not recognized.
Other disabling depressive illnesses
Accuracy and Reliability of Screening Tests
(that also are amenable to treatment)
… Assuming optimal test
include dysthymia (a chronic low-
performance and a prevalence of
grade depression) and minor
major depression of 5–10 percent in
86 Special Report
primary care settings, approximately treatment rates, but four of the five
24–40 percent of patients who screen trials that combined feedback with
positive will have major depression. treatment advice or other systems
Some patients with “false-positive” support reported increased treatment
results on screening may have rates in the intervention group.
dysthymia or subsyndromal
depressive disorders (depressed, but All three trials that compared the
not depressed enough to meet effects of integrated recognition and
diagnostic criteria for major management programs with usual
depression) that might benefit from care in community primary care
treatment or closer monitoring; practices showed significantly
others may have comorbid disorders improved patient outcomes.
such as anxiety disorder, substance Integrated programs included
abuse, panic disorder, posttraumatic feedback, provider and/or patient
stress disorder, or grief reactions; still education, access to case
others may have no disorder at all. management and/or behavioral care,
The finding of a positive screen telephone follow-up, and
therefore requires further diagnostic institutional commitment to quality
questioning by the clinician to improvement.
establish an appropriate diagnosis
and initiate a plan for treatment and Potential Harms of Screening and Treatment
follow-up. The potential harms of screening
include false-positive screening results,
Effectiveness of Early Treatment the inconvenience of further
Effective treatments are available for diagnostic workup, the adverse effects
patients with depressive illness and costs of treatment for patients
detected in primary care settings. who are incorrectly identified as being
Antidepressant medications for depressed, and potential adverse
major depression are clearly more effects of labeling. None of the
effective than placebo. Newer agents
research reviewed provided useful
(medications) perform similarly to
empirical data regarding these
older agents.
potential adverse effects.
Psychosocial and psychotherapeutic
Recent History and Recent USPSTF
interventions are probably as
effective as antidepressant Recommendation
medications for major depression, Much of the expanded interest in depression
but they are clearly more time- is due to the advent of better-tolerated
intensive. Few studies have examined antidepressant medications (Olfson et al.,
the effect of combining medications 2002) and the cost-effectiveness of screening
and psychotherapy.
for depression and managing depression in
Effectiveness of Screening patients with major medical and psychiatric
Trials that examined the effect of comorbidities. These factors converged to
feedback of screening results on the increase the percentage of adult outpatients
proportion of depressed patients who treated for depression from 0.73 per 100 in
received treatment showed mixed 1987 to 2.23 in 1997. During this same
results: in four fair-to-good quality
period, the proportion of individuals treated
trials that used feedback alone, there
was no significant effect on with antidepressant medications increased

from 37.3 percent to 74.5 percent. Use of the primary care physician and patient is the
psychotherapy also decreased in these differentiation of anxiety disorders and
patients from 71.1 percent to 60.2 percent, minor transient depression from major
and the locus of much of this care moved recurrent depression. Although all these
from psychiatrists to primary care disorders can benefit from counseling,
practitioners (Olfson et al., 2002). guidance, and antidepressant medication and
In presenting their recommendations, the all affect workplace productivity, major
USPSTF suggested the use of a simple two- depression is the one with the most
question screen as likely to be as effective as substantial impact on health care costs and
longer screening instruments. The two the highest risk of suicide. Differentiating
questions are: “Over the past 2 weeks, have anxiety disorders and minor depression from
you felt down, depressed, or hopeless?” and major depression also is important because
“Over the past 2 weeks, have you felt little once diagnosed, medication for major
interest or pleasure in doing things?” (US- depression should be maintained for at least
PSTF, 2002b, 2003). These questions are not 6 months to prevent current and future
diagnostic, but they do serve as a starting relapses. For patients with uncomplicated
point for further exploration of depressive general anxiety or minor depression,
symptoms to determine the need for referral reassurance, counseling, relaxation therapy,
to mental health specialists and/or for and stress management techniques often are
prescription of antidepressant medications. effective without medication (Margolis &
In making these recommendations, the Swartz, 2002). Major depression generally
Task Force was careful to specify that such requires more aggressive treatment.
screening should only be done on a routine
basis in health care delivery systems with the Differential Diagnosis (From a
capacity to follow up with more definitive Management/Policy Perspective)
diagnostic interviews and appropriate patient Generalized Anxiety Disorder
management. This last caveat was apparently Patients with a problem of “nerves” account
inserted to refer to education of primary care for approximately 10–30 percent of
practitioners and access to mental health encounters in general medical practice. They
professionals to properly differentiate may complain of being “shaky,” “tense,”
anxiety disorders and minor depression from “irritable,” or “uptight,” or the diagnosis
major depression, and unipolar depression may be made in the course of evaluating a
from bipolar (manic-depressive) disorder. somatic complaint (Dornbrand et al., 1992).
The USPSTF recommendation relative to Initial manifestations most commonly
screening for depression is based on case- present between 20 and 35 years of age,
series studies showing the ability to detect with a slight preponderance in women
depression using a variety of screening (Tierney, McPhee, & Papadakis, 2003).
procedures, as well as the efficacy of treating Generalized anxiety disorder that presents
the cases detected using the screening for the first time after the age of 40 should
procedure—with the efficacy of such probably be considered evidence of
treatment well documented in randomized depression until proven otherwise
controlled trials. (Dornbrand et al., 1992).
A major practical issue at the interface of Anxiety disorders appear to be
88 Special Report
underrecognized and untreated even though depression is substantial. Suicide, the
treatment interventions have been shown to most severe of depressive sequelae,
be effective and cost-efficient (Rice & Miller, has a rate of approximately 3.5
percent among all cases with major
1998). Unfortunately, there are no verified
depression, a risk that increases to
questionnaire instruments short enough for approximately 15 percent in people
routine use in primary care settings, as with who have required psychiatric
alcohol use disorders and depression. hospitalization (Blair-West &
Eyeson-Annan, 1997). The specific
Depression risk for suicide associated with
depressive disorders is elevated 12-
According to the 2002 Systematic Evidence
to 20-fold compared with the general
Review, which serves as the basis for the population (Harris & Barraclough,
USPSTF depression guideline (Pignone et al., 1997). The World Health
2002; USPSTF, 2003)— Organization (WHO) identified
major depression as the fourth
Burden of Suffering leading cause of worldwide disease
Depressive disorders are common, burden in 1990, causing more
chronic, and costly. Lifetime disability than either ischemic heart
prevalence rates from community- disease or cerebrovascular disease. Its
based surveys range from 4.9 percent associated morbidity is expected to
to 17.1 percent (Kessler et al., 1994; increase; unipolar depressive illness is
Robins & Regier, 1991; Depression projected to be the second leading
Guideline Panel, 1993). In primary cause of disability worldwide in
care settings, the prevalence of major 2020. Furthermore, depression
depression is 6–8 percent (Katon, appears to contribute to increased
1987). Longitudinal studies suggest morbidity and mortality from other
that approximately 80 percent of medical disorders, such as
individuals experiencing a major cardiovascular disease (Musselman,
depressive episode will have at least Evans, & Nemeroff, 1998).
one more episode during their
lifetime, with the rate of recurrence Both the chronicity and recurrence of
even higher if minor or subthreshold depressive illness play a large role in
episodes are included (Judd, 1997). depression’s heavy disease burden.
Approx-imately 12 percent of The more severe a depression
patients who experience depression becomes and the longer it lasts, the
will have a chronic, unremitting greater the likelihood that the
course (Judd, 1997). The substantial depression will become chronic
public health and economic (Consensus Development Panel,
significance of the chronic illness is 1985). Consequently, early effective
reflected by the considerable identification and management of
utilization of health care visits and depressive illness will not only
tremendous monetary costs: $43 decrease the substantial morbidity
billion (1990 dollars) annually, with associated with the current episode
$17 billion of that resulting from lost but may also decrease the likelihood
work days (Greenberg, Stiglin, that the illness will become chronic,
Finkelstein, & Berndt, 1993). with its additional associated
morbidity (Pennix et al., 1998).
The burden of suffering from According to the 1996 Second Edition of

the U.S. Preventive Services Task Force’s controls in one study (Waxman,
Guide to Clinical Preventive Services McCreary, Weinrit, & Carner, 1985).
(USPSTF, 1996)— If their depression is not recognized,
these patients may be subjected to
the risks and costs of unnecessary
Depression is more common in
diagnostic testing and treatment
persons who are young, female,
(Katon & Russo, 1989; Katon, Berg,
single, divorced, separated, seriously
Robins, & Risse, 1986).
ill, or who have a prior history or
family history of depression
(Weissman, 1987). The main task of evaluation in primary
care settings is to identify the 5–13 percent
Major depressive disorder can result of patients with the specific psychobiologic
in serious sequelae. The suicide rate disorder—major depression—that will
in depressed persons is at least eight require 6 months of medication and long-
times higher than that of the general
term follow-up (Dornbrand et al., 1992).
population (Monk, 1987). In 1993,
31,230 suicide deaths were reported, Greenberg et al. estimated the total cost of
although the actual number is depression to American society to be
probably much higher (National approximately $43.7 billion in 1990
Center for Health Statistics, 1994). (Greenberg et al., 1993). Given the frequent
Most persons who commit suicide co-occurrence of anxiety and depressive
have a mental disorder, with
disorders (in which the anxiety would be
depression associated with
approximately half of suicides considered a symptom of the depression),
(Greenberg et al., 1993; Weissman, this estimate is reasonably consistent with
1987). The incidence of documented the estimates provided by DuPont, Rice, and
suicides by adolescents and young Miller (DuPont et al., 1996; Rice & Miller,
adults has dramatically increased in 1998) in the preceding discussion of
recent decades, with 5,000 youths generalized anxiety disorder.
committing suicide each year and
The economic cost of anxiety disorders in
perhaps as many as
500,000–1,000,000 making an the United States is highlighted in two papers
attempt (Greydanus, 1986). by DuPont, Rice, and Miller, one each
published in 1996 and 1998 (DuPont et al.,
On a population basis, the most 1996; Rice & Miller, 1998). Considering all
important effect of major depression costs to American society, both medical and
may be on quality of life and
nonmedical, they estimated that the total
productivity rather than suicide. This
effect is widespread and has been cost of all mental illnesses to American
shown to be comparable to that society was $148.8 billion in 1990. Anxiety
associated with major chronic disorders were estimated to affect more than
medical conditions such as diabetes, 10 percent of the U.S. population at some
hypertension, or coronary heart point in their lives, with a total cost of $46.6
disease (Wells, Stewart, Hayes, et al., billion in 1990. Of this, approximately three
1989; Broadhead, Blazer, George, &
quarters were due to lost productivity. This
Tse, 1990). Also, depressed persons
frequently present with a variety of demonstrates that the major economic
physical symptoms—three times the impact is in the workplace, not in health
number of somatic symptoms of care costs. Affective disorders, with much of
90 Special Report
the cost related to depression, cost American staff education to promote the screening,
society another $30.4 billion in 1990. Given differentiation of anxiety disorders, and
that anxiety can present as a symptom of minor depression from major depression,
depression, this group of disorders (anxiety as well as to promote optimal use of
and depression combined) account for more depression-related medications and
than half of the total cost of mental mental health staff resources
disorders in the United States. ■ Tracking of members being treated for
In 2003, Stewart et al. (Stewart, Ricci, major depression (per HEDIS guidelines)
Chee, Hahn, & Morganstein, 2003) to promote treatment of adequate
published data from a survey of employed duration (6 months) and consistency
individuals who participated in the American ■ Separate tracking of patterns of health
Productivity Audit, conducted August 1, care utilization of members with both a
2001, through July 31, 2002. This study was depressive disorder and a major medical
based on 692 persons who responded or behavioral comorbidity
affirmatively to two depression screening ■ Resources within every health care
questions, and a stratified random sample of delivery system to assure that all adults
435 persons who responded in the negative. with likely depressive disorders can be
All of these individuals were then recruited appropriately diagnosed and treated
for and completed a supplemental interview. ■ Direct outreach by telephone to patients
Extrapolating from this sample, workers with depression can be of significant
with depression lost 5.6 hours per week of value in assuring adherence to prescribed
health-related productive time, compared regimens of care and in identifying
with 1.5 hours per week for those without additional issues to be addressed by
depression. Eighty-one percent of the time medical and ancillary staff.
lost was due to reduced performance while ■ Since behavioral disorders—with anxiety
at work. Major depression accounted for 48 and depression most prominent among
percent of the lost productive time among them—have a major impact on worker
those with depression and a majority of the productivity, managed care plans
time lost as reduced performance while at marketing their services to employers
work. Stewart et al. estimated that may wish to consider offering an
employees with depression cost employers expanded package of screening and
$44 billion annually because of health- treatment services to reduce worker
related lost productive time, $31 billion in absenteeism and otherwise improve
excess of those without depression. These employee productivity.
costs do not include labor costs associated
with short- and long-term disability. Rigorous research suggests the following at
the clinic visit:
Service-Related Issues Specific to ■ Routine screening of all adults for
Depression and Adults depressive disorders, using two simple
Rigorous research suggests the following at questions (“Over the past 2 weeks, have
the level of the health care delivery system: you felt down, depressed, or hopeless?”
and “Over the past 2 weeks, have you
■ Policies, procedures, and physician and felt little interest or pleasure in doing

things?”) (USPSTF, 2002b, 2003) should offices and clinics in the context of
be done at most, if not all outpatient quality improvement programming, as
visits, with follow-up as appropriate described elsewhere in this report.
relative to psychotherapy and
medication. This screening may be Evidence for Clinical Benefit: All Adults
conducted at every primary care visit for According to the 1996 Second Edition of the
otherwise well adults and at every U.S. Preventive Services Task Force’s Guide to
primary care and specialist visit for Clinical Preventive Services (USPSTF, 1996)—
members with excessive ambulatory care
utilization and/or major medical or It has been repeatedly documented
psychiatric comorbidity. that primary care providers do not
recognize major depression in
■ Patients selected to receive antidepressant
approximately half of their adult
medication for major depression would patients with this disorder (Schulberg
then be followed for a full 6 months to et al., 1985; Borus, Howes, Devins,
ensure adherence to prescribed regimens Rosenberg, & Livingston, 1988;
of care and success in addressing Wells et al., 1989; Coyne, Schwenk,
depressive symptoms and the & Smolinski, 1991; Attkisson &
complications of depression (per HEDIS Zich, 1990). Because the majority of
persons with depression are seen by
guidelines). Whether such patients are
nonpsychiatrist physicians (Regier et
managed entirely by the primary care al., 1993), and because effective
physician or by a mental health treatments—drugs, psychotherapy, or
professional would depend on the a combination of the two—are
training and comfort level of the primary available for the treatment of
care physician and the availability of depression (Elkin, Shea, Watkings, et
al., 1989), it has been proposed that
specialized mental health staff and other
routine depression screening could
resources available within the managed result in improved recognition and
care plan or health care delivery system. earlier treatment of depression with
■ Primary care practitioners may be made improved patient outcome (USPSTF,
aware of the frequency that they are 1996). Clinical trials have shown
likely to encounter generalized anxiety that use of depression screening tests
disorder and depressive disorders in their in primary care settings can increase
clinician detection of depression
practice and be made aware of the
(Attkisson & Zich, 1990; Moore,
treatment options within their respective Lilmperi & Bobula, 1978; Linn &
health care delivery systems. This in turn Yager, 1980; Zung, Magill, Moore,
will require the managed care plan or & George, 1983; US-PSTF, 1996).
other health care delivery system to Separate research has found that
develop policies and procedures as well treatment of persons with depression
leads to improved outcome (Elkin et
as education and outreach to primary
al., 1989; USPSTF, 1996).
care practitioners and their staff to
ensure that the guidelines are understood In a study published in 2001, Schriger et
and effectively implemented. This al. (Schriger, Gibbons, Langone, Lee, &
probably is best done through the use of Altshuler, 2001) demonstrated a limitation of
facilitators reaching out to primary care screening for behavioral disorders. A
92 Special Report
randomized controlled trial was done in an outcomes in a cost-efficient manner.
emergency room setting in which the cases In a study published in 2001, Katon et al.
and controls were screened with a 7-minute (2001) used three telephone visits and two
questionnaire known as PRIME-MD to visits with a depression specialist. In another
detect undiagnosed psychiatric illness. In the randomized trial of telephone support,
case group, the physicians were given the Hunkeler et al., working in a managed care
report of the screening. In the control group, setting (Hunkeler et al., 2000), demonstrated
this information was not provided to the substantial improvements in depression-
physician. In this study with 92 cases and 98 related symptoms with an intensive nurse
controls, 42 percent of the patients received telehealth intervention. The intervention
a psychiatric diagnosis from the PRIME-MD consisted of 12–14, 10-minute phone calls
questionnaire. Only 5 percent of these from the nurse to the patient over a 16-week
patients were diagnosed by the physician. period with benefits continuing the duration
Either way, very few of these patients of the 6-month follow-up period. In a
received either additional diagnostic multicenter randomized controlled trial
evaluation or treatment for their behavioral involving 181 primary care practitioners in
disorder—whether diagnosed by the 46 clinics in six managed care plans, Wells,
questionnaire or the physician. This study Schoenbaum, et al., (Wells et al., 2000;
graphically illustrates the need to have Schoenbaum et al., 2001) demonstrated that
policies, procedures, and a system in place if a quality improvement initiative aimed at
screening for behavioral disorders is to have improving the quality of the physician and
a favorable impact on behavioral outcomes. nurse care for depression in these clinics
Schriger’s conclusion was basically the same could effectively yield substantial
as that reached by Schade et al. in a 1998 improvements in medication compliance and
literature review (Schade, Jones, & Wittlin, patient outcomes.
1998) where they found that screening did
not necessarily lead to increased medical Program Implementation Issues: Managing
management of depression. Depression Screening and Follow-Up
Tutty et al., in a study of telephone The prevalence and impact of depression
counseling as an adjunct to antidepressant have been demonstrated clearly in both
treatment in the primary care system (Tutty, primary care and specialty settings, and the
Simon, & Ludman, 2000), documented that benefits of psychotherapy, cognitive therapy,
a relatively inexpensive telephone outreach and pharmacological management likewise
system to patients significantly improved have been amply demonstrated in well-done
depression-related outcomes without studies. A limited number of well-done
affecting the number of visits for treatment studies demonstrate a dramatic cost-
of depression. This controlled but effectiveness for detection and management
nonrandomized study was quickly followed of depression in selected patients with one or
by three more studies which were well-done more major chronic diseases (Vickery et al.,
randomized controlled studies leading to the 1983; Olfson et al., 1999; Koproski, Pretto,
same conclusion—that enhanced & Poretsky, 1997). Unfortunately, the
management of depression in primary care broader literature is not consistent in
settings can significantly improve patient findings or quality of study, and many

common clinical situations are not who had participated in an 8-week trial of
addressed. There also are cautionary notes to depression treatment. In this follow-up,
be considered when addressing depression in response to antidepressant therapy was rapid
patients who have selected chronic diseases, and dramatic, but depression frequently
relative to interactions with other drugs recurred, with 23 (92 percent) of the patients
being prescribed, and direct adverse effects experiencing an average of 4.8 depression
of selected antidepressive medications on the episodes over the 5-year period. Presence and
underlying chronic illness (Wamboldt, severity of depression at follow-up correlated
Yancey, & Roesler, 1997; Greenberg, Scharf, with worse glycemic control and neuropathy.
& Green, 1993; Storch, 1996; Gill & Research supports the approach of frequently
Hatcher, 2000; Goodnick, 2001). rescreening patients who have been treated
Yet another factor is that some patients with for depression to detect possible relapse.
one or more major chronic diseases will not In a series of randomized controlled trials
be willing to accept either psychotherapy or of antidepressant treatment of persons with
medication to address their depression diabetes, published from 1995 to 2000,
(Yohannes, Connolly, & Baldwin, 2001). Lustman et al. demonstrated improvement in
Fortunately, the available literature suggests both depressive symptoms and glycemic
that all or almost all patients of all ages and control with nortriptyline (Lustman et al.,
conditions are willing to accept 1997), fluoxetine (Lustman, Freedland,
psychoeducational counseling or group Griffith, & Clouse, 2000), alprazolam
sessions to improve their coping skills, stress (Lustman et al., 1995), and cognitive
management, and other behavioral behavioral therapy (Lustman, Freedland,
capabilities (Thomas & Weiss, 2000; Spiegel, Griffith, & Clouse, 1998; Lustman, Griffith,
1995; Arean, Alvidrez, Barrera, Robinson, & Freedland, Kissel, & Clouse, 1998).
Hicks, 2002). Furthermore, the limited When comanaging depression and a major
literature in this arena also suggests that chronic disease in a given patient, one can
group psychoeducational sessions generally expect improvement in both disorders, but in
are as effective as one-on-one sessions, where most cases, clinical outcomes are not as
group sessions are feasible. The limited favorable for either condition than when
benefits available from the dealing with a depressed patient without a
psychoeducational interventions may be chronic disease, or a chronic disease patient
enough to meet the needs of many of the without depression. This appears to be because
patients suffering from anxiety disorders and of the interaction of the two sets of disorders
minor depression and may be of limited and in some cases, interactions between the
value to some with major depression or drugs used to manage the two disorders.
bipolar disorder. For the rest, however, more The research suggests optimal management
definitive management of the depression, of depression, from both preventive and
probably including pharmacotherapy, will be therapeutic perspectives, in patients of all
required if optimal outcomes and reduction ages, with and without medical
of other health care costs are to be secured. comorbidities, involves a multistep process,
In 1997, Lustman et al. (Lustman, Griffith, as follows:
Freedland, & Clouse, 1997) reported on 5-
year follow-up of 25 persons with diabetes ■ Detection of symptoms suggestive of
94 Special Report
depression disease they specialize in, and the
■ Confirmation of diagnosis and medications used to manage that chronic
determination as to whether the patient disease.
has minor depression, major depression, ■ These educational interventions with
depression related to bipolar psychoeducational components could be
(manic/depressive) disorder, other mental made readily available to family
illness, or a purely situational reaction practitioners managing such patients
without mental illness. Treatments differ without specialist referral.
substantially, depending on diagnosis. The ■ Consultation relative to appropriate
possibility exists that treatment of selection of antidepressant medication
depression related to bipolar disorder as if also could be made readily available to
it were unipolar depression could make family practitioners in their management
things worse. The USPSTF, in its 2002 of patients with medical comorbidities.
recommendation for universal screening ■ Both health care system policy
of adults, makes the following point: development and extensive physician and
“Clinical practices that screen for nurse education are in order relative to
depression should have systems in place depression for the following reasons:
to ensure that positive screening results ● The high prevalence of depression in
are followed by accurate diagnosis, primary care populations, with an even
effective treatment, and careful follow-up. higher prevalence among patients with
Benefits from such screening are unlikely major illnesses
to be realized unless such systems are ● The wide range of therapeutic options
functioning well.” (USPSTF, 2003) ● The need for a full 6 months of
■ Decision as to course of treatment pharmacotherapy for major depression
(drugs, cognitive behavioral therapy ● The reluctance of many patients to be
and/or psychotherapy), duration of referred to psychiatrists or other
treatment, and whether or not a behavioral health specialists
psychiatrist or other mental health ● The relative shortage of psychiatrists
professional will be involved and other behavioral health specialists
■ Follow-up to assure 6 months of drug in most health care systems
treatment for major depression ● The potential harm of managing a
■ Specialists dealing with specific chronic bipolar depressive patient as if he or
diseases may be encouraged and enabled she were a unipolar depressive patient
to include psychoeducational elements in ● The 2002 recommendation by the U.S.
the education they provide patients for Preventive Services Task Force that all
self-management of their chronic disease. adult primary care patients be screened
These elements may include general for depression, but only if the health
coping skills and management of stress, care system has the capacity to confirm
anxiety, and depression. the diagnosis and follow up as
■ These same specialists, according to the appropriate (USPSTF, 2003; Pignone et
literature, also should become expert in al., 2002)
the interactions between the various ■ The need for both primary care and
antidepressant medications, the chronic specialist physicians to be familiar with

the diagnosis and management of 1998 (Katon, 1998)—
depression in their patients with major
chronic diseases Depression can impact chronic medical
■ A continuing high volume of new illness in a number of ways, all of which can
research and new policy unfavorably impact health care costs. In an
recommendations relating to diagnosis elderly cohort of 1,711 ambulatory internal
and management of depression medicine patients with a mean of four
■ Circumstances currently surrounding the chronic medical diagnoses, Calahan et al.
diagnosis and management of depression (Callahan, Hui, Nienafer, et al., 1994) found
are such that annual review of the that patients with depression had mean total
policies and annual reeducation of the outpatient charges of $1,210 over a 9-month
medical staff may be in order, at least period compared with $752 in nondepressed
over the next few years. controls. Unutzer et al. (Unutzer, Patrick,
Simon, et al., 1997) in an elderly cohort of
Data To Be Gathered 2,558 patients from an HMO with a mean
Refer to Appendix D. Data needs specific to of 1.25 chronic medical conditions found
adults and depression are as follows: that patients with depression had total
medical costs over a 1-year period of $1,510,
■ HEDIS parameters relative to outpatient compared with $1,129 in nondepressed
visits and duration of pharmacotherapy controls after adjustment for chronic medical
relative to outpatient visits and duration illness. Simon et al. (Simon, Von Korff, &
of pharmacotherapy for patients Barlow, 1995), in a similar study, showed
diagnosed with major depression health care costs of $4,246 for depressed
■ Incidence and prevalence of major patients versus $2,880 for nondepressed
depression and other depressive patients after adjustment for chronic medical
disorders as determined by claims data, illness. These differences were seen at every
pharmacy data, and/or record review level of increasing medical comorbidity
■ Separate tracking of these data for (Callahan et al., 1994; Unutzer et al., 1997;
patients with diabetes, asthma, and other Simon et al., 1995).
major chronic diseases The first of the major ways that depression
■ Separate tracking should be considered can affect major chronic illness is through
to identify (from claims data) members amplification of symptoms. This means that
who appear to be exceptionally high patients with depression can have more
users of outpatient and/or inpatient symptoms, more severe symptoms, and more
services for the purpose of flagging functional impairment from those symptoms
members who might benefit from than nondepressed controls with similar
supplemental psychoeducation and/or severity of chronic illness. This has been
behavioral health consultation. demonstrated by Walker et al. (Walker,
Gelfand, Gelfand, et al., 1996) in patients
Depression in Patients With a Major Chronic with inflammatory bowel disease, by Fann et
Medical or Psychiatric Illness al. (Fann, Katon, Uomoto, et al., 1995) in
According to a review of the literature on patients with head injury; by Dwight et al.
depression and chronic illness by Katon in (Dwight, Ciechanowski, Katon, et al., 1997)
96 Special Report
in patients with Hepatitis C; and by Lustman impairment. Depression has also been shown
et al. (Lustman, Clouse, & Carney, 1988) in to reduce the effectiveness of rehabilitation
persons with diabetes. Unfortunately, both in older patients with stroke, Parkinson’s
primary care physicians and medical disease, heart disease, fractures, and
specialists can easily confuse worsening of pulmonary disease (Katz, 1996).
symptoms due to worsening of depression Finally, depression can adversely affect a
with worsening of the underlying medical patient’s ability and willingness to adhere to
condition, leading to unneeded medical prescribed regimens of care. In a case series
testing and unneeded increases in medication exploring this issue, Lin et al. (Lin et al.,
dosages (Katon, 1998; Bridges & Goldberg, 2000) noted that 32–42 percent of patients
1985). Two randomized double-blind studies with depression did not refill their initial
have shown that effective treatment of major antidepressant prescriptions—and that this
depression is associated with a significant rate was basically the same among those
decrease in physical symptoms of chronic with and without resolution of depression-
medical illness. Sullivan et al. demonstrated related symptoms. This finding is similar to
this in patients with chronic tinnitus that found in the control groups of studies
(Sullivan, Katon, Russo, et al., 1993). demonstrating the value of supplemental
Borson et al. demonstrated this for patients interventions to improve compliance with
with chronic obstructive pulmonary disease prescribed regimens of care for depression
(Borson, McDonald, Gayle, et al., 1992). (Tutty et al., 2000; Katon et al., 2001;
The second major way that depression can Schoenbaum et al., 2001). This has also been
affect patients with major chronic illness is demonstrated for management of diabetes
by reducing their social and vocational (Glasgow, 1991); coronary artery disease
functionality. In these cases, severity of (Carney, Freedland, Eisen, et al., 1995);
underlying illness and severity of depression participation in rehabilitation following
seemed to have additive impact on both myocardial infarction (Blumenthal, Williams,
perceived severity of symptoms and Wallace, et al., 1982); and persons urged to
functional disability (Wells et al., 1989). quit smoking (Anda, Williamson, Escobedo,
Three papers have shown that severity of et al., 1990).
functional disability varies over time with Stated in other terms, diagnosis and
severity of depression (Bruce & Hoff, 1994; appropriate management of depression in a
Bruce, Seeman, Merrill, et al., 1994; chronic disease patient can reduce health
Lebowitz, Pearson, Schneider, et al., 1997). care costs and provide the following patient
Sullivan et al. (Sullivan, LaCroix, Grothasu, benefits (Lustman, Clouse, & Freedland,
et al., 1997) reported that functional 1998):
impairment in patients with coronary artery
occlusion of 70 percent or more at baseline ■ Relief of depression and anxiety
was more highly correlated with symptoms ■ Restoration of normal sleep and eating
of depression and anxiety than with the habits
number of coronary arteries occluded over a ■ Improved social, occupational, and
1-year period. Rovner et al. (Rovner, physical functionality
Zisselman, & Shmuely, 1996) had similar ■ Improved pain tolerance
findings in elderly patients with visual ■ Improved coping with symptoms of illness

■ Decreased preoccupation with symptoms management of depression in patients with
of illness major medical and behavioral comorbidities
■ Enhanced sexual functioning generates substantial returns on investment
■ Improved adherence with prescribed in terms of reductions in other health care
regimens of care costs (Katon, 1998; Callahan et al., 1994;
Unutzer et al., 1997; Simon et al., 1995).
Since depression can severely adversely
affect the ability of a chronic disease patient Intervention
to adequately self-manage his or her Research indicates that the most appropriate
diabetes, asthma, or other illness, screening depression-related intervention for adults
for depression and management of with major chronic diseases is the same as
depression is of special importance to this that for all adults—screening with two
group of comorbid patients. There is a questions at every outpatient visit, with
substantial body of literature documenting follow-up as appropriate. This separate
the efficacy of effective management of section for adults with major chronic diseases
depression in patients with major chronic is presented because of the potential for such
diseases in improving health-related screening to result in improved management
outcomes for the patient, while substantially of the chronic disease along with
reducing medical complications and use of concomitant reduction in health care costs.
emergency room visits and hospitalization.
An entire section of this literature review is Evidence for Clinical Benefit and Impact
devoted to management of these comorbid on Health Care Cost: Adults With Major
patients. Although the same is probably true Chronic Illness
for a wide range of other behavioral Egede et al., in a record-review study
disorders, the evidence base of well-designed published in 2002 (Egede, Zheng, &
randomized controlled trials is strongest for Simpson, 2002), compared 825 adults with
management of major depression. diabetes to 20,688 adults without diabetes
When only health care costs are using the 1996 Medical Expenditure Panel
considered, screening and enhanced Study. He found that individuals with
management of depression in primary care diabetes were 2.5 times as likely to suffer
patients without major medical or behavioral depression as individuals without diabetes,
comorbidities is highly efficacious and cost- and that health care costs per diabetic were
efficient in terms of the dollar cost of the approximately double for those with
health benefits secured for the patients depression, compared with those without
(Katon et al., 2001; Wells et al., 2000; depression. These general findings held even
Schoenbaum et al., 2001; Tutty et al., 2000). after adjustment for age, sex, race/ethnicity,
These services are cost-efficient, but do not marital status, poverty, and comorbidity.
result in reductions in use of emergency Findings were similar in a study by Jiang et
room and inpatient services sufficient to al. published in 2001 (Jiang et al., 2001),
generate a return on investment related to after reviewing records of patients with
reductions in other health care costs within congestive heart failure in a single medical
12 months of program initiation. By center. Jiang et al. found readmission and
contrast, screening and enhanced mortality rates at both 3 months and 1 year
98 Special Report
to be approximately double for patients with depression. In this paper, he noted that
depression, after adjusting for major clinical depression is underdiagnosed in primary
risk factors. Very similar findings relative to care, and that up to 50 percent or more of
the impact of depression on a major chronic patients presenting in primary care settings
disease were published by Abramson et al. in have no diagnosable medical illnesses. The
2001 (Abramson, Berger, Krumholz, & most common symptoms that could not be
Vaccarino, 2001) when doing a record review traced to a known organic cause were back
of the risk of heart failure among older pain, dyspnea, insomnia, abdominal pain,
persons with isolated systolic hypertension. and numbness (Kroenke & Mangelsdorff,
In a case report associated with a literature 1989). In addition, studies of overutilizers of
review, Zeigelstein (2001) noted a very high medical care by Katon et al. (1990, 1992)
prevalence of depression in patients and Simon (Simon, GE, 1992) showed a high
following myocardial infarction and prevalence of psychiatric illness and 68
observed that depression was associated with percent with a past or current history of
noncompliance with physician depression. These data invite consideration
recommendations and increased mortality. of the possibility that screening for and
His paper did not explore whether effective treatment of depression might
management of the depression could have reduce these physical complaints and visits.
improved patient outcomes. Katzelnick et al. published a randomized
Asthma and chronic obstructive clinical trial of depression management for
pulmonary disease are common lung high users of ambulatory services (Katzelnick
disorders for which tricyclic antidepressants et al., 2000). This paper showed dramatic
are problematic because of their effect on improvements in both behavioral and
pulmonary and cardiovascular function physical health domains. A follow-up paper
(Wamboldt et al., 1997; Greenberg et al., a year later (Simon et al., 2001) confirmed
1993). A number of randomized and the improvements in health indices and an
nonrandomized clinical trials of short increase in health care costs. A similar
courses of cognitive behavioral therapy (one follow-up study by Katon et al. (1992)
to 10 visits) have shown significant benefit showed similar results—but in this study, the
for symptoms of depression and anxiety and control patients also showed substantial
self-management, but not lung function reductions in health care utilization,
(Perez, Feldman, & Caballero, 1999; suggesting the possibility that contamination
Ringsberg, Lepp, & Finnstrom, 2002); for of the controls with the case intervention
lung function, but not symptoms of may have masked a possible benefit. High
depression and anxiety (Kunik et al., 2001; users of ambulatory services also are
Eiser, West, Evans, Jeffers, & Quirk, 1997); addressed in a separate section of this report
or both (Grover, Kumaraiah, Prasadrao, & dealing with somatization and
D’souza, 2002; Colland, 1993). hypochondriasis.
In 1995, Simon et al. published another
Depression in High-Cost Patients paper on health care costs associated with
Without a Major Chronic Disease depressive and anxiety disorders in primary
In 1998, Panzarino (1998) explored the care (Simon, Ormel, Von Korff, & Barlow,
direct and indirect costs of nontreatment of 1995). In this case series, the authors noted

that patients with anxiety or depressive outcomes with concomitant reduction in
disorders had baseline costs approximately health care costs.
double those with subthreshold disorders or
no anxiety or depression, with these Summary: Adults Aged 19 and Over
differences reflecting differences in medical For adults aged 19 and over, the literature
(as opposed to psychiatric) costs. He also suggests some screening and follow-up
noted that improvement in depression over 1 services are more well-researched than
year of follow-up did not reduce health care others. The recent USPSTF universal
costs. In 1997, Simon and Katzelnick (1997) recommendation to screen all adults for
reviewed the older literature on the depression is the most well-documented.
relationship between depression and health Good evidence exists that brief screening is
care costs. In this review, they noted the effective (using either the four-item CAGE or
same general conclusions—that depression is CUGE instruments or the 10-item AUDIT)
associated with substantially higher health for detecting misuse of alcohol. The studies
care costs, and that the limited available data on screening and preventive interventions for
from studies with substantial methodological illicit drug use by adults reveal that drug use
limitations did not demonstrate a reduction initiation is primarily in adolescence; hence,
in health care costs from diagnosis and in adults the goal is discontinuance of use.
management of the depression. On the topic of tobacco use, the literature
indicates screening for tobacco use at every
Intervention adult outpatient visit. The results are
The literature indicates that the depression- substantial, although they are not immediate,
related intervention that may be most except for patients with major medical
effective for high-cost patients without a comorbities. (Immediate benefits to the
major chronic disease is the same as that for health plan of tobacco screening are most
all adults—screening with two questions at substantial in smoking cessation by pregnant
every outpatient visit, with follow-up as women.)
appropriate. This separate section for high-
cost patients without a major chronic disease
is presented because of the potential for such
screening to result in improved patient
100 Special Report

X. Psychoeducation for
Three Categories of
Patients
P
sychoeducation, as explained earlier, is health education combined with
behavioral counseling. The counseling component of psychoeducation
deals with emotions, perceptions, coping, relaxation, and self-care.
Psychoeducation is of value for three categories of patients: (1) Those with
major chronic diseases; (2) persons scheduled to undergo surgical procedures;
and (3) high users of health care services. Psychoeducation can help—
■ Improve coping with pain, distress, and other unpleasant symptoms

■ Improve adherence to recommended regimens of care
Why Psychoeducation? Psychoeducation is the education of

Patients, even with the best of intentions, a person in subject areas that serve
the goals of treatment and
rarely follow prescribed regimens of care
rehabilitation. Psychoeducation
perfectly—and often disregard them involves teaching people about their
completely. For many aches, pains, and other problem, how to treat it, and how to
distressing symptoms, medical science often recognize signs of relapse so that
offers either imperfect relief or therapy more they can get necessary treatment
distressing than the initial symptoms. before their difficulty worsens or
Psychoeducation is an effective way to help occurs again. Family
psychoeducation includes teaching
close some of these gaps between the
coping strategies and problem-
theoretical ideal and the reality each of us
solving skills to families, friends,
must live with on a daily basis. For some, it and/or caregivers to help them deal
offers innovative ways to control pain and more effectively with the individual
other distressing symptoms, and by doing so, (PsychoEducation, 2003).
speeds recovery and improves the quality of
their lives. For others, it helps reduce the Part of the problem is undiagnosed and
psychological and psychosocial barriers that untreated psychiatric disorders. Fulop et al.
inhibit effective adherence to prescribed (Fulop, Strain, Fahs, Schmeidler, & Snyder,
regimens of care. 1998) in a 1998 study explored the impact
A definition of psychoeducation on a Web of psychiatric comorbidity on length of
site devoted to patients with psychiatric hospital stays of elderly medical-surgical
disorders and their families reads as follows: inpatients. Of the 467 admissions included
in the study, 208 (44 percent) met the and somatization-related programming.
standards for one or more DMS-III-R ■ Educate primary care and specialty staff
psychiatric diagnoses. Fifty-one (10.9 as to somatization and psychoeducation
percent) had an anxiety disorder, 88 (18.8 at least once every 2 years. Clinicians
percent) had a depressive disorder, and 126 may be reminded that the presence of
(27 percent) had a cognitive impairment. substance use disorders, schizophrenia,
Although no difference in length of stay was and other behavioral health disorders
noted for those with and without anxiety or does not rule out the possibility of
depression, those with cognitive impairments concurrent depression and anxiety, and
had significantly longer lengths of stay (14.6 that worsening of the depression and
versus 10.6 days). Part of the solution is anxiety may masquerade as worsening of
mobilizing the resiliency and inner strength other physical or behavioral health
of human beings—and helping them more disorders.
effectively help themselves to deal with ■ The designated mental health
painful and difficult circumstances. professional may work closely with the
The literature demonstrating the need for clinical and health education staff to
and effectiveness of psychoeducation in incorporate psychoeducational
patients with chronic disease, those components into the health education
scheduled for surgery, and those with a and disease management protocols.
somatization disorder is reviewed briefly in ■ It may be beneficial to periodically
each of the following sections of this report. review the efficacy of the health
education programming by record
Intervention review, and by small informal surveys or
Research indicates that it would be useful for focus group-like discussions with groups
primary care practitioners and those who of patients and groups of clinical staff.
provide health education and counseling to ■ In health care delivery systems where
patients and their families to be trained in behavioral health services are carved out
psychoeducational counseling and learn or otherwise separated from the main
enough about cognitive behavioral therapy stream of medical care, steps may be
and the more common psychiatric taken to facilitate appropriate
comorbidities to recognize when specific comanagement of behavioral and
patients should be referred to mental health medical disorders in patients with such
professionals for more intensive counseling comorbidities (Olfson et al., 1999).
and care. Psychoeducation can be provided
by these primary care practitioners, health Psychoeducation for Patients With
educators, and surgical staff, with support Chronic Disease
and guidance from a designated mental In 1989, Spiegel et al. (1989) reported the
health professional. results of what he called “psychosocial
The health care delivery system may wish treatment” in a randomized controlled trial
to consider the following: involving 86 patients with metastatic breast
cancer. The cases and controls were similar
■ Designate a lead mental health in severity of illness and treatment
professional to oversee psychoeducation modalities. The intervention consisted of 90-
102 Special Report

minute group meetings with a psychiatrist on favorable results were reported by Miklowitz
a weekly basis for a year, with professional et al. (2000) in a randomized trial of family-
and group member support between the focused psychoeducation for bipolar
meetings. Mean survival time for the cases disorder.
was 36.6 months postrandomization, In 1999, Dusseldorp et al. (1999) reported
compared with 18.9 months for the on a meta-analysis of 37 studies of the
controls—a highly statistically significant effects of psychoeducational (health
difference—attributed by the authors to education and stress management) programs
better patient and family coping skills, more for coronary heart disease patients. The
effective relationships with the oncology results suggested that these programs yielded
staff, social support, and more effective a 34 percent reduction in cardiac mortality, a
control of anxiety, depression, and pain. 29 percent reduction in recurrence of
In 1995, Devine and Reifschneider (1995) myocardial infarction, and statistically
reported on a meta-analysis of 102 studies to significant positive effects on blood pressure,
determine the effects of psychoeducation on cholesterol, body weight, smoking behavior,
care of adults with hypertension. They physical exercise, and eating habits. The
concluded that substantial and statistically pattern of results by study suggested that the
significant beneficial effects on blood mortality and recurrent infarction end points
pressure were due primarily to improved were primarily related to the more proximal
compliance with medication and improved improvements in risk profiles.
compliance with health care appointments. In 1999, Robinson et al. (Robinson, Faris,
In 1998, Roter et al. (1998) reported on a & Scott, 1999) reported on the results of a
meta-analysis of 153 studies to assess the randomized controlled trial of a group
effectiveness of interventions to improve psychoeducational intervention to improve
patient compliance. They concluded that the compliance with prescribed regimens of
most substantial benefits were for chronic vaginal dilatation for women undergoing
disease patients, including those with radiotherapy for gynecological carcinoma.
diabetes, hypertension, cancer, and mental Such dilatation is required to maintain
health problems. Comprehensive vaginal health and good sexual functioning,
interventions combining cognitive, but compliance generally is low. The
behavioral, and affective components were intervention was highly effective, especially
more effective than single-focus in younger women in increasing vaginal
interventions. dilatation and reducing fears about sex after
In 1998, Clarkin et al. (Clarkin, Carpenter, cancer. The authors concluded that such
Hull, Wilner, & Glick, 1998) reported the women are unlikely to follow the
results of a randomized controlled trial of a recommendation to dilate unless given
psychoeducational intervention for married assistance in overcoming their fears and
patients with bipolar disorder and their taught behavioral skills.
spouses. The intervention resulted in In 2001, Lorig at al. demonstrated that a
improved functioning and improved single, low-cost psychoeducational program
medication compliance but did not affect the can be used across a number of different
symptom levels beyond that to be expected chronic diseases, including heart disease, lung
from the medication compliance. Similarly disease, stroke, or arthritis (Lorig, et al., 2001).
In 2002, Mishel et al. (2002) reported on a Psychoeducation for Patients
randomized trial of a nurse-delivered Scheduled for Surgical Procedures
psychoeducational intervention by telephone A number of studies have been published
for 134 White men and 105 African- demonstrating the value of
American men who had undergone surgery psychoeducational interventions for patients
or radiation treatment for localized prostate scheduled to undergo surgery. These studies,
carcinoma. They were enrolled either the oldest of which date back to 1964
immediately after surgery or in the first 3 (Egbert et al., 1964), present a very strong
weeks of radiation therapy. The two case for investment in specially trained staff
interventions both consisted of weekly phone to educate patients as to the nature of the
calls for 8 weeks. The intervention groups surgical procedure, what they may anticipate
reported significantly better control of in terms of pain and discomfort following
incontinence by 4 months postbaseline, the surgery, and techniques they can use to
fewer treatment side effects, and better reduce pain, speed recovery, and reduce their
sexual functioning. Levels of improvement postsurgical in-hospital convalescence. These
were similar in the two racial groups. same staff also can flag patients who might
In each of the studies noted above, the benefit from more definitive psychiatric
psychoeducational intervention group was consultation and intervention prior to the
compared with a “usual care” group who surgical procedure to further improve
received usual physician counseling, postsurgical recovery.
presumably with little or no In a 1964 study, Egbert et al. (1964)
psychoeducational content. The conclusions randomized 97 patients scheduled to
that can be drawn from the literature undergo elective intra-abdominal surgery.
reviewed to date are limited by the lack of The intervention consisted of expanded
specific psychoeducational protocols and the presurgical education by the anesthetist,
presence of many studies of health education including what to expect postsurgery, how
interventions where the studies do not best to relax, how to take deep breaths, and
include adequate description of the how to move to remain comfortable
interventions to determine the presence or postoperatively. This simple intervention
types of psychoeducational content. reduced the need for postoperative narcotic
Although additional research should be medication by half and reduced the average
done to proposed specific educational hospital stay by almost 3 days.
protocols by patient type and disease, the In 1982, Mumford et al. (1982) published
currently available literature clearly indicates a meta-analysis of 34 controlled studies of
that the efficacy of patient educational surgical and heart attack patients and
programming for chronic disease patients demonstrated an average 2-day reduction in
can be enhanced substantially by the what otherwise would have been a 10-day
inclusion of psychoeducational content. This hospital stay for these patients. Although the
enhancement of educational content should protocols varied, most or all included
be seen as a desirable addition to the general patient education coping techniques
screening of all such patients for depression and interventions to address fear, pain, and
and mental health assessment of those with psychological distress. In a similar meta-
other evidence of behavioral disorders. analysis published in 1983, which covered
104 Special Report

49 studies, both controlled and uncontrolled, 20–84 percent of patients in general medical
Devine and Cook (1983) showed very settings have been estimated to show somatic
similar results. complaints for which no organic cause can
In 1988, Devine et al. (1988) conducted a be found (Smith et al., 1995; Kellner et al.,
controlled, but not randomized study of a 1985; Kellner, 1965; Mayou, 1976, 1978).
nurse-based psychoeducational intervention The preventive issue with somatization and
in a post-DRG (diagnostic related group) mind/body connection relates to reduction in
managed-care-type setting in two rural health care costs through effective
hospitals owned by the same corporation. management of these disorders. Somatization
The primary intervention in the study is common in primary care, and it is
hospital was a 3-hour, two-stage workshop generally accepted that there is a connection
for staff nurses to enhance their ability to between the mind and the body and that
provide educational and psychosocial many diseases are caused by the mind-body
support to patients undergoing abdominal connection. The problem, from the
and prostate surgery. This study showed that perspective of this report, is that few high-
even in a managed care environment, quality studies demonstrating the efficacy of
supplemental psychoeducational services can clinical interventions to address these
cut the use of sedatives, antiemetics, and disorders are available. This section is
hypnotics by half, and shave another half- included in this report to alert health care
day off the hospital stay. managers to somatization and mind/body
In 1995, Jay et al. (1995) reported a connection so they may consider possible
clinical trial of cognitive behavioral therapy education and intervention, and so that they
(CBT) versus general anesthesia for 18 may remain alert to further developments in
patients with pediatric cancer (ages 3–12 these rapidly evolving fields.
years) undergoing bone marrow aspirations. When somatization is fully developed, the
The CBT children exhibited more behavioral proper diagnostic term is “somatization
distress for the first minute on the treatment disorder” or “Birquet’s Syndrome” or
table, but according to the parents, showed “hysteria.” The full-blown syndrome is
significantly better behavioral adjustment 24 characterized by multiple physical
hours following the procedure than the complaints referable to several organ
children who had been anesthetized. systems. Anxiety, panic disorder, and
depression often are present. Polysurgery
Psychoeducation for Patients With often is part of the history, and
Somatization preoccupation with medical and surgical
Somatization is a term used to describe true therapy becomes a lifestyle that excludes
physical symptoms and true physical illness most other activities (Tierney et al., 2003).
that are psychogenic in nature. The term Although the full-blown syndrome is
“mind/body connection” is used to denote relatively uncommon, somatoform behavior
the role of the human mind in creating, that does not meet the full diagnostic criteria
exaggerating, minimizing, or totally for somatization disorder is quite common,
eliminating symptoms and perceptions of and quite costly in utilization of health care
pain in patients with and without services. Recent reviews have estimated the
diagnosable organic illness. By some criteria, prevalence of somatoform disorders in the
range of 10–15 percent of primary care patient’s quality of life and in reducing health
patients (Kroenke et al., 1998; Kirmayer & care costs by reducing health care use.
Robbins, 1991; Spitzer et al., 1994; Kellner Although there are several studies
et al., 1985) and have documented the suggesting that screening for somatization,
impact of these disorders on both quality of followed by diagnosis and management of
life and health care utilization (Kroenke et psychiatric illness and psychoeducational
al., 1998; Katon et al., 1991; Smith et al., interventions are of value (Smith et al., 1995;
1986, 1995; Swartz et al., 1991; Kroenke et Fifer et al., 2003), specification of exact
al., 1997; Escobar et al., 1989; Deighton, screening and follow-up procedures are
Nicol, 1985; Hiller et al., 1995). insufficient to suggest implementation of
Effective management of these patients psychoeducational services for somatization
requires recognition of this possibility by the as a “general” clinical preventive service.
primary care practitioner and great sensitivity
in approaching this issue to avoid suggesting Summary of Psychoeducation
that the patient is either “crazy” or faking the Psychoeducation has been shown to improve
illness. Although management of full-blown health outcomes and reduce short-term
somatization disorder tends to be frustrating health care costs for patients with major
for both patient and physician, there is at chronic diseases and for patients scheduled
least one recent randomized study (Smith et for surgical procedures. The literature has
al., 1995) and a recent review by the Lewin demonstrated the service’s ability to shorten
Group (Fifer et al., 2003) suggesting that the length of inpatient stay, to reduce pain,
recognition and intervention in patients with and to increase adherence to a regimen of
somatizing behavior not meeting the care. Psychoeducation may also be of value
diagnostic criteria of full-blown somatization for selected high-cost patients whose illnesses
disorder may be of value in improving the may be psychosomatic in origin.
106 Special Report

XI. Conclusions
T
his report summarizes the literature on preventive behavioral services
to be delivered by health care systems to improve both medical and
mental health outcomes. Some of the interventions covered in this
report demonstrate potential to reduce health care expenditures within 12
months of program initiation, thus providing a “return on investment” in
terms of short-term health care costs. Because of the enormity of the
literature, not all potential behavioral preventive services that might be
considered for implementation in health care settings have been covered. This
report updates a previous SAMHSA literature revew on this topic published
in 2000 (Dorfman, 2000).
This updated analysis of the literature with major chronic diseases, and selected
suggests the following clinical preventive other heavy users of health care services
behavioral services as worthy of
consideration for implementation in all Of these, the following have the potential
health care settings: to reduce overall health care costs within 12
months of initiation of new or expanded
■ Universal screening of pregnant women preventive services:
for use of tobacco, alcohol, and illicit
drugs ■ Screening pregnant women for use of
■ Home visitation for selected pregnant tobacco, alcohol, and illicit drugs
women, and some children up to age 5 ■ Screening for depression in persons with
■ Supplemental educational services for major chronic medical disease
vulnerable infants from disadvantaged ■ Psychoeducation for persons scheduled
families for major surgical procedures, persons
■ Screening children and adolescents for with major chronic diseases, and selected
behavioral disorders other heavy users of health care services
■ Screening adolescents for tobacco,
alcohol, use of illicit drugs, depression, For many of these clinical preventive
and anxiety behavioral services, the effect size in
■ Screening adults for use of tobacco, randomized controlled trials is in the range
excessive use of alcohol, depression, and of 5–30 percent. Therefore, the preventive
anxiety interventions can be expected to reduce the
■ Psychoeducation for persons scheduled burden of behavioral illnesses and substance
for major surgical procedures, persons use disorders, but not totally prevent them.
Some of the reduction in burden will be the Because of these seemingly modest effect
result of eliminating the problem entirely for sizes, health care systems are urged to track
some patients—usually those with mild or risk factors, process indicators, outcomes,
moderate risk of illness or substance use. and costs to document the efficacy and cost-
The preventive services may also reduce the efficiency of each of the suggested preventive
severity of illness in those more severely interventions. These data will also be of
affected. Even with such seemingly modest value in securing the support of health care
effect sizes, the adverse consequences of the managers and fiscal officers for these
underlying disorders are such that the preventive services. This monograph includes
preventive services can be expected to pay suggestions and guidelines for tracking these
for themselves in reduced health care costs measures in a practical and cost-efficient
and improved clinical and/or social manner.
outcomes.
108 Special Report

XII. References
AAFP. See American Academy of Family Physicians.
AAP. See American Academy of Pediatrics.
AAP/ACOG. See American Academy of Pediatrics and American College of Obstetricians
and Gynecologists.
Abel, E., & Sokol, R. (1991). A revised conservative estimate of the incidence of FAS and
its economic impact. Alcoholism in Clinical and Experimental Research, 15, 514-524.
Abernathy, T., & Bertrand, L. (1992). Preventing cigarette smoking among children:
Results of a 4-year evaluation of the PAL program. Canadian Journal of Public
Health, 83, 226-229.
Abraham, H., & Fava, M. (1999, January–February). Order of onset of substance abuse
and depression in a sample of depressed outpatients. Comprehensive Psychiatry,
40(1), 44-50.
Abramson, J., Berger A., Krumholz, H., & Vaccarino, V. (2001, July 23). Depression and
risk of heart failure among older persons with isolated systolic hypertension.
Archives of Internal Medicine 161, 1725-1730.
ACOG. See American College of Obstetricians and Gynecologists.
ADA. See American Dental Association.
Aertgeerts, B., Buntinx, F., Ansoms, S., & Fevery, J. (2001, March). Screening properties
of questionnaires and laboratory tests for the detection of alcohol abuse or
dependence in a general practice population. British Journal of General Practice,
51(464), 206-217.
Aertgeerts, B., Buntinx, F., Bande-Knops, J., Vandermeulen, C., Roelants, M., Ansoms, S.,
et al. (2000, January). The Value of CAGE, CUGE, and AUDIT in screening for
alcohol abuse and dependence among college freshmen. Alcoholism in Clinical and
Experimental Research, 24(1), 53-57.
Agelink, M., Ullrich, H., Lemmer, W., Dirkes-Kersting, A., & Zeit, T. (1999, June).
Screening for concomitant alcohol abuse in schizophrenia: Clinical significance of
the Munich Alcoholism Test and laboratory tests. European Addiction Research,
5(2), 82-87.
Agency for Healthcare Research and Quality. (2003, June 23). A step-by-step guide to
delivering clinical preventive services: A systems approach from “Put prevention
into practice” publications. AHRQ Pub. No. APPIP01-0001, and slide
presentation.
AHRQ. See Agency for Healthcare Research and Quality.
Allen, J., & Columbus, M. (1995). Assessing alcohol problems: A guide for clinicians and
researchers. National Institute on Alcohol Abuse and Alcoholism Treatment
Handbook Series 4. Bethesda, MD: National Institutes of Health.
AMA. See American Medical Association.
American Academy of Family Physicians. (1987). AAFP stop smoking program. Kansas City,
MO: Author.
American Academy of Family Physicians. (1994). Age charts for periodic health examinations
(Reprint No. 510). Kansas City, MO: Author.
American Academy of Otolaryngology—Head and Neck Surgery. (1992). Smokeless tobacco.
Washington, DC: Author.
American Academy of Pediatrics. (1988). Guidelines for health supervision II. Elk Grove
Village, IL: Author.
American Academy of Pediatrics. (1989). Screening for drugs of abuse in children and
adolescents. Pediatrics, 84, 396-398.
American Academy of Pediatrics. (1994). Tobacco-free environment: An imperative for the
health of children and adolescents. Pediatrics, 93, 866-868.
American Academy of Pediatrics and American Academy of Obstetricians and Gynecologists.
(1992). Guidelines for perinatal care (3rd ed.). Washington, DC: Author.
American Academy of Pediatrics Committee on Adolescence. (1995). Alcohol use and abuse:
A pediatric concern. Pediatrics, 95, 439-442.
American Academy of Pediatrics Committee on Substance Abuse. (1993). Role of the
pediatrician in prevention and management of substance abuse. Pediatrics, 91, 1010-
1013.
American Academy of Pediatrics Committee on Substance Abuse and Committee on Children
with Disabilities. (1993). Fetal alcohol syndrome and fetal alcohol effects. Pediatrics,
91, 1004-1006.
American College of Obstetricians and Gynecologists. (1993). Smoking and reproductive
health (Technical Bulletin No. 180). Washington, DC: Author.
American College of Obstetricians and Gynecologists. (1994). Substance abuse in pregnancy
(Technical Bulletin No. 195). Washington, DC: Author.
American College of Physicians Health and Public Policy Committee. (1986). Methods for
stopping cigarette smoking. Annals of Internal Medicine, 105, 281-295.
American Dental Association. (1992). Transaction (Vol. 26).
American Medical Association. (1988). Drug abuse in the United States: A policy report
(Report of the Board of Trustees). Chicago: Author.
American Medical Association. (1993). Policy compendium. Chicago: Author.
American Medical Association. (1994). Guidelines for adolescent preventive services (GAPS):
Recommendations and rationale. Chicago: Author.
American Medical Association CPT Editorial Panel and AMA CPT Advisory Committee.
(1999). Current procedural terminology: CPT 2000 (CPT Code Book). Chicago:
American Medical Association.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
disorders (4th ed.). Washington, DC: Author.
Anda, R., Remington, P., Sienko, D., et al. (1987). Are physicians advising smokers to quit?
The patient’s perspective. Journal of the American Medical Association, 257, 1916-
1919.
110 Special Report

Anda, R., Williamson, D., Escobedo, L., et al. (1990). Depression and the dynamics of
smoking. Journal of the American Medical Association, 264, 1541-1545.
Anderson, P., Cremona, A., Paton, A., et al. (1993). The risk of alcohol. Addiction, 88, 1493-
1508.
APA. See American Psychiatric Association.
Arean, P., Alvidrez, J., Barrera, A., Robinson G. S., & Hicks, S. (2002, June). Would older
medical patients use psychological services? Gerontologist, 42(3), 392-398.
Armbruster, D., Schwartzoff, R., Hubster, E., et al. (1993). Enzyme immunoassay, kinetic
microparticle immunoassay, radioimmunoassay, and fluorescence polarization
immunoassay compared for drugs-of-abuse screening. Clinical Chemistry, 39, 2137-
2142.
Armstrong, K., Fraser, J., Dadds, M., & Morris, J. (1999, June). A randomized controlled
trial of nurse home visiting to vulnerable families with newborns. Journal of Paediatric
Child Health, 35(3), 237-244.
Attkisson, C., & Zich, J., (Eds.). (1990). Depression in primary care: Screening and detection.
New York: Routledge.
Azrin, N., and Teichner, G. (1998, September). Evaluation of an instructional program for
improving medication compliance for chronically mentally ill patients. Behavior
Research and Therapy, 36(9), 849-861.
Babor, T., & Grant, M. (Eds.). (1992). Project on identification and management of alcohol-
related problems. Report on phase II: A randomized clinical trial of brief interventions
in primary health care. Geneva, Switzerland: World Health Organization.
Babor, T. F., Higgins-Biddle, J., & Monterio, M. (2001). AUDIT—The alcohol use disorders
identification test: Guidelines for use in primary care. Geneva, Switzerland: World
Health Organization, Department of Mental Health and Substance Dependence.
Bao, X., Sun, S., & Wei, S. (1999, June). Early intervention promotes intellectual development
of premature infants: A preliminary report. Early Intervention of Premature Infants
Cooperative Research Group. Chinese Medical Journal, 112(6), 520-523.
Beardslee, W., Salt, P., Porterfield, K., Rothberg, P., van de Velde, Swatling, S., et al. (1993).
Comparison of preventive interventions for families with parental affective disorder.
Journal of the American Academy of Child and Adolescent Psychiatry, 32, 254-263.
Beardslee, W., Versage, E., & Gladstone, T. (1998). Children of affectively ill parents: A
review of the past 10 years. Journal of the American Academy of Child and
Adolescent Psychiatry, 37, 1134-1141.
Bell, G., & Lau, K. (1995). Perinatal and neonatal issues in substance abuse. Pediatric Clinics
of North America, 42, 261-281.
Bennett, J., & Beaudin, C. (2000, July–August). Collaboration for preventing substance abuse
in the work place: Modeling research partnerships in prevention. Journal of
Healthcare Quality, 22(4), 24-30.
Bergmann, P., Smith, M., & Hoffman, N. (1995). Adolescent treatment: Implications for
assessment, practice guidelines, and outcome management. Pediatric Clinics of North
America, 42, 453-472.
Berkowitz, G., Brindis, C., & Peterson, S. (1998, Fall). Substance use and social outcomes
among participants in perinatal alcohol and drug treatment. Women’s Health, 4(3),
231-254.
Bernadt, M., Mumford, J., Taylor, C., et al. (1982). Comparison of questionnaire and
laboratory tests in the detection of excessive drinking and alcoholism. The Lancet, 1,
325-328.
Bernal, P., Estroff, D., Aboudarham, J., Murphy, M., Keller, A., & Jellinek, M. (2000,
March). Psychosocial morbidity: The economic burden in a pediatric health
maintenance organization sample. Archives of Pediatric and Adolescent Medicine,
154(3), 261-266.
Birmaher, B., Ryan, N., Williamson, D., Brent, D., Kaufman, J., Dahl, R., et al. (1996).
Childhood and adolescent depression, I: A review of the past 10 years. Journal of the
American Academy of Child and Adolescent Psychiatry, 35(1), 1427-1439.
Black, M., Nair, P., Knight, C., Wachtel, R., Roby, P., & Schuler, M. (1994, October).
Parenting and early development among children of drug-abusing women: Effects of
home intervention. Pediatrics, 94(4), 440-448.
Blair-West, G., Mellsop, & Eyeson-Annan, M. (1997). Down-rating lifetime suicide risk in
major depression. Acta Psyciatrica Scandinavica, 95, 259-263.
Blumenthal, J., Williams, R., Wallace, A., et al. (1982). Physiological and psychological
variables predict compliance to prescribed exercise therapy in patients recovering from
myocardial infarction. Psychosomatic Medicine, 1(44), 519-527.
Boffetta, P., & Garfinkel, L. (1990). Alcohol drinking and mortality among men enrolled in
an American Cancer Society prospective study. Epidemiology, 1, 342-348.
Borges, G., & Cherpitel, C. (2001). Selection of screening items for alcohol abuse and alcohol
dependence among Mexican and Mexican Americans in the emergency department.
Journal of Studies on Alcohol, 62(3), 277-285.
Borson, S., McDonald, G., Gayle, T., et al. (1992). Improvement in mood, physical symptoms,
and function with nortriptyline for depression in patients with chronic obstructive
pulmonary disease. Psychosomatics, 33, 190-201.
Borus, J., Howes, M., Devins, N., Rosenberg, R., & Livingston, W. (1988). Primary care
providers’ recognition and diagnosis of mental disorders in their patients. General
Hospital Psychiatry, 10, 317-321.
Botvin, G., Baker, E., Dusenbury, L., et al. (1995). Long-term follow-up results of a
randomized drug abuse prevention trial in a White, middle-class population. Journal
of the American Medical Association, 273, 1106-1112.
Botvin, G., & Botvin, E. (1992). School-based and community-based prevention approaches.
In J. Lowinson, P. Ruiz, and R. Millman (Eds.), Substance abuse: A comprehensive
textbook (pp. 910-927). Baltimore: Williams & Wilkins.
Botvin, G., Dusenbury, L., Tortu, S., et al. (1990). Preventing adolescent drug abuse through a
mutimodal cogitive-behavioral approach: Results of a 3-year study. Journal of
Consulting and Clinical Psychology, 58, 437-446.
Bradley, K. (1994). The primary care provider’s role in the prevention and management of
alcohol problems. Alcohol Health Research World, 18, 97-104.
112 Special Report

Bradley, K., Donovan, D., and Larson, E. (1993). How much is too much? Advising patients
about safe levels of alcohol consumption. Archives of Internal Medicine, 153, 2734-
2740.
Bridges, K., & Goldberg, D. (1985). Somatic presentations of DSM-III psychiatric disorders in
primary care. Journal of Psychosomatic Research, 29, 563-569.
Broadhead, W., Blazer, D., George, L., and Tse, C. (1990). Depression, disability days, and
days lost from work in a prospective epidemiologic survey. Journal of the American
Medical Association, 264, 2524-2528.
Bronson, D., Flynn, B., Solomon, L., et al. (1989). Smoking cessation counseling during
periodic health examinations. Archives of Internal Medicine, 149, 1653-1656.
Broskowski, A., & Smith, S. (2002). Estimating the cost of preventive services in mental
health and substance abuse under managed care. U.S. Department of Health and
Human Services.
Brown, R., Leonard, T., Saunders, L., & Papasouliotis, O. (2001, March–April). A two-item
conjoint screen for alcohol and other drug problems. Journal of the American Board
of Family Practitioners, 14(2), 95-106.
Bruce, M., & Hoff, R. (1994). Social and physical health risk factors for first onset major
depressive disorder in a community sample. Social Psychiatry and Psychiatric
Epidemiology, 29, 165-171.
Bruce, M., Seeman, T., Merrill, S., et al. (1994). The impact of depressive symptomology on
physical disability: MacArthur studies of successful aging. American Journal of Public
Health, 84, 1796-1799.
Buchsbaum, D., Buchanan, R., Centor, R., et al. (1991). Screening for alcohol abuse using
CAGE scores and likelihood ratios. Annals of Internal Medicine, 115, 774-777.
Buchsbaum, D., Welsh, J., Buchanan, R., et al. (1995). Screening for drinking problems by
patient self-report: Even “safe” levels may indicate a problem. Archives of Internal
Medicine, 155, 104-108.
Buckwalter, K., Gerdner, L., Kohout, F., Hall, G., Kelly, A., Richards, B., et al. (1999, April).
A nursing intervention to decrease depression in family caregivers of persons with
dementia. Archives of Psychiatric Nursing, 13(2), 80-88.
Bueno de Mesquita, H., Miasonneuve, P., Moerman, C., et al. (1991). Life-time history of
smoking and exocrine carcinoma of the pancreas: A population-based case-control
study in the Netherlands. International Journal of Cancer, 49, 816-822.
Bull, L., Kvigne, V., Leonardson, G., Lacina, L., & Welty, T. (1999, April). Validation of a
self-administered questionnaire to screen for prenatal alcohol use in Northern Plains
Indian Women. American Journal of Preventive Medicine, 16(3), 240-243.
Burke, M., & Roth, D. (1993). Anonymous cocaine in a private obstetric population.
Obstetrics and Gynecology, 79, 354-356.
Burkett, G., Gomez-Martin, O., Yasin, S., & Martinez, M. (1998, August). Prenatal care in
cocaine-exposed pregnancies. Obstetrics and Gynecology, 92(2), 193-200.
Burnett, D., Lader, S., & Richens, A. (1990). A survey of drugs of abuse testing by clinical
laboratories in the United Kingdom. Annals of Clinical Biochemistry, 27, 213-222.
Bush, B., Shaw, S., Cleary, P., et al. (1987). Screening for alcohol abuse using the CAGE
questionnaire. American Journal of Medicine, 82, 231-235.
Butz, A., Lears, M., O’Neil, S., & Lukk, P. (1998, October). Home intervention for in utero
drug exposed infants. Public Health Nursing, 15(5), 307-318.
Callahan, C., Hui, S., Nienafer, N., et al. (1994). Longitudinal study of depression and health
services among elderly primary care patients. Journal of the American Geriatrics
Society, 42, 833-838.
Canadian Task Force on the Periodic Health Examination. (1994a). Canadian guide to clinical
preventive health care (pp. 52-61, 826-836). Ottawa, Canada: Canada
Communication Group.
Canadian Task Force on the Periodic Health Examination. (1994b). Canadian guide to clinical
preventive health care. Ottawa, Canada: Canada Communication Group.
Carney, R., Freedland, K., Eisen, S., et al. (1995). Major depression and medication adherence
in coronary artery disease. Health Psychology, 14, 88-90.
CDC. See Centers for Disease Control and Prevention.
Centers for Disease Control and Prevention. (1987). Drinking and driving and binge drinking
in selected states, 1982 and 1985: The Behavioral Risk Factor Surveys. MMWR, 35,
788-791.
Centers for Disease Control and Prevention (1990). The health benefits of smoking cessation:
A report of the Surgeon General. Publication No. DHHS (CDC) 90-8416. Rockville, MD.
Centers for Disease Control and Prevention. (1993a). Cigarette smoking-attributable mortality
and years of potential life lost, United States, 1990. MMWR, 42, 645-649.
Centers for Disease Control and Prevention. (1993b). Fetal alcohol syndrome, United States,
1979-1992. MMWR, 42, 339-341.
Centers for Disease Control and Prevention. (1993c). Physician and other health-care
professional counseling of smokers to quit, United States, 1991. MMWR, 42, 854-857.
Centers for Disease Control and Prevention. (1994). Update: Acquired immunodeficiency
syndrome, United States, 1994. MMWR, 44, 64-67.
Centers for Disease Control and Prevention. (1994a). Cigarette smoking among adults, United
States, 1993. MMWR, 43, 925-930.
Centers for Disease Control and Prevention. (1994b). Frequent alcohol consumption among
women of childbearing age, Behavioral Risk Factor Surveillance System, 1991.
MMWR, 43, 328-329, 335.
Centers for Disease Control and Prevention. (1995a). Sociodemographic and behavioral
characteristics associated with alcohol consumption during pregnancy, United States,
1988. MMWR, 44, 261-264.
Centers for Disease Control and Prevention. (1995b). Youth risk behavior surveillance, United
States, 1993. MMWR, 44(SS-1), 1-56.
Centers for Disease Control and Prevention. (2002). Women and smoking (MMWR, 51 No.
RR-12). Atlanta, GA: U.S. Department of Health and Human Services.
Chan, A., Pristach, E., & Welte, J. (1994). Detection by the CAGE of alcoholism or heavy
drinking in primary care outpatients and the general population. Journal of Substance
Abuse, 6, 123-135.
114 Special Report

Chan, A., Pristach, E., Welte, J., et al. (1993). Use of the TWEAK test in screening for
alcoholism/heavy drinking in three populations. Alcoholism in Clinical and
Experimental Research, 17, 1188-1192.
Chang, G. (2001). Alcohol-screening instruments for pregnant women. Alcohol Research and
Health, 25(3), 204-209.
Chang, G., Goetz, M., Wilkins-Haug, L., & Berman, S. (1999, Spring). Identifying prenatal
alcohol use: Screening instruments versus clinical predictors. American Journal of
Addiction, 8(2), 87-93.
Chang, G., Wilkins-Haug, L., Berman, S., Goetz, M., Behr, H., & Hiley, A. (1998, June).
Alcohol use and pregnancy: Improving identification. Obstetrics and Gynecology,
91(6), 892-898.
Chasnoff, I., Griffith, D., Freier, C., & Murray, J. (1992). Cocaine/polydrug use in pregnancy:
Two-year follow-up. Pediatrics, 89, 284-289.
Chasnoff, I., Griffith, D., MacGregor, S., et al. (1989). Temporal patterns of cocaine use in
pregnancy. Journal of the American Medical Association, 261, 1741-1744.
Chasnoff, I., Neuman, K., Thornton, C., & Callaghan, M. (2001, March). Screening for
substance abuse in pregnancy: A practical approach for the primary care physician.
American Journal of Obstetrics and Gynecology, 184(4), 752-758.
Cherpitel, C. (1999). Screening for alcohol problems in the U.S. general population: A
comparison of the CAGE and TWEAK by gender, ethnicity, and service utilization.
Journal of Studies on Alcohol, 60(5), 705-711.
Cherpitel, C. (2000). Brief screening instrument for problem drinking in the emergency room:
The RAPS4. Journal of Studies on Alcohol, 61(3), 447-449.
Chitwood, D., Sanchez, J., Comerford, M., & McCoy, C. (2001, May–June). Primary
preventive health care among injection drug users, other sustained drug users, and
non-users. Substance Use and Misuse, 36(6-7), 807-824.
Chung, T., Colby, S., Barnett, N., et al. (2000). Screening adolescents for problem drinking:
Performance of brief screens against DSM-IV alcohol diagnoses. Journal of Studies on
Alcohol, 61(4), 579-587.
Chung, T., Colby, S., Barnett, N., & Monti, P. (2002). Alcohol use disorders identification
test: Factor structure in an adolescent emergency department sample. Alcoholism:
Clinical and Experimental Research, 26(2), 223-231.
Clark, K., Dee, D., Bale, P., & Martin, S. (2001, February). Treatment compliance among
prenatal care patients with substance abuse problems. American Journal of Drug and
Alcohol Abuse, 27(1), 121-136.
Clarke, G., Hawkins, W., Murphy, M., Sheeber, L., Lewinsohn, P., & Seeley, J. (1995, March).
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(3), 312-321.
Clarke, G., Hornbrook, M., Lynch, F., Polen, M., Gale, J., Beardslee, W., et al. (2001,
December). A randomized trial of a group cognitive intervention for preventing
depression in adolescent offspring of depressed parents. Archives of General
Psychiatry, 58(12), 1127-1134.
Clarke, G., Hornbrook, M., Lynch, F., Polen, M., Gale, J., O’Connor, E., et al. (2002, March).
Group cognitive-behavior treatment for depressed adolescent offspring of depressed
parents in a health maintenance organization. Journal of the American Academy of
Child and Adolescent Psychiatry, 41(3), 305-313.
Clarkin, J., Carpenter, D., Hull, J., Wilner, P., & Glick, I. (1998, April). Effects of
psychoeducational intervention for married patients with bipolar disorder and their
spouses. Psychiatric Services, 49(4), 531-533.
Clay, S. (1997). Comparison of AUDIT and CAGE questionnaires in screening for alcohol use
disorders in elderly primary care outpatients. Journal of the American Osteopathic
Association, 97(10), 588-592.
Coffey, R.M., Mark, T., King, E., Harwood, H., McKusick, D., Genuardi, J., Dilonardo, J., &
Buck, J.A. (2000, July). National estimates of expenditures for mental health and
substance abuse treatment, 1997. SAMHSA Pub No. SMA-00-3499. Rockville, MD:
CSAT and CMHS, SAMHSA.
Cohen, S., Stookey, G., Katz, B., et al. (1989). Encouraging primary care physicians to help
smokers quit: A randomized, controlled trial. Annals of Internal Medicine, 110, 648-
652.
Coker, A., Rosenberg, A., McCann, M., et al. (1992). Active and passive cigarette smoke
exposure and cervical intraepithelial neoplasia. Cancer Epidemiology, Biomarkers and
Prevention, 1, 349-356.
Colland, V. (1993, December 31). Learning to cope with asthma: A behavioral self-
management program for children. Patient Education and Counseling, 22(3), 141-
152.
Consensus Development Panel. (1985). NIMH/NIH Consensus Development Conference
Statement. Mood disorders: Pharmacologic prevention of recurrences. American
Journal of Psychiatry, 142, 469-476.
Corse, S., & Smith, M. (1998, September–October). Reducing substance abuse during
pregnancy. Discriminating among levels of response in a prenatal setting. Journal of
Substance Abuse Treatment, 15(5), 457-467.
Coyne, J., Schwenk, T., & Smolinski, M. (1991). Recognizing depression: A comparison of
family physicians ratings, self-report, and interview measures. Journal of the American
Board of Family Practitioners, 4, 207-215.
Critchley, J. A., & Capewell, S. (2003, July 2). Mortality risk reduction associated with
smoking cessation in patients with coronary heart disease. Journal of the American
Medical Association, 290(1), 86-97.
CTF. See Canadian Task Force.
Cummings, S., Rubin, S., & Oster, G. (1989, January 6). The cost-effectiveness of counseling
smokers to quit. Journal of the American Medical Association, 261(1), 75-79.
Curry, S., Marlatt, G., Gordon, J., et al. (1988). A comparison of alternative theoretical
approaches to smoking cessation and relapse. Health Psychology, 7, 545-556.
Daughton, D., Heatly, S., Prendergast, J., et al. (1991). Effect of transdermal nicotine delivery
as an adjunct to low-intervention smoking cessation therapy: A randomized, placebo-
controlled, double-blind study. Archives of Internal Medicine, 151, 749-752.
116 Special Report

Daumit, G., Bouleware, L., Powe, N., Minkovitz, C., Frick, K., Anderson, L., et al. (2001). A
computerized tool for evaluating the effectiveness of preventing interventions. Public
Health Reports, 116 (suppl 1), 244-253.
Dawson, D. (2000). U.S. low-risk drinking guidelines: An examination of four alternatives.
Alcoholism: Clinical and Experimental Research, 24(11), 1820-1829.
Dawson, D., Das, A., Faden, V., et al. (2001). Screening for high- and moderate-risk drinking
during pregnancy: A comparison of several TWEAK-based screeners. Alcoholism:
Clinical and Experimental Research, 25(9), 1342-1349.
Day, N., & Richardson, G. (1991). Prenatal marijuana use: Epidemiology, methodologic
issues, and infant outcomes. Clinical Perinatology, 18, 77-91.
DeGraff, R., Bijl, R., Smit, F., Vollenbergh, W., & Spijker, J. (2002, April). Risk factors for
12-month comorbidity of mood, anxiety, and substance abuse disorders: Findings
from the Netherlands Mental Health Survey and Incidence Study. American Journal of
Psychiatry, 159(4), 620-629.
deHaan, R. (2002, May). Measuring the quality of life after stroke using the SF-36. Stroke,
33(5), 1176-1177.
Deighton, C., & Nicol, A. (1985). Abnormal illness behavior in young women in a primary
care setting: Is Briquet’s Syndrome a useful category? Psychological Medicine, 15, 515-
520.
Depression Guideline Panel. (1993). Depression in primary care: Volume 1. Detection and
diagnosis (Clinical Practice Guideline Number 5, No. AHCPR No. 93-0550).
Rockville, MD: U.S. Department of Health and Human Services.
Devine, E., & Cook, T. (1983, September–October). A meta-analytic analysis of effects of
psychoeducational interventions on length of postsurgical hospital stay. Nursing
Research, 32(5), 267-274.
Devine, E., O’Connor, F., Cook, T., Wenk, V., & Curtin, T. (1988, October). Clinical and
financial effects of psychoeducational care provided by staff nurses to adult surgical
patients in the post-DRG environment. American Journal of Public Health, 78(10),
1293-1297.
Devine, E., & Reifschneider, E. (1995, July–August). A meta-analysis of the effects of
psychoeducational care in adults with hypertension. Nursing Research, 44(4), 237-
245.
DHHS. See U.S. Department of Health and Human Services.
D’Ononfrio, G., Bernstein, E., Woolard, R., Brewer, P., Craig, S., & Zink, B. (1998,
December). Patients with alcohol problems in the emergency department, Part 1:
Improving detection. Academy of Emergency Medicine, 5(12), 1200-1209.
Dorfman, S. (2000). Preventive interventions under managed care: Mental health and
substance abuse services (DHHS Publication No. [SMA] 00-3437). Rockville, MD:
Center for Mental Health Services, Substance Abuse and Mental Health Services
Administration.
Dorfman, S., & Smith, S. (2002, August). Preventive mental health and substance abuse
programs and services in managed care. Journal of Behavioral Health Services and
Research, 29(3), 233-258.
Dornbrand, L., Hoole, A., & Pickard, C. J. (1992). Manual of clinical problems in adult
ambulatory care. Boston: Little, Brown and Company.
Downey, G., and Coyne, J. (1990). Children of depressed parents: An integrative review.
Psychology Bulletin, 108, 50-76.
Drake, R., Mercer-McFadden, C., Mueser, K., McHugo, G., & Bond, G. (1998). Review of
integrated mental health and substance abuse treatment for patients with dual
diagnosis disorders. Schizophrenia Bulletin, 24(4), 589-608.
DuPont, R., Rice, D., Miller, L., Shiraki, S., Rowland, C., & Harwood, H. (1996). Economic
costs of anxiety disorders. Anxiety, 2, 167-172.
Durlak, J., & Wells, A. (1997). Primary prevention mental health programs for children and
adolescents: A meta-analytic review. American Journal of Community Psychology,
25(2), 115-151.
Durlak, J., & Wells, A. (1998). Evaluation of indicated preventive interventions (secondary
prevention) mental health programs for children and adolescents. American Journal of
Community Psychology, 26(5), 775-802.
Dusseldorp, E., van Elderen, T., Maes, S., Meulman, J., & Kraaij, V. (1999, September). A
meta-analysis of psychoeducational programs for coronary heart disease patients.
Health Psychology, 18(5), 506-519.
Duszynski, K., Nieto, F., & Vanente, C. (1995). Reported practices, attitudes, and confidence
levels of primary care physicians regarding patients who abuse alcohol and other
drugs. Maryland Medical Journal, 44, 193-202.
Dwight, M., Ciechanowski, P., Katon, W., et al. (1997, September 5–6). Psychiatric illness and
fatigue in patients with hepatitis C. Washington, DC: National Institute of Mental
Health presented at the Eleventh International Conference on Mental Health Problems
in General Health Sector.
Eckenrode, J., Ganzel, B., Henderson, C., Smith, E., Olds, D., Powers, J., et al. (2000,
September 20). Preventing child abuse and neglect with a program of nurse home
visitation: The limiting effects of domestic violence. Journal of the American Medical
Association, 284(11), 1385-1391.
Edlin, B., Irwin, K., Faruque, S., et al. (1994). Intersecting epidemics—crack cocaine use and
HIV infection among inner-city young adults: Multicenter Crack Cocaine and HIV
Infection Team. New England Journal of Medicine, 331, 1422-1427.
Egbert, L., Battit, G., Welch, C., & Bartlett, M. (1964, April 16). Reduction of postoperative
pain by encouragement and instruction of patients: A study of doctor-patient rapport.
New England Journal of Medicine, 270(16), 825-827.
Egede, L., Zheng, D., & Simpson, K. (2002, March). Comorbid depression is associated with
increased health care use and expenditures in individuals with diabetes. Diabetes Care,
25(3), 464-470.
Eisen, M., Keyser-Smith, J., Dampeer, J., & Sambrano, S. (2000, January–February).
Evaluation of substance use outcomes in demonstration projects for pregnant and
postpartum women and their infants: Findings from a quasi-experiment. Addictive
Behaviors, 25(1), 123-129.
118 Special Report

Eiser, N., West, C., Evans, S., Jeffers, A., & Quirk, F. (1997, July). Effects of psychotherapy in
moderately severe COPD: A pilot study. European Respiratory Journal, 10(7), 1581-
1584.
Elder, J., Wildey, M., de Moor, C., et al. (1993). The long-term prevention of tobacco use
among junior high school students: Classroom and telephone interventions. American
Journal of Public Health, 83, 1239-1244.
Elk, R., Mangus, L., Rhoades, H., Andres, R., & Grabowski, J. (1998, January–February).
Cessation of cocaine use during pregnancy: Effects of contingency management
interventions on maintaining abstinence and complying with prenatal care. Addictive
Behaviors, 23(1), 57-64.
Elkin, I., Shea, T., Watkings, J., et al. (1989). National Institute of Mental Health Treatment
of Depression Collaborative Research Program: General effectiveness of treatments.
Archives of General Psychiatry, 46, 971-982.
ElSohly, H., & ElSohly, M. (1990). Poppy seed ingestion and opiates urinalysis: A closer look.
Journal of Analytical Toxicology, 14, 308-310.
Emrick, C. (1987). Anonymous: Affiliation processes and effectiveness as treatment.
Alcoholism in Clinical and Experimental Research, 11, 416-423.
Ennett, S., Tobler, N., Ringwalt, C., et al. (1994). How effective is drug abuse resistance
education? A meta-analysis of project DARE outcome evaluations. American Journal
of Public Health, 84, 1394-1401.
EPA. See U.S. Environmental Protection Agency.
Ershoff, D., Mullen, P., & Quinn, V. (1989, February). A randomized trial of a serialized self-
help smoking cessation program for pregnant women in an HMO. American Journal
of Public Health, 79(2), 182-187.
Ershoff, D., Quinn, V., Boyd, N., Stern, J., Gregory M, & Wirschafter, D. (1999, October).
The Kaiser Permanente perinatal smoking-cessation trial: When more isn’t better, what
is enough? American Journal of Preventive Medicine, 17(3), 161-168.
Ershoff, D., Quinn, V., & Mullen, P. (1995, May–June). Relapse prevention among women
who stop smoking early in pregnancy: A randomized clinical trial of a self-help
intervention. American Journal of Preventive Medicine, 11(3), 178-184.
Ershoff, D., Quinn, V., Mullen, P., & Lairson, D. (1990, July–August). Pregnancy and medical
cost outcomes of a self-help prenatal smoking cessation program in an HMO. Public
Health Reports, 105(4), 340-347.
Escobar, J., Rubio-Stipec, M., Canino, G., et al. (1989). Somatic Symptom Index (SSI): A new
and abridged somatization construct. Prevalence and epidemiological correlates in two
large community samples. Journal of Nervous and Mental Disease, 177, 144-146.
Ewing, J. (1984). Detecting alcoholism: The CAGE questionnaire. Journal of the American
Fann, J., Katon, W., Uomoto, J., et al. (1995). Psychiatric disorders and functional disability
in patients with traumatic brain injuries. American Journal of Psychiatry, 152, 1493-1499.
Ferguson, R., Robinson, A., & Splaine M. (2002, September). Use of the reliable change index
to evaluate clinical significance of SF-36 outcomes. Quality of Life Research, 11(6),
509-516.
Fiellin, D., Reid, M., & O’Connor, P. (2000). Screening for alcohol problems in primary care:
A systematic review. Archives of Internal Medicine, 160(13), 1977-1989.
Fifer, S., Buesching, D., Henke, C., Potter, L., Mathais, S., Schonfeld, W., et al. (2003,
January-February). Functional status and somatization as predictors of medical offset
in anxious and depressed patients. Value Health, 6(1), 40-50.
Fiore, M., Jorenby, J., Baker, T., et al. (1992). Tobacco dependence and the nicotine patch:
Clinical guidelines for effective use. Journal of the American Medical Association, 268,
2687-2694.
Fiore, M., Kenford, S., Jorenby, D., et al. (1994). Two studies of the clinical effectiveness of
the nicotine patch with different counseling treatments. Chest, 105, 524-533.
Fiore, M., Novotny, T., Peirce, J., et al. (1990). Methods used to quit smoking in the United
States. Do cessation programs help? Journal of the American Medical Association,
263, 2760-2765.
Fiore, M., Smith, S., Jorenby, D., et al. (1994). The effectiveness of the nicotine patch for
smoking cessation: A meta-analysis. Journal of the American Medical Association,
271, 1940-1947.
Flay, B., Koepke, D., Thomson, S., et al. (1989). Six-year follow-up of the first Waterloo
school smoking prevention trial. American Journal of Public Health, 79, 1371-1376.
Fleming, M., Barry, K., Manwell, L., Johnson, K., & London, R. (1997, April 2). Brief
physician advice for problem alcohol drinkers. Journal of the American Medical
Association, 277(13), 1039-1045.
Fleming, M., Manwell, L., Barry, K., Adams, W., & Stauffacher, E. (1999, May). Brief
physician advice for alcohol problems in older adults: A randomized community-based
trial. The Journal of Family Medicine, 48(5), 378-384.
Fleming, M., Mundt, M., French, Manwell, L., Stauffacher, E., & Barry, K. (2000, January).
Benefit-cost analysis of brief physician advice with problem drinkers in primary care
settings. Medical Care, 38(1), 7-18.
Forrest, F., Florey, C., Taylor, et al. (1991). Reported social alcohol consumption during
pregnancy and infants’ development at 18 months. British Medical Journal, 1881, 22-
26.
Frank, D., Bresnahan, K., & Zuckerman, B. (1993). Maternal cocaine use: Impact on child
health and development. Advances in Pediatrics, 40, 65-99.
Franken, I., & Hendriks, V. (2001, Winter). Screening and diagnosis of anxiety and mood
disorders in substance abuse patients. American Journal of Addiction, 10(1), 30-39.
Frankowski, B., & Secker-Walker, R. (1989). Advising patients to stop smoking:
Opportunities and barriers in pediatric practice. American Journal of Diseases of
Children, 143, 1091-1094.
Freeborn, D., Polin, M., Hollis, J., & Senft, R. (2000, November). Screening and brief
intervention for hazardous drinking in an HMO: Effects on medical care utilization.
Journal of Behavioral Health Services and Research, 27(4), 446-453.
Friedman, P., Saitz, R., Gogineni, A., Zhang, J., & Stein, M. (2001). Validation of the
screening strategy in the NIAAA Physicians’ Guide to Helping Patients With Alcohol
Problems. Journal of Studies on Alcohol, 62(2), 234-238.
120 Special Report

Frings, C., Bataglia, D., & White, R. (1989). Status of drug-of-abuse testing in urine under
blind conditions: An AACC study. Clinical Chemistry, 35, 891-894.
Frohna, J., Lantz, P., & Pollack, H. (1999). Maternal substance abuse and infant health:
Policy options across the life span. Milbank Q, 77(4), 531-570.
Fuchs, C., Stampfer, M., Colditz, G., et al. (1995). Alcohol consumption and mortality among
women. New England Journal of Medicine, 332, 1245-1250.
Fulop, G., Strain, J., Fahs, M., Schmeidler, J., & Snyder, S. (1998, May–June). A prospective
study of the impact of psychiatric comorbidity on length of hospital stays of elderly
medical-surgical inpatients. Psychosomatics, 39(3), 273-280.
Gardner, W., Kelleher, K., & Pajer, K. (2002, September). Multidimensional adaptive testing
for mental health problems in primary care. Medical Care, 40(9), 812-823.
Garnick, D., Horgan, C., Merrick, E., Hodgkin, D., Faulkner, D., & Bryson, S. (2002,
October). Managed care plans’ requirements for screening for alcohol, drug, and
mental health problems in primary care. American Journal of Managed Care, 8(10),
879-888.
Gaziano, J., Buring, J., Breslow, J., et al. (1993). Moderate alcohol intake, increased levels of
high-density lipoprotein and its subfractions, and decreased risk of myocardial
infarction. New England Journal of Medicine, 329, 1829-1835.
Ghadirian, P., Simard, A., & Baillargeon, J. (1991). Tobacco, alcohol, and coffee and cancer
of the pancreas: A population-based case-control study in Quebec, Canada. Cancer,
67, 2664-2670.
Gill, D., & Hatcher, S. (2000). Antidepressants for depression in medical illness. Cochrane
Database Sys Rev, 4(CD001312).
Gitlin, L., Corcoran, M., Winter, L., Boyce, A., & Hauck, W. (2001, February). A
randomized, controlled trial of a home environmental intervention: Effect on efficacy
and upset in caregivers and on daily function of persons with dementia. Gerontologist,
41(1), 4-14.
Glasgow, R. (1991). Compliance to diabetic regimens: Conceptualization, complexity, and
determinants. In J. Cramer & B. Spiker (Eds.), Patients Compliance in Medical
Practice and Clinical Trials. New York: Raven.
Glaze, L., & Coggan, P.G. (1987). Efficacy of an alcoholism self-report questionnaire in a
residency clinic. Journal of Family Practice, 25, 60-64.
Gold, M., Washton, A., & Dackis, C. (1985). Cocaine abuse: Neurochemistry,
phenomenology, and treatment (National Institute of Drug Abuse Research
Monograph Series 1985; 61). Bethesda, MD: National Institute of Drug Abuse.
Goodnick, P. (2001, March). Use of antidepressants in treatment of comorbid diabetes
mellitus and depression as well as in diabetic neuropathy. Annals of Clinical
Psychiatry, 13(1), 31-41.
Goodwin, M., Bruce, C., Zahniser, S., et al. (1994). Behavioral risk factors before and during
pregnancy. In L. Wilcox & J. Marks (Eds.), CDC’s public health surveillance for
women, infants, and children (pp. 93-104). Washington, DC: Department of Health
and Human Services.
Gordon, R. (1983). An operational classification of disease prevention. Public Health Reports,
98, 107-109.
Graham, K., Dimitrakoudis, D., Pellegrini, E., et al. (1989). Pregnancy outcomes following
first trimester exposure to cocaine in social users in Toronto, Canada. Veterinary and
Human Toxicology, 31, 143-148.
Gram, I., Austin, H., & Stalsberg, H. (1992). Cigarette smoking and the incidence of cervical
intraepithelial neoplasia, grade III, and cancer of the cervix uteri. American Journal of
Epidemiology, 135, 341-346.
Grant, B. (1997). Prevalence and correlates of alcohol use and DSM-IV alcohol dependence in
the United States. Journal of Studies on Alcohol, 58(5), 464-473.
Grant, B., Harford, T., Dawson, D., et al. (1994). Prevalence of DSM-IV alcohol abuse and
dependence: United States 1992. Alcohol Health Research World, 18, 243-248.
Green, M. (Ed.). (1994). Bright futures: National guidelines for health supervisions of infants,
children, and adolescents. Arlington, VA: National Center for Education in Maternal
and Child Health.
Greenberg, H., Scharf, S., & Green, H. (1993, May). Nortriptyline-induced depression of
ventilatory control in a patient with chronic obstructive pulmonary disease. The
American Review of Respiratory Disease, 147(5), 1303-1305.
Greenberg, P., Stiglin, L., Finkelstein, S., & Berndt, E. (1993, November). The economic
burden of depression in 1990. Journal of Clinical Psychiatry, 54(11), 405-418.
Greydanus, D. (1986). Depression in adolescence: A perspective. Journal of Adolescent Health
Care, 7, 109S-120S.
Grover, N., Kumaraiah, V., Prasadrao, P., & D’souza, G. (2002, July). Cognitive behavioral
intervention in bronchial asthma. The Journal of the Association of Physicians of
India, 50, 896-900.
Halmesmaki, E. (1988). Alcohol counseling of 85 pregnant problem drinkers: Effect on
drinking and fetal outcome. British Journal of Obstetrics and Gynaecology, 95, 243-
247.
Hammerlid, E., Persson, L., Sullivan, M., & Westin, T. (1999, April). Quality-of-life effects of
psychosocial intervention in patients with head and neck cancer. Otolaryngology—
Head and Neck Surgery, 120(4), 507-516.
Handmaker, N., Hester, R., & Delaney, H.D. (1999, February). Videotaped training in alcohol
counseling for obstetric care practitioners: A randomized controlled trial. Obstetrics
and Gynecology, 93(2), 213-218.
Hankin, J., McCaul, M., & Heussner, J. (2000, August). Pregnant, alcohol-abusing women.
Alcoholism in Clinical and Experimental Research, 24(8), 1276-1286.
Hansen, W. (1992). School-based substance abuse prevention: A review of the state of the art
in curriculum, 1980-1990. Health Education Research, 7, 403-430.
Hansen, W., Johnson, C., Flay, B., et al. (1988). Affective and social influences approaches to
the prevention of multiple substance abuse among seventh-grade students: Results
from project SMART. Prevention Medicine, 17, 135-154.
Harris, E., & Barraclough, B. (1997). Suicide as an outcome for mental disorders. A meta-
analysis. British Journal of Psychiatry, 170, 205-228.
122 Special Report

Hartge, P., Silverman, D., Schairer, C., et al. (1993). Smoking and bladder cancer risk in
Blacks and Whites in the United States. Cancer Causes Control, 4, 391-394.
Harwood, H., Sullivan, K., & Malhorta, D. (2001, June). Data analysis identified major
disparities in alcohol treatment across various groups. Frontlines: Linking Alcohol
Services Research and Practice, 7, 3-5.
Hayes, B., Muller, R., & Bradley, B. (2001, March). Perinatal depression: A randomized
controlled trial of an antenatal education intervention for primiparas. Birth, 28(1), 28-35.
Hays, J., & Spickard, W. (1987). Alcoholism: Early diagnosis and intervention. Journal of
General Internal Medicine, 2, 420-427.
Helzer, J. B., & McEvoy, L. (1991). Alcohol abuse and dependence. In L. Robins & D. Regier
(Eds.), Psychiatric disorders in America: The Epidemiologic Catchment Area Study
(pp. 81-115). New York: Free Press.
Henningfield, J., Cohen, C., & Pickworth, W. (1994). Psychopharmacology of nicotine. In C.
Orleans & J. Slade (Eds.), Nicotine Addiction (pp. 24-25). New York: Oxford
University Press.
Hermansson, U., Helander, A., Brandt, L., Huss, A., & Ronnberg, S. (2002). The alcohol use
disorders identification test and carbohydrate-deficient transferrin in alcohol-related
sickness absence. Alcoholism: Clinical and Experimental Research, 26(1), 28-35.
Hermansson, U., Helander, A., Huss, A., Brandt, L., & Ronnberg, S. (2000). The alcohol use
disorders identification test (AUDIT) and carbohydrate-deficient transferrin (CDT) in
a routine work place health examination. Alcoholism: Clinical and Experimental
Research, 24(2), 180-187.
Hiller, W., Rief, W., & Fichter, M. (1995). Further evidence for a broader concept of
somatization disorder using Somatic Symptom Index. Psychosomatics, 36, 285-294.
Hjalmarson, A., Hahn, L., & Svanberg, B. (1991). Stopping smoking in pregnancy: Effect of a
self-help manual in controlled trial. British Journal of Obstetrics and Gynecology, 98,
260-264.
Hollis, J., Lichtenstein, E., Vogt, T., Stevens, V., & Biglan, A. (1993, April 1). Nurse-assisted
counseling for smokers in primary care. Annals of Internal Medicine, 118(7), 521-525.
Hopkins, C. & Kachur, K. (2002). CPT Expert: Enhanced for accurate procedural coding
2003 (3rd ed.). Salt Lake City, UT: Ingenix St Anthony Publishing Group.
Horgan, C. M., Merrick, E. L., Garnick, D. W., Hodgkin, D., Cenczyk, R. E., Lusenhop, R.
W., et al. (2003). The provision of mental health services in managed care
organizations (SAMHSA Special Report No. SMA 03 3797). Rockville, MD:
Department of Health and Human Services.
Horwath, E., Johnson, J., Klerman, G., & Weissman, M. (1992). Depressive symptoms as
relative and attributable risk factors for first-onset major depression. Archives of
General Psychiatry, 49, 817-823.
Howe, G., Jain, M., Burch, J., et al. (1991). Cigarette smoking and cancer of the pancreas:
Evidence from a population-based case-control study in Toronto, Canada.
International Journal of Cancer, 47, 323-328.
Hughes, J., Gust, S., Kennan, R., et al. (1989). Nicotine vs. placebo gum in general medical
practice. Journal of the American Medical Association, 261, 1300-1305.
Hunkeler, E., Meresman, J., Hargreaves, W., Fireman, B., Berman, W., Kirsch, A., et al. (2000,
August). Efficacy of nurse telehealth care and peer support in augmenting treatment of
depression in primary care. Archives of Family Medicine, 9(8), 700-708.
Hurt, R., Dale, L., Fredrickson, P., et al. (1994). Nicotine patch therapy for smoking cessation
combined with physician advice and nurse follow-up: One-year outcome and percentage
of nicotine replacement. Journal of the American Medical Association, 271, 595-600.
Hutchings, D. (1982). Methadone and heroin during pregnancy: A review of behavioral effects in
human and animal offspring. Neurobehavioral Toxicology and Teratology, 4, 429-434.
Institute of Medicine. (1989). Prevention and treatment of alcohol problems: Research
opportunities. Washington, DC: National Academy Press.
Institute of Medicine. (1990). Broadening the base of treatment for alcohol problems: Report
of a study by a committee of the Institute of Medicine. Washington, DC: National
Academy Press.
IOM. See Institute of Medicine.
Jackson, P., Stapleton, J., Russell, M., et al. (1986). Predictors of outcome in general
practitioner intervention against smoking. Preventive Medicine, 15, 244-253.
Jacobson, J., Jacobson, S., Sokol, R., et al. (1993). Teratogenic effects of alcohol on infant
development. Alcoholism in Clinical and Experimental Research, 17, 174-183.
Jansson, L., Svikis, D., Lee, J., Paluzzi, P., Rutigliano, P., & Hackerman, F. (1996,
July–August). Pregnancy and addiction. A comprehensive care model. Journal of
Substance Abuse Treatment, 13(4), 321-329.
Janz, N., Becker, M., Kirscht, M., et al. (1987). Evaluation of minimal contact smoking
cessation intervention in an outpatient setting. American Journal of Public Health, 77,
805-808.
Jarvis, M., Raw, M., Russell, M., et al. (1982). Randomised controlled trial of nicotine
chewing gum. British Medical Journal, 285, 537-540.
Jay, S., Elliott, C., Fitzgibbons, I., Woody, P., & Siegel, S. (1995, July). A comparative study of
cognitive behavior therapy versus general anesthesia for painful medical procedures in
children. Pain, 62(1), 3-9.
Jaycox, L., Reivich, K., Gillham, J., & Seligman, M. (1994). Prevention of depressive
symptoms in school children. Behavior Research and Therapy, 32, 801-816.
Jellinek, M., Little, M., Murphy, J., & Pagano, M. (1995, July). The pediatric symptom
checklist. Support for a role in a managed care environment. Archives of Pediatric and
Adolescent Medicine, 149(7), 740-746.
Jellinek, M., & Murphy, J. (1988, November). Screening for psychosocial disorders in
pediatric practice. American Journal of Diseases of Children, 142(11), 1153-1157.
Jellinek, M., & Murphy, J. (1999, December 3). Psychosocial problems, screening, and the
pediatric symptom checklist. Developmental and Behavioral News, 8(1). Retrieved
June 6, 2003, from http://www.dbpeds.org/section/fall_1999/jellinek.html
Jellinek, M., Murphy, J., Little, M., Pagano, M., Comer, D., & Kelleher, K. (1999, March).
Use of the Pediatric Symptom Checklist to screen for psychosocial problems in
pediatric primary care: A national feasibility study. Archives of Pediatric and
Adolescent Medicine, 153(3), 254-260.
124 Special Report

Jellinek, M., Murphy, J., Robinson, J., Feins, A., Lamb, S., & Fenton, T. (1988, February).
Pediatric Symptom Checklist: Screening school-age children for psychosocial
dysfunction. Journal of Pediatrics, 112(2), 201-109.
Jiang, W., Alexander, J., Christopher, E., Kuchibhatla, M., Gaulden, L., Cuffe, M., et al.
(2001, August 13–27). Relationship of depression to increased risk of mortality and
rehospitalization in patients with congestive heart failure. Archives of Internal
Medicine, 161, 1849-1856.
Johnson, R., Steven, V., Hollis, J., et al. (1992). Nicotine chewing gum use in the outpatient
care setting. Journal of Family Practice, 34, 61-65.
Jones, R. (1984). Marijuana: Health and treatment issues. Psychiatric Clinics of North
America, 7, 703-712.
Jordan-Marsh, M. (2002, December). The SF-36 quality of life instrument; updates and
strategies for critical care research. Critical Care Nurse, 22(6), 35-43.
Judd, L.L. (1997). The clinical course of unipolar major depressive disorders. Archives of
General Psychiatry, 54, 989-991.
Katon, W. (1987). The epidemiology of depression in medical care. International Journal of
Psychiatric Medicine, 17, 93-112.
Katon, W. (1998, April). The effect of major depression on chronic medical illness. Seminars
in Clinical Neuropsychiatry, 3(2), 82-86.
Katon, W., Berg, A., Robins, A., & Risse, S. (1986). Depression: Medical utilization and so-
matization. Western Journal of Medicine, 144, 564-568.
Katon, W., Lin, E., Von Korff, M., et al. (1991). Somatization: A spectrum of severity.
American Journal of Psychiatry, 148, 34-40.
Katon, W., & Russo, J. (1989). Somatic symptoms and depression. Journal of Family Practice,
29, 65-69.
Katon, W., Rutter, C., Ludman, E., Von Korff, M., Lin, E., et al. (2001, MAR). A randomized
trial of relapse prevention of depression in primary care. Archives of General
Psychiatry, 58, 241-247.
Katon, W., Von Korff, M., Lin, E., Bush, T., Russo, J., Lipscomb, P., et al. (1992). A
randomized trial of psychiatric consultation with distressed high utilizers. General
Hospital Psychiatry, 14, 86-98.
Katon, W., Von Korff, M., Lin, E., Lipscomb, P., Russo, J., Wagner, E., et al. (1990).
Distressed high utilizers of medical care. DSM-III-R diagnoses and treatment needs.
General Hospital Psychiatry, 12(6), 355-362.
Katz, I. (1996). On the inseparability of mental and physical health in aged persons. American
Journal of Geriatric Psychiatry, 4, 1-16.
Katzelnick, D., Simon, G., Pearson, S., Manning, W., Helstad, C., Henk, H., et al. (2000,
April). Randomized trial of a depression management program in high utilizers of
medical care. Archives of Family Medicine, 9, 345–351.
Keer, D., Colliver, J., & Kopstein, A. (1994). Restricted activity days and other problems
associated with use of marijuana and cocaine among persons 18–44 years of age:
United States 1991 (Advanced data from vital and health statistics; no246).
Hyattsville, MD: National Center for Health Statistics.
Kellner, R. (1965). Neurosis in general practice. British Journal of Clinical Practice, 19, 681-
682.
Kellner, W., Lin, E., Von Korff, M., et al. (1985). Functional somatic symptoms and
hypochondriasis: A survey of empirical studies. Archives of General Psychiatry, 42,
821-833.
Kenford, S., Fiore, M., & Jorenby, D. (1994). Predicting smoking cessation: Who will quit
with and without the nicotine patch. Journal of the American Medical Association,
271, 589-594.
Kessler, R., McGonagle, K., 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.
King, M. (1986). At risk drinking among general practice attenders: Validation of the CAGE
questionnaire. Psychological Medicine, 16, 213-217.
Kirmayer, L., & Robbins, J. (1991). Three forms of somatization in primary care: Prevalence,
co-occurrence, and sociodemographic characteristics. Journal of Nervous and Mental
Disease, 179, 647-655.
Kitzman, H., Olds, D., Henderson, C., Hanks, C., Cole, R., Tatelbaum, R., et al. (1997,
August 27). Effect of prenatal and infancy home visitation by nurses on pregnancy
outcomes, childhood injuries, and repeated childbearing: A randomized controlled
trial. Journal of the American Medical Association, 278(8), 644-652.
Kitzman, H., Olds, D., Sidora, K., Henderson, C. J., Hanks, C., Cole, R., et al. (2000, April
19). Enduring effects of nurse home visitation on maternal life course: A 3-year
follow-up of a randomized trial. Journal of the American Medical Association,
283(15), 1983-1989.
Klatsky, A., Armstrong, A., & Friedman, G. (1990). Risk of cardiovascular mortality in
alcohol drinkers, ex-drinkers and non-drinkers. American Journal of Cardiology, 66,
1237-1242.
Klatsky, A., Armstrong, A., & Friedman, G. (1992). Alcohol and mortality. Annals of Internal
Medicine, 117, 646-654.
Knupfer, G. (1991). Abstaining for fetal health: The fiction that even light drinking is
dangerous. British Journal of Addiction, 86, 1063-1073.
Koproski, J., Pretto, Z., & Poretsky, L. (1997, October). Effects of an intervention by a
diabetes team in hospitalized patients with diabetes. Diabetes Care, 20(10), 1553-1555.
Kottke, T., Battista, R., DeFriese, G., et al. (1988). Attributes of successful smoking cessation
interventions in medical practice: A meta-analysis of 39 controlled trials. Journal of
the American Medical Association, 259, 2882-2889.
Kottke, T., Willms, D., Solberg, L., et al. (1994). Physician-delivered smoking cessation
advice: Issues identified during ethnographic interviews. Tobacco Control, 3, 46-49.
Kroenke, K., & Mangelsdorff, A. (1989). Common symptoms in ambulatory care: Incidence,
evaluation, therapy, and outcome. American Journal of Medicine, 86(3), 262-266.
Kroenke, K., Spitzer, R., deGruy, F., et al. (1997). Multisomatoform disorder: An alternative
to undifferentiated somatoform disorder for the somatizing patient in primary care.
Archives of General Psychiatry, 54, 352-358.
126 Special Report

Kroenke, K., Spitzer, R., deGruy, F., & Swindle, R. (1998, May–June). A symptom checklist to
screen for somatoform disorders in primary care. Psychosomatics, 39(3), 263-272.
Kukko, H., & Halmesmaki, E. (1999, January). Prenatal care and counseling of female drug-
abusers: Effects on drug abuse and perinatal outcome. Acta Obstetricia et
Gynecologica Scandinavica, 78(1), 22-26.
Kunik, M., Braun, U., Stanley, M., Wristers, K., Molinari, V., Stoebner, D., et al. (2001, May).
One session cognitive behavioral therapy for elderly patients with chronic obstructive
pulmonary disease. Psychological Medicine, 31(4), 717-723.
Lagerberg, D. (2000, September). Secondary prevention in child health: Effects of
psychological intervention, particularly home visitation, on children’s development and
other outcome variables. Acta Paediatrica Suppl, 89(434), 43-52.
Lam, W., Sze, P., Sacks, H., et al. (1987). Meta-analysis of randomised controlled trials of
nicotine chewing-gum. The Lancet, 2, 27-30.
Larson, G. (1983). Prevention of fetal alcohol effects. Acta Obstetricia et Gynecologica
Scandinavica, 62, 171-178.
Latts, L., Prochaska, A., Salas, N., & Young, D. (2002). Smoking cessation in pregnancy:
Failure of an HMO pilot project to improve guideline implementation. Nicotine and
Tobacco Research, 4(Suppl 1), S25-30.
Lebowitz, B., Pearson, J., Schneider, L., et al. (1997). Diagnosis and treatment of depression in
late life: Consensus state update. Journal of the American Medical Association, 278,
1186-1190.
Lewinsohn, P., Hops, H., Roberts, R., Seeley, J., & Andrews, J. (1993). Adolescent
psychopathology I: Prevalence and incidence of depression and other DSM-III-R
disorders in high school students. Journal of Abnormal Psychology, 102, 133-144.
Lin, E., Katon, W., Simon, G., VonKorff, M., Bush, T., Walker, E., et al. (2000, March–April).
Low-intensity treatment of depression in primary care: Is it problematic? General
Hospital Psychiatry, 22(2), 78-83.
Linn, L., & Yager, J. (1980). The effect of screening, sensitization, and feedback on notation
of depression. Journal of Medical Education, 55, 942-949.
Lorig, K., Ritter, P., Stewart, A., Sobel, D., Brown, W. B., Jr., Bandura, A., et al. (2001,
November). Chronic disease self-management program: 2-year health status and
health care utilization outcomes. Medical Care, 39:(11), 1217-1223.
Lumley, J., Olver, S., & Waters, E. (2000). Interventions for promoting smoking cessation
during pregnancy. Cochrane Database Syst Rev, 2.
Lustman, P., Clouse, R., & Carney, R. (1988). Depression and the reporting of diabetes
symptoms. International Journal of Psychiatry in Medicine, 18, 295-303.
Lustman, P., Clouse, R., & Freedland, K. (1998, April). Management of major depression in
adults with diabetes: Implications of recent clinical trials. Seminars in Clinical
Neuropsychiatry, 3(2), 102-114.
Lustman, P., Freedland, K., Griffith, L., & Clouse, R. (1998, September). Predicting response
to behavior therapy of depression in type 2 diabetes. General Hospital Psychiatry,
20(5), 302-306.
Lustman, P., Freedland, K., Griffith, L., & Clouse, R. (2000, May). Fluoxetine for depression
in diabetes: A randomized double-blind placebo-controlled trial. Diabetes Care, 23(5),
618-623.
Lustman, P., Griffith, L., Clouse, R., Freedland, K., Eisen, S., Rubin, E., et al. (1995, August).
Effects of alprazolam on glucose regulation in diabetes. Results of a double-blind,
placebo-controlled trial. Diabetes Care, 18(8), 1133-1139.
Lustman, P., Griffith, L., Clouse, R., Freedland, K., Eisen, S., Rubin, E., et al. (1997,
May–June). Effects of nortriptyline on depression and glycemic control in diabetes:
Results of a double-blind, placebo-controlled trial. Psychosomatic Medicine, 59(3),
241-250.
Lustman, P., Griffith, L., Freedland, K., & Clouse, R. (1997, March). The course of major
depression in diabetes. General Hospital Psychiatry, 19(2), 138-143.
Lustman, P., Griffith, L., Freedland, K., Kissel, S., & Clouse, R. (1998, October 15).
Cognitive behavior therapy for depression in type 2 diabetes mellitus. A randomized,
controlled trial. Annals of Internal Medicine, 129(8), 613-621.
Maclure, M. (1993). Demonstration of deductive meta-analysis ethanol intake and risk of
myocardial infarction. Epidemiologic Reviews, 15, 328-351.
Manley, M., Epps, R., Husten, C., et al. (1991). Clinical interventions in tobacco control: A
national cancer institute training program for physicians. Journal of the American
Marcenko, M., & Spence, M. (1994, July). Home visitation services for at-risk pregnant and
postpartum women: A randomized trial. American Journal of Orthopsychiatry, 64(3),
468-478.
Margolis, P., Lannon, C., Stevens, R., Harlan, C., Bordley, W., Carey, T., et al. (1996, August).
Linking clinical and public health approaches to improve access to health care for
socially disadvantaged mothers and children. A feasibility study. Archives of Pediatric
and Adolescent Medicine, 150(8), 815-821.
Margolis, P., Stevens, R., Bordley, W., Stuart, J., Harlan C, Keyes-Elstein, L., et al. (2001,
September). From concept to application: The impact of a community-wide
intervention to improve the delivery of preventive services to children. Pediatrics,
108(3), E42.
Margolis, S., & Swartz, K. (2002). The Johns Hopkins white papers: Depression and anxiety
2002. Baltimore, MD: The Johns Hopkins Medical Institutions.
Mark, T.L., Dilonardo, J., Chalk, M., & Coffey, R.M. (2002, September). Substance abuse
detoxification: Improvements needed in linkage to treatment. SAMHSA Pub. No.
SMA-02-3728. Rockville, MD: Center for Substance Abuse Treatment, SAMHSA.
Markovic, N., Ness, R., Cefilli, D., Grisso, J., Stahmer, S., & Shaw, L. (2000, September).
Substance use measures among women early in pregnancy. American Journal of
Obstetrics and Gynecology, 183(3), 627-632.
Marks, J., Koplan, J., Hogue, C., & Dalmat, M. (1990, September–October). A cost-
benefit/cost-effectiveness analysis of smoking cessation for pregnant women. American
Journal of Preventive Medicine, 6(5), 282-289.
128 Special Report

Mayer, J., Hawkins, B., & Todd, R. (1990, January). A randomized evaluation of smoking
cessation interventions for pregnant women at a WIC clinic. American Journal of
Public Health, 80(1), 76-78.
Mayes, L., Granger, R., Borstein, M., et al. (1992). The problem of prenatal cocaine exposure.
A rush to judgment. Journal of the American Medical Association, 267, 406-408.
Mayou, R. (1976). The nature of bodily symptoms. British Journal of Psychiatry, 129, 55-60.
Mayou, R. (1978). Chest pain in the cardiac clinic. Journal of Psychosomatic Research, 17,
353-357.
McAfee, T., Grossman, R., Dacey, S., & McClure, J. (2002). Capturing tobacco status using
an automated billing system: Steps toward a tobacco registry. Nicotine and Tobacco
Research, 4(Suppl 1), S31-S37.
McCarton, C., Brooks-Gunn, J., Wallace, I., Baur, C., Bennett, F., & Bernbaum, J. (1997,
January 8). Results at age 8 years of early intervention for low-birthweight premature
infants. The Infant Health and Development Program. Journal of the American
McGlynn, E. A., Asch, S., M, Adams, J., Keesey, J., Hicks, J., DeCristofaro, A., et al. (2003,
June 26). The quality of health care delivered to adults in the United States. New
England Journal of Medicine, 348(26), 2635-2645.
McLellan, A., Luborsky, L., Woody, G., et al. (1980). An improved diagnostic evaluation
instrument for substance abuse patients. The Addiction Severity Index. Journal of
Nervous and Mental Disease, 168, 26-33.
Meberg, A., Halvorsen, B., Holter, B., et al. (1986). Moderate alcohol consumption-need for
intervention programs in pregnancy? Acta Obstetricia et Gynecologica Scandinavica,
65, 861-864.
Melvin, C., Dolan-Mullen, P., Windsor, R., Whiteside, H. J., & Goldenberg, R. (2000).
Recommended cessation counseling for pregnant women who smoke: A review of the
evidence. Tobacco Control, 9(Suppl 3), III80-III84.
Merrick, J. (1993). Maternal substance abuse during pregnancy. Policy implications in the
United States. Journal of Legal Medicine, 14, 57-71.
Midanik, L., Zahnd, E., & Klein, D. (1998, February). Alcohol and drug CAGE screeners for
pregnant, low-income women: The California Perinatal Needs Assessment. Alcoholism
in Clinical and Experimental Research, 22(1), 121-125.
Miklowitz, D., Simoneau, T., George, E., Richards, J., Kalbag, A., Sachs-Ericsson, N., et al.
(2000, September 15). Family-focused treatment of bipolar disorder: 1-year effects of
a psychoeducational program in conjunction with pharmacotherapy. Biological
Psychiatry, 48(6), 582-592.
Mishel, M., Belyea, M., Germino, B., Stewart, J., Bailey, D. J., Robertson, C., et al. (2002,
March 15). Helping patients with localized prostate carcinoma manage uncertainty
and treatment side effects: Nurse-delivered psychoeducational intervention over the
telephone. Cancer, 94(6), 1854-866.
Misri, S., Kostaras, X., Fox, D., & Kostaras, D. (2000, August). The impact of partner
support in the treatment of postpartum depression. Canadian Journal of Psychiatry,
45(6), 554-558.
Mitchell, E., Ford, R., Steward, A., et al. (1993). Smoking and the sudden infant death
syndrome. Pediatrics, 91, 893-896.
Monk, M. (1987). Epidemiology of suicide. Epidemiologic Reviews, 9, 51-68.
Moore, J., Lilmperi, D., & Bobula, J. (1978). Recognition of depression by family medicine
residents: The impact of screening. Journal of Family Practice, 7, 509-513.
Moore, S., Logerfo, J., Inui, T. (1980). Effect of a self-care book on physician visits. Journal
of American Medical Association, 243, 2317-2322.
Moser, J., Jones, V., & Kuthy, M. (1993). Use of cocaine during immediate prepartum period
by childbearing women in Ohio. American Journal of Preventive Medicine, 9, 85-91.
Mrazek, P. (1998). Preventing mental health and substance abuse problems in managed health
care settings. National Mental Health Association.
Mrazek, P., & Haggerty, R. (Eds.). (1994). Reducing risks for mental disorders: Frontiers for
preventive intervention research. Institute of Medicine Committee on Prevention of
Mental Disorders. Washington, DC: Institute of Medicine, National Academy Press.
Mullen, P. (1999, September). Maternal smoking during pregnancy and evidence-base
intervention to promote cessation. Primary Care, 26(3), 577-589.
Muller, P., Abelin, T., Ehrsam, R., et al. (1990). The use of transdermal nicotine in smoking
cessation. Lung, 168(supp), 445-453.
Mumford, E., Schlesinger, H., & Glass, G. (1982, February). The effects of psychological
intervention on recovery from surgery and heart attacks: An analysis of the literature.
American Journal of Public Health, 72(2), 141-151.
Munoz, R. (1993). The prevention of depression: Current research and practice. Applied and
Preventive Psychology, 2, 21-33.
Murphy, J., Arnett, H., Bishop, S., Jellinek, M., & Reede, J. (1992, November). Screening for
psychosocial dysfunction in pediatric practice. A naturalistic study of the Pediatric
Symptom Checklist. Clinical Pediatrics (Philadelphia), 31(11), 660-667.
Murphy, J., Ichinose, C., Hicks, R., Kingdon, D., Crist-Whitzel, J., Jordan, P., et al. (1996,
December). Utility of the Pediatric Symptom Checklist as a psychosocial screen to
meet the Federal Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
standards: A pilot study. Journal of Pediatrics, 129(6), 864-869.
Murphy, J., Reede, J., Jellinek, M., & Bishop, S. (1992, November). Screening for
psychosocial dysfunction in inner-city children: Further validation of the Pediatric
Symptom checklist. Journal of the American Academy of Child and Adolescent
Psychiatry, 31(6), 1105-1111.
Murray, C. J. & Lopez, A. (Eds.). (1996). The global burden of disease. Cambridge, MA:
Harvard University Press for WHO and the World Bank.
Murray, D., Pirie, P., Luepker, R., et al. (1989). Five- and six-year follow-up results from four
seventh-grade smoking prevention strategies. Journal of Behavioral Medicine, 12, 207-218.
Musselman, D., Evans, D., & Nemeroff, C. (1998). The relationship of depression to
cardiovascular disease. Archives of General Psychiatry, 55, 580-592.
Naimi, T., Brewer, R., Mokdad, A., Denny, C., Serdula, M., & Marks, J. (2002, January 1).
Binge drinking among U.S. adults. Journal of the American Medical Association,
289(1), 70-75.
130 Special Report

National Cancer Institute. (1993). Smokeless tobacco or health: An international perspective
(Publication No. DHHS (NIH) 93-3461). Bethesda: National Institutes of Health.
National Center for Health Statistics. (1994). Advance report of final mortality statistics,
1993 (Monthly Vital Statistics Report; Vol 42 No. 13 (suppl)). Hyattsville, MD: Public
Health Service.
National Center for Infectious Diseases. (1993). National HIV Serosurveillance summary-
results through 1992. Vol 3 (Publication no. HIV/NCID/11-93/036). Atlanta: Centers
for Disease Control and Prevention.
National Center on Addiction and Substance Abuse at Columbia University. (2000, May).
Missed opportunity: National survey of primary care physicians and patients on
substance abuse. Retrieved August 1, 2002, from
http://www.casacolumbia.org/pdshopprov/shop/item.asp?itemid=9
National Committee for Quality Assurance. (2002, August 5). The health plan employer data
and information set (HEDIS®). Available from
http://www.ncqa.org/communications/publications/hedispub.htm
National Highway Traffic Safety Administration. (1994). Traffic safety facts 1993: Alcohol.
Washington, DC: U.S. Department of Transportation, National Highway Traffic
Safety Administration.
National Institute on Alcohol Abuse and Alcoholism. (1993). Alcohol and health: Eighth
special report to the U.S. Congress from the Secretary of Health and Human Services
(NIH Publication No. 94-3699). Rockville, MD: Department of Health and Human
Services, National Institutes of Health.
National Institute on Alcohol Abuse and Alcoholism. (1995). The physician’s guide to helping
patients with alcohol problems. Rockville, MD: NIH.
National Institute on Alcohol Abuse and Alcoholism. (2002, April). Screening for alcohol
problems: An update. Alcohol Alert (56). Retrieved January 5, 2003, from
http://www.niaaa.nih.gov/publications/aa56.htm
National Institute on Alcohol Abuse and Alcoholism. (2003). Helping patients with alcohol
problems. Retrieved from
http://www.niaaa.nih.gov/publications/practitioner/HelpingPatients-Printing.htm
National Institute on Alcohol Abuse and Alcoholism. Unpublished data from the 1992
National Longitudinal Alcohol Epidemiology Study (NLAES), a nationwide household
survey of 42,862 U.S. adults aged 18 or older.
National Institute on Drug Abuse. (1993). National survey results on drug use from
Monitoring the Future Study, 1975-1992 (NIH Publications Nos. 93-3596 and 3597).
Rockville, MD: Department of Health and Human Services, National Institute on
Drug Abuse.
National Institute on Drug Abuse. (1994a). Epidemiologic trends in drug abuse. Vol I-II (NIH
Publication Nos. 94-3745, 3546). Rockville, MD: National Institutes of Health.
National Institute on Drug Abuse. (1994b). Monitoring future study, 1975-1994 (NIDA
Capsules, November 1994). Rockville, MD: Author.
National Institute on Drug Abuse. (1994c). NIDA press briefing, September 12, 1994.
Rockville, MD: Author.
National Institutes of Health. (1986). Clinical opportunities for smoking intervention: A guide
for the busy physician (Publication No. DHHS (NIH) 86-2178). Bethesda: National
Institutes of Health.
National Institutes of Health. (1989). How to help your patient stop smoking: A National
Cancer Institute manual for physicians (Publication No. DHHS (NIH) 89-3064).
Bethesda: National Institutes of Health.
National Institutes of Health. (1994). Tobacco and the clinician: Interventions for medical and
dental practice (Publication No. DHHS (NIH) 94-3693). Bethesda: Author.
Navon, M., Nelson, D., Pagano, M., & Murphy, M. (2001, June). Use of the pediatric
symptom checklist in strategies to improve preventive behavioral health care.
Psychiatric Services, 52(6), 800-804.
NCI. See National Cancer Institute.
NCQA. See National Committee for Quality Assurance.
New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental
Health Care in America. Final Report. (2003) DHHS Pub. No. SMA-03-3832.
Rockville, MD.
Newschaffer, C., Cocroft, J., Hauck, W., Fanning, T., & Turner, B. (1998, June). Improved
birth outcomes associated with enhanced Medicaid prenatal care in drug-using women
infected with the human immunodeficiency virus. Obstetrics and Gynecology, 91(6),
885-891.
NIAAA. See National Institute on Alcohol Abuse and Alcoholism.
NIDA. See National Institute on Drug Abuse.
NIH. See National Institutes of Health.
Okene, J., Kristeller, J., Goldberg, R., et al. (1991). Increasing the efficacy of physician-
delivered smoking interventions: A randomized clinical trial. Journal of General
Internal Medicine, 6, 1-8.
Olds, D. (1992, June). Home visitation for pregnant women and parents of young children.
American Journal of Diseases of Children, 146(6), 704-708.
Olds, D. (1994, January). Does prenatal and infancy nurse home visitation have enduring
effects on qualities of parental caregiving and child health at 25 to 50 months of life?
Pediatrics, 93(1), 89-98.
Olds, D., Eckenrode, J., Henderson, C., Kitzman, H., Powers, J., Cole, R., et al. (1997,
August 27). Long-term effects of home visitation on maternal life course and child
abuse and neglect: Fifteen-year follow-up of a randomized trial. Journal of the
American Medical Association, 278(8), 637-643.
Olds, D., Henderson, C., Jr, Chamberlin, R., & Tatelbaum, R. (1986, July). Preventing child
abuse and neglect: A randomized trial of nurse visitation. Pediatrics, 78(1), 65-78.
Olds, D., Henderson, C. J., Cole, R., Eckenrode, J., Kitzman, H., Luckey, D., et al. (1998,
October 14). Longer-term effects of nurse home visitation on children’s criminal and
antisocial behavior: 15-year follow-up of a randomized controlled trial. Journal of the
Olds, D., Henderson, C. J., Kitzman, H., & Cole, R. (1995, March). Effects of prenatal and infancy
nurse home visitation on surveillance of child maltreatment. Pediatrics, 95(3), 365-372.
132 Special Report

Olds, D., Henderson, C., Phelps, C., Kitzman, H., & Hanks, C. (1993). Effect of prenatal and
infancy nurse home visitation on government spending. Medical Care, 31(2), 155-174.
Olds, D., Henderson, C. J., & Tatelbaum, R. (1994, February). Prevention of intellectual
impairment in children of women who smoke cigarettes during pregnancy. Pediatrics,
93(2), 228-233.
Olds, D., Henderson, C. J., Tatelbaum, R., & Chamberlin, R. (1986, January). Improving the
delivery of prenatal care and outcomes of pregnancy: A randomized trial of nurse
home visitation. Pediatrics, 77(1), 16-28.
Olds, D., Henderson, C. J., Tatelbaum, R., & Chamberlin, R. (1988, November). Improving
the life-course development of socially disadvantaged mothers: A randomized
controlled trial of home visitation. American Journal of Public Health, 78(11), 1436-
1445.
Olfson, M., Marcus, S.C., Druss, B., Elinson, L., Tanielian, T., & Pincus, H.A. (2002, January
9). Trends in the outpatient treatment of depression. Journal of the American Medical
Association, 287(2), 203-209.
Olfson, M., Sing, M., & Schlesinger, H. (1999, March–April). Mental health/medical care cost
offsets: Opportunities for managed care. Health Affairs, 18(2), 79-90.
Orleans, C., Resch, N., Noll, E., et al. (1994). Use of transdermal nicotine in a state-level
prescription plan for the elderly: A first look at “real-world” patch users. Journal of
Oster, G., Huse, D., Delea, T., & Colditz, G. (1986, September 12). Cost-effectiveness of
nicotine gum as an adjunct to physicians’ advice against cigarette smoking. Journal of
the American Medical Association, 256(10), 1315.
Ostwald, S., Hepburn, K., Caron, W., Burns, T., & Mantell, R. (1999, June). Reducing
caregiver burden: A randomized psychoeducational intervention for caregivers of
persons with dementia. Gerontologist, 39(3), 299-309.
Panzarino, P. J. (1998). The costs of depression: Direct and indirect; treatment versus
nontreatment. Journal of Clinical Psychiatry, 59(Suppl 20), 11-14.
Parcel, G., Swank, P., Mariotto, M., Bartholomew, M., Czyzewski, D., Sockrider, M., et al.
(1994, May). Self-management of cystic fibrosis: A structural model for educational
and behavioral variables. Social Science and Medicine, 38(9), 1307-1315.
Pennix, B., Guralnik, J., Ferrucci, L., Simonsick, E., Deeg, D., & Wallace, R. (1998).
Depressive symptoms and physical decline in community-dwelling older persons.
Journal of the American Medical Association, 276, 1720-1726.
Perez, M., Feldman, L., & Caballero, F. (1999, January). Effects of a self-management
educational program for the control of childhood asthma. Patient Education and
Counseling, 36(1), 47-55.
Perper, J., & Van Thiel, D. (1992). Cardiovascular complications of cocaine abuse. Recent
Developments in Alcoholism, 10, 343-361.
Perry, A., Tarrier, N., Morriss, R., McCarthy, E., & Limb, K. (1999, January 16). Randomised
controlled trial of efficacy of teaching patients with bipolar disorder to identify early
symptoms of relapse and obtain treatment. British Medical Journal, 318(7177), 149-
153.
Pignone, M., Gaynes, B., Rushton, J., Burchell, C., Orleans, C., Mulrow, C., et al. (2002, May
21). Screening for depression in adults: A summary of the evidence for the U.S.
Preventive Services Task Force. Annals of Internal Medicine, 136(10), 765-776.
Podorefsky, D., McDonald-Dowdell, M., & Beardslee, W. (2001, August). Adaptation of
preventive interventions for a low-income, culturally diverse community. Journal of
the American Academy of Child and Adolescent Psychiatry, 40(8), 879-886.
Poikolainen, K. (1999, May). Effectiveness of brief interventions to reduce alcohol intake in
primary health care populations: A meta-analysis. Preventive Medicine, 28(5), 503-
509.
Pokorny, A., Miller, B., & Kaplan, H. (1972). The brief MAST: A shortened version of the
Michigan Alcoholism Screening Test. American Journal of Psychiatry, 129, 342-345.
Pouwer, F., & Snoek, F. (2001, July). Association between symptoms of depression and
glycaemic control may be unstable across gender. Diabetic Medicine, 18(7), 595-598.
PsychoEducation. (2003, March 22) (Introduction to Psychoeducation). Retrieved from
Psycho-Educational Counseling Services, Inc.:
http://www.psychoeducation.com/psychoeducation.htm
Ramey, C., Bryant, D., Wasik, B., Sparling, J., Fendt, K., & LaVange, L. (1992, March).
Infant health and development program for low birthweight, premature infants:
Program elements, family participation, and child intelligence. Pediatrics, 89(3), 454-
465.
Ramey, C., & Landesman R.S. (1992, December). Effective early intervention. Mental
Retardation, 30(6), 337-345.
Ramey, C., & Ramey, S. (1998, March–April). Prevention of intellectual disabilities: Early
interventions to improve cognitive development. Preventive Medicine, 27(2), 224-232.
Regier, D., Narrow, W., Rae, D., et al. (1993). The de facto U.S. Mental and Addictive
Disorders Service System: Epidemiologic catchment area prospective 1-year prevalence
rates of disorders and services. Archives of General Psychiatry, 50, 85-94.
Reinert, D., & Allen, J. (2002). The Alcohol Use Disorders Identification Test (AUDIT): A
review of recent research. Alcoholism: Clinical and Experimental Research, 26(2),
272-279.
Rice, D., & Miller, L. (1998). Health economics and cost implications of anxiety and other
mental disorders in the United States. British Journal of Psychiatry, 173(34), 4-9.
Richardson, G., Hamel, S., Goldschmidt, L., & Day, N. (1999, August). Growth of infants
prenatally exposed to cocaine/crack: Comparison of a prenatal care and no prenatal
care sample. Pediatrics, 104(2), e18.
Ridker, P., Vaughan, D., Stampfer, M., et al. (1994). Association of moderate alcohol
consumption and plasma concentration of endogenous tissue-type plasminogen
activator. Journal of the American Medical Association, 272, 929-933.
Ringsberg, K., Lepp, M., & Finnstrom, B. (2002, June). Experiences by patients with asthma-
like symptoms of a problem-based learning health education programme. Family
Practice, 19(3), 290-293.
Roberts, R. (1987). Epidemiologic issues in measuring preventive effects. In R. Munoz (Ed.),
Depression prevention: Research directions (pp. 45-68). New York, NY: Hemisphere.
134 Special Report

Robins, L., & Mills, J. (Eds.). (1993). Effects of in utero exposure to street drugs. American
Journal of Public Health, 83 (suppl), 1-32.
Robins, L., & Regier, D. (1991). Psychiatric disorders in America. New York: Free Press.
Robinson, J., Faris, P., & Scott, C. (1999, June 1). Psychoeducational group increases vaginal
dilation for younger women and reduces sexual fears for women of all ages with
gynecological carcinoma treated with radiotherapy. International Journal of
Radiation, Oncology, Biology, and Physics, 44(3), 497-506.
Rosenbaum, S., Kamoie, B., Mauery, D., & Walitt, B. (2003). Medical necessity in private
health plans: Implications for behavioral health care. (DHHS Pub. No. No. (SMA) 03-
3790). Rockville, MD: Department of Health and Human Services, Substance Abuse
and Mental Health Administration, Center for Mental Health Services.
Rosenberg, L., Metzger, L., & Palmer, J. (1993). Alcohol consumption and risk of breast
cancer: A review of the epidemiological evidence. Epidemiologic Reviews, 15, 133-
168.
Rosenstock, L. (1987). Routine urine testing for evidence of drug abuse in workers: The
scientific, ethical, and legal reasons not to do it. Journal of General Internal Medicine,
2, 135-137.
Rosett, H., Weiner, L., & Edelin, K. (1983). Treatment experience with pregnant problem
drinkers. Journal of the American Medical Association, 249, 2029-2033.
Roter, D., Hall, J., Merisca, R., Nordstrom, B., Cretin, D., & Svarstad, B. (1998).
Effectiveness of interventions to improve patient compliance: A meta-analysis. Medical
Care, 36(8), 1138-1161.
Rovner, B., Zisselman, P., & Shmuely, Y. (1996). Depression and disability in elderly persons
with impaired vision: A follow-up study. Journal of the American Geriatric Society,
44, 181-184.
Russell, M. (1991). Clinical implications of recent research on the fetal alcohol syndrome.
Bulletin of the NY Academy of Sciences, 67, 207-222.
Russell, M., Martier, S., Sokol, R., et al. (1991). Screening for pregnancy risk-drinking:
Tweaking the tests. Alcoholism: Clinical and Experimental Research, 15(2), 368.
Russell, M., Martier, S., Sokol, R., et al. (1994). Screening for pregnancy risk-drinking.
Alcoholism in Clinical and Experimental Research, 18, 1156-1161.
Russell, M., Wilson, C., Taylor, C., et al. (1979). Effect of general practioners’ advice against
smoking. British Medical Journal, 2, 231-235.
Sachs, D., Sawe, U., & Leischow, S. (1993). Effectiveness of a 16-hour transdermal nicotine
patch in a medical practice setting, without intensive group counseling. Archives of
SAMHSA. See Substance Abuse and Mental Health Services Administration.
Sanders, D., Fowler, G., Mant, D., et al. (1989). Randomized control trial of anti-smoking
advice by nurses in general practice. The Journal of the Royal College of General
Practitioners, 39, 273-276.
Sanger, M., MacLean, W. J., & Van Slyke, D. (1992, August). Relation between maternal
characteristics and child behavior ratings. Implications for interpreting behavior
checklists. Clinical Pediatrics (Philadelphia), 31(8), 461-466.
Saunders, J., Aasland, O., Babor, T., et al. (1993). Development of the alcohol use disorders
identification test (AUDIT): WHO collaborative project on early detection of persons
with harmful alcohol consumption, II. Addiction, 88, 791-804.
Saunders, W., & Kershaw, P. (1979). Spontaneous remission from alcoholism: A community
study. British Journal of Addiction, 74, 251-265.
Schade, C., Jones, E. J., & Wittlin, B. (1998, January). A ten-year review of the validity and
clinical utility of depression screening. Psychiatric Services, 49(1), 55-61.
Schermer, C., & Wisner, D. (1999). Methamphetamine use in trauma patients: A population-
based study. Journal of the American College of Surgeons, 189(5), 442-449.
Schinke, S., Brounstein, P., & Gardner, S. (2002). Science-based prevention programs and
principles (DHHS Pub. No. (SMA) 03-3764). Rockville, MD: Center for Substance
Abuse Prevention, Substance Abuse and Mental Health Services Administration
(SAMHSA’s National Clearinghouse for Alcohol and Drug Information 1-800-729-
6686 or 1-800-487-4889 (TDD)).
Schmidt, A., Barry, K., & Fleming, M. (1995). Detection of problem drinkers: The alcohol use
disorders identification test (AUDIT). Southern Medical Journal, 88, 52-59.
Schoenbaum, M., Unutzer, J., Sherbourne, C., Duan, N., Rubenstein, L., Miranda, J., et al.
(2001, September 19). Cost-effectiveness of practice initiated quality improvement for
depression: Results of a randomized controlled trial. Journal of the American Medical
Association, 286(11), 1325-1330.
Schoendorf, K., & Kiely, J. (1992). Relationship of sudden infant death syndrome to maternal
smoking during and after pregnancy. Pediatrics, 90, 905-908.
Schorling, J. (1993). The prevention of prenatal alcohol abuse: A critical analysis of
intervention studies. Journal of Studies on Alcohol, 54, 261-267.
Schriger, D., Gibbons, P., Langone, C., Lee, S., & Altshuler, L. (2001, February). Enabling the
diagnosis of occult psychiatric illness in the emergency department: A randomized,
controlled trial of the computerized, self-administered PRIME-MD diagnostic system.
Annals of Emergency Medicine, 37(2), 132-140.
Schulberg, H., Saul, M., McClelland, M., Ganguli, M., Christy, W., & Frank, R. (1985).
Assessing depression in primary medical and psychiatric practices. Archives of General
Psychiatry, 42, 1164-1170.
Schuler, M., Nair, P., Black, M., & Kettinger, L. (2000, September). Mother-infant interaction:
Effects of a home intervention and ongoing maternal drug use. Journal of Clinical
Child Psychology, 29(3), 424-431.
Schulman, M., Morel, M., Karmen, A., et al. (1993). Perinatal screening for drugs of abuse:
Reassessment of current practice in a high-risk area. American Journal of
Perinatology, 10, 374-377.
Schwartz, R. (1987). Marijuana: An overview. Pediatric Clinics of North America, 34, 305-
317.
Schwartz, R., & Wirtz, P. (1990). Potential substance abuse: Detection among adolescent
patients. Clinical Pediatrics, 29, 38-43.
Selzer, M. (1971). The Michigan Alcoholism Screening Test: The quest for a new diagnostic
instrument. American Journal of Psychiatry, 127, 1653-1658.
136 Special Report

Seppa, K., Lepisto, J., & Sillanaukee, P. (1998, November). Five-shot questionnaire on heavy
drinking. Alcoholism in Clinical and Experimental Research, 22(8), 1788-1799.
Serdula, M., Williamson, D., Kendrick, J., et al. (1991). Trends in alcohol consumption by
pregnant women: 1985 through 1988. Journal of the American Medical Association,
265, 876-879.
Sexto, M., & Hebel, J. (1984). A clinical trial of change in maternal smoking and its effects
on birth weight. Journal of the American Medical Association, 251, 911-915.
Sharp, C. (1992). Introduction to inhalent abuse. Inhalent abuse: A volatile research agenda
(National Institute on Drug Abuse Research Monograph 1992). National Institute on
Drug Abuse.
Sher, K. (Ed.). (1991). Children of alcoholics: A critical appraisal of theory and research.
Chicago: University of Chicago Press.
Silagy, C., Mant, D., Fowler, G., et al. (1994). Meta-analysis on efficacy of nicotine
replacement therapies on smoking cessation. The Lancet, 343, 139-142.
Simon, G., & Katzelnick, D. (1997). Depression, use of medical services and cost-offset
effects. Journal of Psychosomatic Research, 42(4), 333-343.
Simon, G., Manning, W., Katzlenick, D., Pearson, C., Henk, H., & Helstad, C. (2001,
February). Cost-effectiveness of systematic depression treatment for high utilizers of
general medical care. Archives of General Psychiatry, 58(2), 181-187.
Simon, G., Ormel, J., Von Korff, M., & Barlow, W. (1995, March). Health care costs
associated with depressive and anxiety disorders in primary care. American Journal of
Psychiatry, 152(3), 352-357.
Simon, G., & Unutzer, J. (1999, October). Health care utilization and costs among patients
treated for bipolar disorder in an insured population. Psychiatric Services, 50(10),
1303-1308.
Simon, G., Von Korff, M., & Barlow, W. (1995). Healthcare costs of primary care patients
with recognized depression. Archives of General Psychiatry, 52, 850-856.
Simon, G.E. (1992). Psychiatric disorder and functional somatic symptoms as predictors of
health care use. Psychiatric Medicine, 10(3), 49-59.
Skinner, H. (1982). The drug abuse screening test. Addictive Behaviors, 7, 363-371.
Sloan, L., Gay, J., & Snyder, S., et al. (1992). Substance abuse during pregnancy in a rural
population. Obstetrics and Gynecology, 79, 245-248.
Smart, R. (1975-1976). Spontaneous recovery in alcoholics: A review and analysis of the
available research. Drug and Alcohol Dependence, 1, 277.
Smith, G. (1994). The course of somatization and its effects on utilization of health care
resources. Psychosomatics, 35, 263-267.
Smith, G., Monson, R., & Ray, D. (1986). Patients with multiple unexplained symptoms:
Their characteristics, functional health, and health care utilization. Archives of
Smith, G., Rost, K., & Kashner, T. (1995, March). A trial of the effect of a standardized
psychiatric consultation on health outcomes and costs in somatizing patients. Archives
of General Psychiatry, 52, 238-243.
Sokol, R., Martier, S., & Ager, J. (1989). The T-ACE questions: Practical prenatal detection of
risk-drinking. American Journal of Obstetrics and Gynecology, 160, 863-870.
Sood, A. (1991). Cigarette smoking and cervical cancer: Meta-analysis and critical review of
recent studies. American Journal of Preventive Medicine, 7, 208-213.
Spiegel, D. (1995, July). Essentials of psychotherapeutic intervention for cancer patients.
Support Care Cancer, 3(4), 252-256.
Spiegel, D., Kraemer, H., Bloom, J., & Gottheil, E. (1989). Effect of psychosocial treatment
on survival of patients with metastatic breast cancer. The Lancet, pp. 1-8.
Spitzer, R., Williams, J., Kroenke, et al. (1994). Utility of a new procedure for diagnosing
mental disorders in primary care: The PRIME-MD 1000 study. Journal of the
American Medical Association, 272, 1749-1756.
Stampfer, M., Golditz, G., Willett, W., et al. (1988). A prospective study of moderate alcohol
consumption and the risk of coronary disease and stroke in women. New England
Journal of Medicine, 319, 267-273.
Stampfer, M., Rimm, E., & Walsh, D. (1993). Commentary: Alcohol, the heart, and public
policy. American Journal of Public Health, 83, 801-804.
Stapleton, J., Russell, M., Feyerabend, C., et al. (1995). Dose effects and predictors of
outcome in a randomized trial of transdermal nicotine patches in general practice.
Addiction, 90, 31-42.
Steinbauer, J., Canton, S., Holzer, C., & Volk, R. (1998). Ethnic and sex bias in primary care
screening tests for alcohol use disorders. Annals of Internal Medicine, 129(5), 353-362.
Stevens, V., & Hollis, J. (1989). Preventing smoking relapse, using an individually tailored
skills-training technique. Journal of Consulting and Clinical Psychology, 57, 420-424.
Stewart, W. F., Ricci, J. A., Chee, E., Hahn, S. R., & Morganstein, D. (2003, June 18). Cost of
lost productive time among U.S. workers with depression. Journal of the American
Stinson, F., Nephew, T., Dufour, M., & Grant, B. (1996). State trends in alcohol-related
mortality, 1979-92. In NIAAA (Ed.), U.S. Alcohol Epidemiologic Data Reference
Manual, Vol 5, 1st Ed. Bethesda, MD: NIAAA.
Storch, D. (1996, March). Do antidepressants promote tumor growth? American Journal of
Psychiatry, 153(3), 446.
Streissguth, A., Barr, H., & Sampson, P. (1990). Moderate prenatal alcohol exposure: Effects
on child IQ and learning problems at age 7.5 years. Alcoholism in Clinical and
Experimental Research, 14, 662-669.
Substance Abuse and Mental Health Services Administration. (1994). National household
survey on drug abuse: Population estimates 1993. Publication No. SMA 94-3017.
Rockville, MD: U.S. Department of Health and Human Services.
Substance Abuse and Mental Health Services Administration. (2002). Results from the 2002
national survey on drug use and health: National findings. Office of Applied Studies,
NHSDA Series H-22, DHHS Publication No. SMA 03-3836. Rockville, MD.
Sullivan, M., Katon, W., Russo, J., et al. (1993). A randomized trial of nortriptyline for severe
chronic tinnitis. Effects on depression disability and tinnitis symptoms. Archives of
138 Special Report

Sullivan, M., LaCroix, A., Grothasu, L., et al. (1997). Functional status in coronary artery
disease: A one-year prospective study of the role of anxiety and depression. American
Surgeon General. (1981). U.S. Surgeon General’s advisory on alcohol and pregnancy. FDA
Drug Bulletin, 11, 9-10.
Svikis, D., Golden, A., Huggins, G., Pickens, R., McCaul, M., Velez, M., et al. (1997, April
14). Cost-effectiveness of treatment for drug-abusing pregnant women. Drug and
Alcohol Dependence, 45(1-2), 105-113.
Swartz, M., Landerman, R., George, L., et al. (1991). Somatization disorder. In L. Robins and
D. Regier (Eds.), Psychiatric disorders in America (pp. 220-257). New York: Free
Press.
Taj, N., Devera-Sales, A., & Vinson, D. (1998, April). Screening for problem drinking: Does a
single question work? Journal of Family Practice, 46(4), 328-335.
Tang, L., Law, M., & Wald, N. (1994). How effective is nicotine replacement therapy in
helping people to stop smoking? British Medical Journal, 308, 21-26.
Task Force on Community Preventive Services. (2003). First reports evaluating the
effectiveness of strategies for preventing violence: Early childhood home visitation
(U.S. DHHS Pub. No. 52(RR14)). Atlanta: Centers for Disease Control and
Prevention.
TFCPS. See Task Force on Community Preventive Services.
Thomas, E., & Weiss, S. (2000, March–April). Nonpharmacological interventions with
chronic cancer pain in adults. Cancer Control, 7(2), 157-164.
Thurstin, A., Alfano, A., & Sherer, M. (1986). Pretreatment MMPI profiles of A.A. members
and nonmembers. Journal of Studies on Alcohol, 47, 468-471.
Tierney, L. J., McPhee, S., & Papadakis, M. (2003). Current medical diagnosis and treatment
2003. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division.
Tonnesen, P., Fryd, V., Hansen, M., et al. (1988). Effect of nicotine chewing gum in
combination with group counseling on the cessation of smoking. New England
Tonnesen, P., Norregaard, J., Simonsen, K., et al. (1991). A double-blind trial of a 16-hour
transdermal nicotine patch in smoking cessation. New England Journal of Medicine,
325, 311-315.
Trachtenberg, A., & Fleming, M. (1994). Diagnosis and treatment of drug abuse in family
practice (American Family Physician monograph, Summer 1994). Kansas City, MO:
American Academy of Family Physicians.
Transdermal Nicotine Study Group. (1991). Transdermal nicotine for smoking cessation: Six-
months results from two multi-center controlled clinical trials. Journal of the
American Medical Association, 266, 3133-3138.
Tremper, R. (2003, May). HIPAA Local Codes Status Report, internal document prepared
under contract for Center for Mental Health Services.
Tutty, S., Simon, G., & Ludman, E. (2000, July-August). Telephone counseling as an adjunct
to antidepressive treatment in the primary care system. Effective Clinical Practice,
3(4), 170-178.
Unutzer, J., Patrick, D.L., Simon, G., Grembowski, D., Walker, E., Rutter, C., & Katon, W.
(1997). Depressive symptoms and the cost of health services in HMO patients aged 65
years and older: A 4-year prospective study. Journal of the American Medical
Association, 277(20):1618-23.
US DHHS. See U.S. Department of Health and Human Services.
U.S. Department of Health and Human Services. (1986). The health consequences of
smokeless tobacco: A report of the advisory committee to the Surgeon General
(Publication no. DHHS (PHS) 86-2874). Washington, DC: National Institutes of
Health.
U.S. Department of Health and Human Services. (1988). The health consequences of smoking:
Nicotine addiction. A report of the Surgeon General. (Publication No. DHHS (CDC)
88-8406). Rockville, MD: Author.
U.S. Department of Health and Human Services. (1989). Reducing the health consequences of
smoking: 25 years of progress. A report of the Surgeon General (Publication No.
DHHS (CDC) 89-8411). Rockville, MD: Author.
U.S. Department of Health and Human Services. (1994). Preventing tobacco use among
young people: A report of the Surgeon General (Publication No. S/N 017-001-00491-
0). Washington, DC: Government Printing Office.
U.S. Department of Health and Human Services. (1999). Mental health: A report of the
Surgeon General. Rockville, MD: Center for Mental Health Services, Substance
Abuse and Mental Health Services Administration, National Institutes of Health, and
National Institute of Mental Health.
U.S. Department of Health and Human Services. (2000). Healthy people 2010, conference
edition. Washington DC: U.S. Department of Health and Human Services. Available at
http://www.healthypeople2010.gov
U.S. Department of Health and Human Services. (2001). Mental health: Culture, race and
ethnicity: A supplement to mental health. A report of the surgeon general.
Washington, DC: Author.
U.S. Department of Health and Human Services. (2003). Steps to a healthier U.S. Washington,
DC: Office of Disease Prevention and Health Promotion. Available at
http://www.healthierus.gov/steps/steps_brochure.html
U.S. Environmental Protection Agency. (1992). Respiratory health effects of passive smoking:
Lung cancer and other disorders (Publication No. EPA/600/6-90/006F). Washington,
DC: Environmental Protection Agency, Office of Health and Environmental
Assessment, Office of Research and Development.
U.S. Preventive Services Task Force. (1996). Guide to clinical preventive services (2nd ed.).
Alexandria, Virginia: International Medical Publishing, Inc.
U.S. Preventive Services Task Force. (2002). Guide to clinical preventive services (3rd
ed.)(AHRQ Publication No. 02-500.) Available from Agency for Healthcare Research
and Quality, Rockville, MD, and online at http://www.preventiveservices.ahrq.gov/
U.S. Preventive Services Task Force. (2002, May 21). Screening for depression:
Recommendations and rationale. Annals of Internal Medicine, 136(10), 760-764.
140 Special Report

U.S. Preventive Services Task Force. (2003). Guide to clinical preventive services (3rd ed.,).
Periodic Updates (AHRQ Publication No. 03-0007). Retrieved October 23, 2003,
from http://www.ahrq.gov/clinic/periodorder.htm
USPSTF. See U.S. Preventive Services Task Force.
Vega, W., Kolodny, B., Hwang, J., & Noble, A. (1993). Prevalence and magnitude of perinatal
substance exposures in California. New England Journal of Medicine, 329, 850-854.
Verkerk, P., Noord-Zaadstra, B., Florey, C., et al. (1993). The effect of moderate maternal
alcohol consumption on birth weight and gestational age in a low risk population.
Early Human Development, 32, 121-129.
Vickery, D., Kalmer, H., Lowry, D., Constatine, M., Wright, E., & Loren, W. (1983,
December 2). Effect of a self-care education program on medical visits. Journal of the
Virji, S. (1991). The relationship between alcohol consumption during pregnancy and infant
birthweight: An epidemiologic study. Acta Obstetricia et Gynecologica Scandinavica,
pp. 303-308.
Volk, R., Steinbauer, J., Cantor, S., & Holtzer, C. (1997). The alcohol use disorders
identification test (AUDIT) as a screen for at-risk drinking in primary care patients of
different racial/ethnic backgrounds. Addiction, 92(2), 197-206.
Volpe, J. (1992). Effect of cocaine use on the fetus. New England Journal of Medicine, 327,
399-407.
Von Korff, M., Moore, J., Lorig, K., Cherkin, D., Saunders, K., Gonzales, V., et al. (1998,
December 1). A randomized trial of lay person-led self-management group
intervention for back pain patients in primary care. Spine, 23(23), 2608-2615.
Walker, E., Gelfand, M., Gelfand, A., et al. (1996). The relationship of current psychiatric
disorder to functional disability and distress in patients with inflammatory bowel
disorders. General Hospital Psychiatry, 18, 220-229.
Walker, W. J., LaGrone, R., & Atkinson, A. (1989, June). Psychosocial screening in pediatric
practice: Identifying high-risk children. Journal of Developmental and Behavioral
Pediatrics, 10(3), 134-138.
Wamboldt, M., Yancey, A. J., & Roesler, T. (1997, Spring). Cardiovascular effects of tricyclic
antidepressants in childhood asthma: A case series and review. Child and Adolescent
Psychopharmacology, 7(1), 45-64.
Warner, E. (1993). Cocaine abuse. Annals of Internal Medicine, 119, 226-235.
Waterson, E., & Murray-Lyon, I. (1990). Preventing fetal alcohol effects: A trial of three methods
of giving information in the antenatal clinic. Health Education Research, 5, 53-61.
Waxman, H., McCreary, G., Weinrit, R., & Carner, E. (1985). A comparison of somatic
complaints among depressed and nondepressed older persons. Gerontologist, 25, 501-507.
Wechsler, H., Davenport, A., Dowdall, G., et al. (1994). Health and behavioral consequences
of binge drinking in college: A national survey of students at 140 campuses. Journal of
Weisner, C., & Matzger, H. (2003, July). Missed opportunities in addressing drinking
behavior in medical and mental health services. Alcoholism: Clinical, and
Experimental Research, 27(8), 1132-1142.
Weissman, M. (1987). Advances in psychiatric epidemiology: Rates and risks for depression.
American Journal of Public Health, 77, 445-451.
Weissman, M., Fendrich, M., Warner, V., & Wickramaratne, P. (1992). Incidence of
psychiatric disorder in offspring at high and low risk for depression. Journal of the
American Academy of Child and Adolescent Psychiatry, 31, 640-648.
Wells, K., Hayes, R., Burnam, M., Rogers, W., Greenfield, S., & Ware, J. (1989). Detection of
depressive disorder for patients receiving prepaid or fee-for-service care: Results of the
Medical Outcomes Study. Journal of the American Medical Association, 262, 3298-
3302.
Wells, K., Sherbourne, C., Schoenbaum, M., Duan, N., Meredith, L., Unutzer, J., et al. (2000,
January 12). Impact of disseminating quality improvement programs for depression in
managed primary care: A randomized controlled trial. Journal of the American
Wells, K., Stewart, A., Hayes, R., 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. See World Health Organization.
Williams, R., & Strasser, P. (1999, November). Depression in the work place. Impact on
employees. American Association of Occupational Health Nurses Journal, 47(11),
526-537.
Williams, R., & Vinson, D. (2001, April). Validation of a single screening question for
problem drinking. Journal of Family Practice, 50(4), 307-312.
Wilson, D., Taylor, D., Gilbert, J., et al. (1988). A randomized trial of family physician
intervention for smoking cessation. Journal of the American Medical Association, 260,
1570-1574.
Windsor, R., Lowe, J., Perkins, L., et al. (1993). Health education for pregnant smokers: Its
behavioral impact and cost benefit. American Journal of Public Health, 83, 201-206.
Windsor, R., Warner, K., & Cutter, G. (1988, January–February). A cost-effectiveness analysis
of self-help smoking cessation methods for pregnant women. Public Health Reports,
103(1), 83-88.
Winkler, R., Underwood, P, Fatovich, B., James, R., & Gray, D. (1989). A clinical trial of self-
care approach to the management of chronic headache in general practice. Social
Science and Medicine, 29(2), 213-219.
Woodward, A., Epstein, J., Gfroerer, J., Melnick, D., Thoreson, R., & Willson, D. (1997). The
drug abuse treatment gap: Recent estimates. Health Care Finance Review, 18(3), 5-17.
World Health Organization. (1992). International classification of diseases, 10th revision.
Geneva: Author.
World Health Organization Brief Intervention Study Group. (1996, July). A cross national
trial of brief interventions with heavy drinkers. American Journal of Public Health,
86(7), 948-955.
Yohannes, A., Connolly, M., & Baldwin, R. (2001, May). A feasibility study of antidepressant
drug therapy in depressed elderly patients with chronic obstructive pulmonary disease.
International Journal of Geriatric Psychiatry, 16(5), 451-454.
142 Special Report

Ziegelstein, R. (2001, July 3). Depression in patients recovering from a myocardial infarction.
Journal of the American Medical Association, 286(13), 1621-1627.
Zuckerman, B., Frank, D., Hingson, R., et al. (1989). Effects of maternal marijuana and
cocaine use on fetal growth. New England Journal of Medicine, 320, 762-768.
Zung, W., Magill, M., Moore, J., & George, D. (1983). Recognition and treatment of
depression in a family medicine practice. Journal of Clinical Psychiatry, 44, 3-6.
144 Special Report
XIII. Appendix A:
Literature Search
Methods and Results
T
his Appendix supplements the information presented in the Methods
section of this monograph. Details of the advanced searches conducted
and their results, key words or search terms and methods used, and
notes on selected search findings are presented here. In addition to the
PubMed literature review for publications from 1964 through 2002, selected
additional references were included in this report, as published between July
20, 2002, and October 27, 2003.
Keywords for Searches in PubMed 8. Case management AND mental disorders

for 1998–2002 9. Psychoeducational (any reference where
The primary database used was PubMed. The this term was used in title, abstract, or
following advanced searches were conducted: text; there is no MeSH term on this topic)
1. Preventive health services OR preventive The literature search initially focused on

medicine OR preventive psychiatry OR the identification of pertinent and well-
primary prevention AND mental conducted randomized controlled trials
disorders NOT specific topics listed in (RCTs). This was done to conduct the initial
items 2–9 below evaluation of interventions that deserve
2. Mass screening and mental disorders consideration for widespread implementation
NOT in topics 3–9 below by health care systems. The search included
3. Health education OR health promotion the RCTs, literature reviews, and meta-
OR patient education AND mental analyses integrating data from multiple
disorders NOT topics 2, or 4–9 trials. Once this search was accomplished,
4. Home care services or home nursing additional literature on the selected topics
AND mental disorders was explored.
5. Self-care and mental disorders (Note:
there was no way to separately search on Table 5: Searches From 1964 To 2002 to Collect
health risk appraisal in PubMed.) “Negative Studies” and More Recent Studies,
6. Prenatal care OR perinatal care AND Relative to the Interventions Recommended in
mental disorders the SAMHSA 2000 Report
7. Disease management AND managed care These searches were conducted using an
AND mental disorders alternative PubMed search technique; that is,
Table 3: Tabular Summary of Initial PubMed Search for 1998–2002
Selected to Pertinent
Initial Abstracts
Topic Pull Total RCTs*
Download Pulled RCTs
1
Abstracts
Preventive
1 Health 258 41 10 0 0
2
Services
Mass
2 3
1,041 132 77 3 0
Screening
Health
3 4
240 37 10 1 1
Education
Home Care
4 314 36 20 5 3
Services
5 Self-Care 426 105 17 6 5
Prenatal/Peri-
6 139 56 26 4 4
natal Care
Disease
7 482 99 68 15 14
Management
Case
8 373 154 59 22 2
Management
Psychoeduca-
9 163 80 54 20 20
tional
TOTALS 3,436 740 341 76 49
1. RCT = Randomized Controlled Trial

2. Excluding topics 2–9
4. Excluding topic 2, and topics 4–9; limited to MeSH terms rather than all fields
Note: Since the search terms used for this initial search captured all the studies included relative to the six SAMHSA 2000 monograph topics, the num-
bers of abstracts and RCTs presented in this table, and the table immediately following, reflect only those not included in the SAMHSA 2000 search.
146 Special Report

Table 4: Notes on Randomized Controlled Trials in Advanced Searches
Topic Randomized 1
Randomized Controlled Trials Considered Pertinent
Controlled Trials
Rejected as Not
Pertinent
1 Preventive Health (No RCTs) The lack of RCTs appeared to be an artifact of the literature
2 search procedure.
Services
2 3 Two were (None) It is important to note that the USPSTF guidelines on

Mass Screening
misclassified— they screening for depression are based on non-RCT studies of the
were not RCTs. The screening procedures plus RCT studies of the efficacy of
third was too poorly treatment of depression in persons detected by the screening
conducted to be of procedures.
practical value
(Schriger et al.,
2001)
3 4 (None rejected) Perry et al., 1999 (Perry, Tarrier, Morriss, McCarthy, & Limb,
Health Education
1999)—successful RCT on educational program for patients
with bipolar disease to reduce the frequency of manic relapse
4 Home Care Two were purely Two studies—Armstrong, Fraser, Dadds, & Morris, 1999, and
Services therapeutic, with no Lagerberg, 2000—were preventive interventions to families
preventive content with children considered at high risk because of social
deprivation or “environmental factors.” Both showed positive
results. Largerberg was a literature review.
The third study—Gitlin, Corcoran, Winter, Boyce, & Hauck,
2001—was outreach to caregivers of patients with dementia,
also showing positive results.
5 Self-Care One study (Pouwer Three were meta-analyses or literature reviews—one each
& Snoek, 2001) dealing with “adult problem behaviors,” dementia, and
dealt with diabetes, depression. The two RCTs addressed “chronically mentally ill
depression, and outpatients” and anxiety attacks.
gender and appeared
to be severely All five are considered worthy of a closer look. The one on
flawed dementia is included to see if the intervention is for the
patient or the caregiver.

(table continues...)
Table 4 (continued): Notes on Randomized Controlled Trials in Advanced
Searches
6 Prenatal/Perinatal (None Rejected) Two RCTs dealt with depression, and one each with alcohol and
Care drugs.
7 Disease (None Rejected) Nine of the 15 dealt with the cost-effectiveness of various
Management approaches to treatment of depression. While therapeutic
instead of preventive, these relate to the guideline to screen
for depression.
Of the other six, three dealt with alcohol, and one each with
tobacco and depression.
8 Case Management 20 of the 22 were Of the two pertinent studies, one (Azrin & Teichner, 1998)
purely therapeutic, was an instructional program to improve medication
with no preventive compliance for “chronically mentally ill” outpatients and the
components other (Buckwalter et al., 1999) dealt with a nursing
intervention to decrease depression in caregivers of persons
with dementia.
9 Psychoeducational (None Rejected) Most

All 20ofstudies
the 20instudies in this
this group aregroup are therapeutic and
therapeutic.
lessen the progression of an illness or improve self-efficacy
by the 20,
Of the patient.
three have been pulled as “anchor” studies for Task
Three have been pulled as “anchor” studies:
3 interventions:
- Misri et al., 2000 (Misri, Kostaras, Fox, & Kostaras, 2000)

deals with partner support in the treatment of postpartum
depression.
- Von Korff et al., 1998 is a study of the treatment of

depression
- Ostwald et al., 1999 (Ostwald, Hepburn, Caron, Burns, &

Mantell, 1999) is an intervention for caregivers of patients
with dementia

148 Special Report

Table 5: Searches From 1964 To 2002 To Collect Negative Studies
Papers Controlled
Utilized as Total Trials and
Topic Comment
basis for References Meta-
Searches Analyses
D1 Prenatal and
Perinatal
Home Visits Olds 141 25
67 unduplicated abstracts (duplicates
eliminated in Ramey and Field counts)
Ramey 107 17
Field 115 25
D2 Tobacco
Marks 118 26
Cessation
D3 Short-Term This category was deleted as a discrete category from this 2004 update, with the
MH Therapy various interventions distributed to other categories not represented in the 2000
report.
D4 HRA/Self-
Care/Self Help
102 unduplicated abstracts. The
Kemper 251 54 Vickery 48 exclude papers listed in
Kemper search. One study by S.
Moore (1980) showed no
significant effects.
Vickery 109 48
D5 Presurgical
Education
Devine 107 4 The Mumford 12 exclude papers listed
in Devine Search.
Mumford 109 12
D6 Brief This is a high volume of studies, with
Education and the duration/length of the
Counseling To Estimated– intervention and number of
Fleming 172
Reduce 120 interventions per client highly variable
Alcohol Use and not well described in many
papers.
TOTALS 1132 340
Table 6: Preliminary Analysis of SAMHSA 2000 Monograph Search for
Negative Studies
Topic Pertinent Trials and Comment

Meta-Analyses
(unduplicated)
D1 Prenatal and 67 Of the 67 unduplicated clinical trials and meta-analyses in

Perinatal this group of papers, 34 showed positive results, one
Home Visits negative results, and 32 were considered non-pertinent to
this preliminary analysis—most because they were not
home care or were not prenatal/perinatal visits.
Of the 34 positive papers, Olds and/or Kitzman and Ramey

authored 12. As a result, the number of actual clinical trials
is less than the number of papers.
In almost every instance, it seemed clear that the home
care was part of a more comprehensive package of health
and medical services—suggesting that simply adding a
home care element to a straight clinical service is unlikely to
be effective.
Most of the studies could be classified along three general
lines:
1. General risk (economically and socially vulnerable

groups)
2. Drug/alcohol/tobacco users
3. Children of mentally retarded mothers
4. (A few of the studies dealt with infants with specific

disorders or risk profiles)
The benefits were mainly long-term social, psychological,
and behavioral, rather than health care utilization. The
babies were healthier and needed less long-term care.
These studies were generally very well designed and
showed strong positive benefits. The benefits, however,
related to social dependency and issues other than offset
of health care costs. While of obvious interest to health
care systems serving Medicaid populations and health care
providers serving economically vulnerable populations,
these studies will be of relatively little interest to health
care systems serving more well-to-do clientele.
D2 Tobacco 26 Of the 26 papers in this set, nine showed positive results,
Cessation seven showed negative results, four were reviews, and six
were not pertinent. The problem is one of getting an
intervention that is intense enough to be effective—but not
too costly—and then finding some way to extend the
benefits beyond the end of the pregnancy.
(table continues...)
150 Special Report

Table 6 (continued): Preliminary Analysis of SAMHSA 2000 Monograph
Search for Negative Studies
D3 Short-Term This category was deleted as a discrete category from this 2004 update, with
MH Therapy the various interventions distributed to other categories not represented in the
2000 report.
D4 Self-Care/Self- ~100 More than 100 unduplicated papers are included in this
Help self-help/self-care management data set; one negative
study (randomized by family) by Moore (1980); and at
least six positive studies, of which five used randomization.
Most deal with education and training to help patients and
family members do a better job of managing a medical
chronic disease. The literature on managing chronic mental
disorders is an entirely separate body of literature, with
remarkably little overlap. Yet a third body of literature
relates to the management of mental disorders as an aid
to management of chronic medical conditions. This topic
was merged into “Psychoeducation.”
D5 Presurgical ~16 Scanning the literature for relevant studies developed two
Education nonrandomized clinical trials, one RCT, and two
meta-analyses that were most relevant. Five were very
positive. The large number of publications in this arena
represents other and weaker study designs. This area has
potential within the area of psychoeducation and the
“activated” patient literature.
D6 Brief ~120 Overall, two studies showed no effect of the intervention,

Education while four were positive with strong results. This large
and data set includes a single meta-analysis (Poikolainen,
Counseling To 1999). This study concludes “for very brief interventions
Reduce the change in alcohol consumption (6–12 month
Alcohol Use follow-up) was not significant among men or women.” For
“extended brief interventions the reduction was
statistically significant, but too small to be of clinical
importance.” Most of the studies appeared to be more
intensive.
Table 7: Topics from SAMHSA 2000 Monograph Reflected in This
Monograph (SAMHSA 2004)
2000 Topic Heading 2004 Topic Heading

D1 Prenatal and Perinatal Home Visits High-Risk Pregnant Women and Children to Age 5
D2 Tobacco Cessation Screening: Tobacco; Pregnant Women, Adolescents, and Adults
D3 Short-Term MH Therapy Psychoeducation for Patients with Chronic Diseases
D4 HRA/Self-Care/Self-Help Psychoeducation for Patients with Chronic Diseases
D5 Presurgical Education Psychoeducation for Patients Scheduled for Surgical Procedures

Brief Education and Counseling To Screening: Alcohol; Pregnant Women, Adolescents, and Adults
D6
Reduce Alcohol Use
listing the key studies used by Dorfman in dyads, birth to 5 years of age
the SAMHSA 2000 report, and then ■ Children 5–11 years of age
searching what Pub Med lists as “Related ■ Adolescents 12–18 years of age
Articles.” While initially envisioned as a ■ Adults 19 years of age and older
search from 1964 through 1999, the search (including seniors)
was expanded through 2002 to eliminate the
need for yet additional search exercises. The This approach compresses what otherwise
searches are listed here according to the six would have been six or seven age groupings
categories recommended in the SAMHSA into five because the literature analysis
2000 report, and the results are summarized showed that implementation guidelines were
below: similar enough to warrant such compression.
New topics added as a result of the broader Pregnant women appear in two of the five
literature review include screening of groupings because of a discrete body of
children and adolescents for evidence of literature on the provision of preventive
behavioral disorder, screenings for illicit drug home visitation services to socially and
use, screening of adolescents for depression, economically vulnerable pregnant women,
and psychoeducation for persons with infants, and preschool children.
somatization. The adult population, previously divided
into three age ranges (19–44 years; 45–64
Life Cycle Convention Used in This Report years, and 65 years and older), was
After reviewing the literature and trying compressed into a single group after it
several alternative approaches, the following became clear that the processes for screening,
life cycle classification was used in this intervention, and follow-up basically were
report: the same across all these age groups.
Although there are vast differences in risk
■ Pregnant women profiles of children and adolescents, as they
■ Pregnant women and mother-child progress year by year from 5 to 18 years of
152 Special Report

age, the entire population in this lifestyle ■ Possible interventions
group tends to be neglected by the health ■ Review of literature: efficacy-evidence
care delivery system because of the group’s base for the guideline, including
resiliency, generally good physical and assessment of need, proof of efficacy,
mental health, and the ambiguity (which positive and negative studies, and studies
increases year by year into midadolescence) addressing program implementation
as to whether they or their parents are issues
responsible for addressing risk-related and ■ Review of literature: effectiveness;
behavioral issues. program implementation issues; how to
manage the intervention so that it
Format for Presentation of Guidelines succeeds in securing the desired benefits
A common format is used for presentation of ■ Data to be tracked for surveillance,
all basic interventions as follows: member selection, feasibility assessment,
and program evaluation
■ Introduction and conclusions
154 Special Report
XIV. Appendix
Policy and
B:
Management Issues
and Guidelines
T
his appendix is intended as a primer for health care administrators,
policymakers and fiscal officers—to set the stage for successful
implementation of preventive behavioral-related services in health care
delivery settings.
Additional guidance on policy and ■ Employee productivity

management issues can be found in ■ Cost containment
Appendix D, Implementation and Evaluation ■ Image/reputation of health plan
of Preventive Services. Appendix C provides
guidelines for billing for preventive services. Need
The following issues are addressed here: ■ Incidence and period prevalence
■ Case identification
Translation of Research Into Practice ■ Severity of illness
■ Deciding on benefit packages ■ Severity of risk
■ Interpreting the medical literature
■ Projecting benefits and desired Efficacy
consequences ■ Projection and modeling
■ Effectiveness and cost-efficiency
Unintended Benefits and Adverse
Consequences Infrastructure
■ Pareto’s Law (the “80/20” rule) ■ Surveillance and data systems
■ Perceptions and biases often shared by ■ Screening policies and procedures
administrators and physicians ■ Follow-up protocols
■ Time intervals from cost to benefit ■ Counseling
■ Build versus buy options—disease and ■ Psychoeducation
demand management ■ Health education (individual, group, and
Web site)
Benefits of Preventive Services ■ Case management
■ Member health status and quality of life ■ Call centers
■ Quality of care ■ Home visitation
Translating Research Into Practice For most preventive behavioral services,
Translating preventive behavioral research there is little question as to the fiscal
into health care practice is a complex matter. responsibility of health care plans and
There are several questions to be addressed managed care organizations. However, some
at policy, management, and clinical levels as of the services discussed, which clearly are
well as perceptions to be addressed— social or educational in nature, are intended
perceptions that historically have limited to secure social and educational nonmedical
patient access to behavioral services within benefits. Included are some of the services
health care delivery systems. The major suggested for economically and socially
questions can be summarized as follows: disadvantaged women and their families.
Although the value of these services is firmly
■ What preventive behavioral services established, the question remains as to who
should be considered for inclusion in should pick up the cost. The answers to
benefit packages and why? these questions will vary by health plan,
■ How does a health care plan control the depending on the public versus private
utilization of preventive behavioral orientation and the needs of membership.
services?
■ How does a health care plan determine Interpreting the Medical Literature
the need for preventive behavioral Randomized controlled trials present the
services? strongest evidence for or against a suggested
■ How does a health care plan measure the intervention, but the process of selecting
impact of preventive behavioral services both cases and controls almost always
on health care costs? creates a situation in which the cases and
■ How does a health care plan manage controls differ in substantial ways from the
preventive behavioral services to assure enrollment of any given health care system.
quality, cost-efficiency, and effectiveness? Cohort and cross-sectional studies usually
have more typical patient and control
Deciding on Services and Benefit Packages populations, but they are weaker study
Health care plans and managed care designs.
organizations are mandated to provide When conducting a randomized controlled
mental health coverage by State and Federal trial, the research team must carefully select
authorities and to meet the National both cases and controls to assure that the
Committee for Quality Assurance’s Health differences between these groups after the
Plan Employer Data and Information Set intervention can be reasonably attributed to
(HEDIS) guidelines. Even if this were not the the intervention. Health care plans wishing
case, the impact of such preventive services to implement services based on the research
on other health care expenditures for can consider the degree to which findings in
selected preventive behavioral services make each paper might or might not apply to their
investment in such services a wise choice for provider panel and membership. One major
health care plans and managed care difference is the willingness of the patient to
organizations. Systems must be in place, comply fully with prescribed regimens of
however, to assure the quality and care. Research subjects are selected for
appropriate utilization of such services. nearly 100 percent cooperation. Patients in
156 Special Report

conventional health care settings are far less to be structured as small-scale, separate,
compliant. Even with very careful selection stand-alone data systems.
of cases and controls, however, even the “Effectiveness” denotes whether a specified
research studies still must address attrition intervention will work under the conditions
and noncompliance. of a randomized controlled trial. “Efficacy”
To further complicate matters, real-life denotes whether this same intervention will
patients are likely to deny behavioral work under conditions of routine health care
problems such as smoking, drinking, delivery (Daumit et al., 2001). Depending on
substance use disorder, and depression, and how it is managed, a theoretically effective
primary care practitioners in conventional intervention might not be efficacious within
health care settings are not likely to address a given health care delivery system. The
these issues because of lack of comfort, challenge for both health plan administrators
desire not to weaken the patient/practitioner and clinicians is how best to manage
relationship, and lack of time. implementation of the intervention to secure
Another problem is that enrollees might the desired efficacy.
not be similar in demographics, cultural, or Finally, ethical considerations sometimes
clinical profile to the subjects used in the make randomization and/or control
research. Environmental factors also are impossible to implement in research and
important, with many patients and health health care delivery settings. The best
care systems facing economic and example within the scope of this report is
administrative barriers that inhibit provider- identifying the cause of poor pregnancy
patient communication (especially between outcomes among pregnant women using
clinic visits) and the high cost of some illicit drugs (such as marijuana, cocaine, and
prescription medications. heroin). The problem is that one cannot tell
Research studies present their results as if a the degree to which the low birthweight and
cohort of cases and controls begin the other “non-specific” poor pregnancy
intervention at the same time and are outcomes are due to the drug or due to the
followed for the duration of the study, which mother’s lack of prenatal care, poor
then comes to an end. Health plan nutrition, etc. Since it would not be ethical
implementation must take place in the real to treat the substance use disorder without
world, where members are at all stages of providing prenatal care, or provide prenatal
illness at all times; where enrollment and care while ignoring the substance use
processing must take place at all points in disorder, randomized controlled studies to
time; where concurrent comparable controls differentiate the impact of prenatal care from
are not feasible; and where the intervention the impact of substance use disorder
is anticipated to extend into the indefinite counseling never will be done. This being the
future. This severely complicates projections case, health care systems and individual
of costs and benefits, especially after the physicians must establish some health
initial year of intervention. This set of policies and procedures without the benefit
complications requires establishment of of randomized controlled trials.
tracking mechanisms that are not traditional
in managed care plans—tracking Projecting Benefits and Desired Consequences
mechanisms that at least initially may have The researchers who generate the published
literature generally avoid fiscal and the impression that the program has lost its
management issues. The complexity of health effectiveness and thus lead to elimination of
care finance, pricing, and billing the preventive service. The literature
methodology, bundling and capitation, bad indicates that preventing such premature
debt and cash flow issues, and annual program demise is best done by establishing
changes in health plan enrollments all baselines, benchmarks, and year-to-year
complicate attempts to link provision of projections prior to initiating the preventive
preventive services with their impact on other programming, then tracking the
health care expenditures. Although programming against these projections.
researchers can and often do document Precautions such as these are rarely taken
changes in health care utilization in response when new preventive services are initiated.
to effective delivery of preventive services, Failure to establish these baselines and
taking the next step and relating these benchmarks can lead to premature
changes to health plan expenditures usually is elimination of the preventive services when
beyond the scope of their research protocols. additional year-to-year reductions in health
These fiscal and administrative issues are care costs cease to occur.
the issues of greatest importance to health
care administrators and fiscal officers. From Unintended Benefits and Unanticipated
their perspective, morbidity and health care Adverse Consequences
utilization are but two of many factors Prevention programming can have
affecting the cost of health care delivery. To unintended benefits and unanticipated
further complicate matters, fiscal incentives adverse consequences more substantial than
often are perverse in health care delivery, the direct costs and intended benefits. An
with cost savings for the health plan often example of an unintended benefit would be a
being seen as revenue reductions for health education program to motivate
hospitals and providers. patients to quit smoking, which might also
The most tenuous aspect of documenting result in lifestyle enhancements such as a
the benefit of preventive services is more sensible diet or less binge drinking. An
accurately and reliably projecting what example of an unanticipated adverse
would have occurred had the preventive consequence would be the process by which
service not been provided. This problem high-quality depression management
becomes more subjective with every passing programming by a managed care plan might
year after initiation of the preventive service. result in physicians urging patients with
Researchers can address this issue by depression to switch to that plan. In this
dividing their subjects into cases and case, the adverse consequence would be to
controls. This is something a health care the health plan and take the form of adverse
system cannot do. patient selection. Health plan managers
After the first few years of effective should try to project possible unintended
delivery of a new preventive service, there benefits and adverse consequences of
will be few differences in outcomes from preventive services, and plan to measure
year to year, as previously secured benefits them for purposes of program planning,
are maintained on an ongoing basis. This program evaluation, and future policy
lack of year-to-year improvements can leave development.
158 Special Report

Pareto’s Law (The “80/20” Rule) of the health care delivery systems to
Pareto was a sixteenth century Italian successfully target the services to those most
economist who stated that in any human at risk, while avoiding provision of the more
activity, a small percentage of the expensive and more individualized services
participants will account for most of the to members not in need of these more
action. As commonly interpreted, in any expensive interventions. For most of these
given year, approximately 20 percent of the interventions, this depends on the skill and
enrollees in a health care plan will be level of training of the primary care
expected to account for approximately 80 practitioners.
percent of the cost, with the top 5 percent The second way for health care systems to
accounting for approximately 50 percent of identify individual and group risk involves
the total health plan expenditures. In this data mining and use of predictive modeling
context, the challenge to health care delivery software; in other words, skilled
systems is to identify those individuals who manipulation of claims, pharmacy, and other
are likely to become high-cost patients in the data. Unfortunately, these procedures do not
near future, then take the action necessary to lend themselves to randomized controlled
reduce the number of individuals at risk of trials. Unlike the screening procedures, the
falling into these high-cost groups. guidelines and software are proprietary and
An example appears in the behavioral not subject to the scrutiny of peer-reviewed
literature where Simon and Untzer published journals. Because of the lack of high-quality
a study in 1999 (Simon & Unutzer, 1999) peer reviewed literature in this arena, these
presenting health care utilization and costs data mining and predictive modeling
among patients treated for bipolar disorder interventions were considered outside the
in an insured population. Five percent of the scope of this report.
patients accounted for approximately 40
percent of costs for (outpatient) specialty Perceptions and Biases Often Shared by
mental health and substance abuse services; Administrators and Practicing Physicians
90 percent of inpatient costs for specialty Bias against prevention:
mental health and substance abuse services; There is a widely held belief that
and 95 percent of out-of-pocket costs for prevention sounds good but just does
not work.
inpatient care.
Health care systems can address both these Bias against behavioral/mental health
risk profiles in two ways. One is through the services:
use of the IOM “universal” screening Behavioral needs and benefits are
procedures presented in this report, which seen as “soft” since they usually are
not verifiable by laboratory testing
are to be followed by the “selective”
or physical examination.
preventive services to confirm or deny the
finding of the initial screening and identify Stratification and discrimination:
those who could benefit from more intensive Stratification of both subpopulations
“indicated” services. and individuals is critical to cost-
efficient provision of selective and
A major key to success in implementing
indicated preventive services. In this
the more expensive and more individualized context, “stratification” refers to the
preventive behavioral services is the ability process by which a health care
delivery system might identify groups members frequently switching
of members to receive specific managed care plans on the basis of
preventive services not offered to premium cost, some health care
other members. Health care system systems are reluctant to invest in
managers often are uncomfortable preventive services where they will
with any form of stratification pick up the cost of the preventive
because of their perception that it is service, but a competing health care
not ethical to offer some services to system will enjoy the fiscal benefit of
some members, but not others, when the illness prevented. To address this
all are paying the same premium. issue at the national level, certifying
They also worry about accusations of and regulatory bodies now require the
discrimination, stereotyping, and provision of selected preventive
inappropriate use of confidential data. services.
This issue and these conflicts can be
very carefully explored. Failure to do Reluctance to develop supplemental data
so may severely inhibit the cost- systems:
efficiency of preventive services. Supplemental data systems to track
Uncertainty: individuals and small groups often
Administrators and fiscal officers are required for the cost-efficient
dislike uncertainty. The inability to implementation of preventive and
directly document what might have disease management services.
occurred had a preventive service not Supplemental systems can be seen as
been provided creates a situation costly, as violations of patient and
where there often is substantial physician confidentiality, and as an
uncertainty about the benefit to be inappropriate use of premium dollars
secured by almost any preventive to fund research. Despite this
service. The most effective way to reluctance, supplemental data
address this uncertainty may be by systems along these lines now are
generating epidemiologically sound being widely implemented in health
projections of likely costs and care systems to address the
benefits, then measuring the outputs overlapping needs of quality
and outcomes so they can be assurance, disease management, and
compared with the original preventive service programming.
projections. The supplemental information systems
often can be developed and initially managed
Competition and cost: on desktop computers using off-the-shelf
Health care systems and health spreadsheet or database software until such
insurance plans are highly cost- time as the data can be incorporated into
competitive. From their perspective,
larger claims-based or electronic medical
preventive services sometimes are
perceived as overhead costs of no record (EMR) systems.
benefit to the plan. As a result, some The perceptions and biases noted above
managed care plans may feel that they often may be best addressed directly within
cannot afford the cost of providing individual health care delivery systems if
preventive behavioral services unless preventive services and therapeutic
such services are imposed as a behavioral services are to be effectively and
requirement or promise to reduce
efficiently implemented with full
other health care costs within a year
of program implementation. With accountability for costs and outcomes.
160 Special Report

Time Intervals From Cost to Benefit developed and debugged systems, and a
Changes in a health care system’s client base much greater chance to secure health care
can dramatically alter both costs and savings in excess of program cost within 12
perceptions of benefit. To track both costs months of initial program implementation.
and benefits, the possibility of such changes Vendors also offer expertise not otherwise
can be considered in the initial design of the available to many health care delivery
systems used to track costs and benefits. systems.
Since there is little published literature on the Once developed, the health plan can plan
time-related issues noted above, guidelines to maintain the preventive/disease
may be based on personal/professional management program on a long-term basis.
opinion until such time as the needed Even with vendored programs, much work is
research can be done. required to get the patients and physicians
Time-related issues are critically important into the program and used to the system.
given the need for administrators and fiscal Initially, the tracking systems will be the
officers to look at costs and benefits by means by which the health care system
calendar-quarter and fiscal year. There is a documents the savings and other investments
time delay between the decision to initiate from the preventive programming, by
the service and the time the preventive tracking year-to-year changes in the outcome
program comes online. There are options parameters. Three to 5 years into the
concerning how quickly the plan or medical program, however, the year-to-year
center will saturate the initial need for the differences will disappear, creating a
service in question, with rapid coverage situation where the tracking system becomes
usually requiring an intensity of staffing that even more important to documenting
need not be maintained in future years. maintenance of the desired benefit.
There also are delays between the provision A major problem is that the dramatic
of the service and reduction in subsequent reductions in health care costs from year to
health care costs that must be well year will phase out over the first 3 to 5
understood. years, as the benefit is achieved and
maintained. This creates a situation where
Build vs. Buy Options: Disease and Demand the higher costs of fully vendored systems
Management will be harder and harder to justify to
Health plans may wish to carefully consider financial managers, with each passing year.
whether they wish to build their own disease This problem may be anticipated when such
management systems in-house, purchase the programs are initiated, either in-house,
services from disease management and data vendored, or hybrid, with understandings
system vendors, or pursue a hybrid reached among program advocates, program
approach. As a rule of thumb, one can staff, the vendor(s) and the financial
generally expect a system purchased from an managers as to how these issues are to be
outside vendor to cost more than it would addressed in subsequent years. One
cost to provide the service in-house. In possibility is to plan to transition the
return for this higher cost, the purchase vendored services in-house over the first 3 to
option offers the advantages of very little, if 5 years. If this is to be considered, attention
any, development time, access to well- must be paid to the issue of software
licensure at the time the vendored service is management programming on member
initiated. outcomes, and the manner in which HEDIS
has framed preventive/disease management
Benefits of Preventive Services programming in the name of health care
Member Health Status and Quality of Life quality, all the guidelines in this report can
Major depression is one of a number of be seen as quality-control measures.
behavioral health disorders reviewed in this Increasingly, more and more
report with major impact on overall health preventive/disease management programming
status (especially in members with will be required of managed care plans
concurrent major chronic diseases), quality wishing to score well on quality of care
of life, and workplace productivity. The most “score cards.”
effective and objective way for a health care
system to measure functional health status Employee Productivity
and overall quality of life is through use of Most of the commercial market for managed
questionnaires, such as the SF-36 (Jordan- care plans is employer-based. There is ample
Marsh, 2002; Ferguson, Robinson, & literature to document that poor health can
Splaine, 2002; deHaan, 2002). The SF-36 is adversely affect employee productivity, with
one of a number of currently available health behavioral problems among the most costly
status questionnaires that measures current (Williams & Strasser, 1999). Ironically,
physical health and mental health status in preventive/disease management programming
terms of what a patient is able to do and does not commonly cover these disorders,
how the patient feels on a day-to-day basis. presumably because they do not result in
Such questionnaires can help the clinician large numbers of emergency room visits and
identify undetected illness and depression hospitalizations.
and can help the health care system track the
overall quality of care provided to patients Cost Containment
with medical and behavioral chronic The overwhelming importance of financial
diseases. concerns in the management of health care
systems has resulted in almost single-minded
Quality of Care focus on “return on investment,” which
“Quality of care” has multiple domains. One usually is calculated on the basis of program
domain is physician, nurse, and other health costs and reductions in other health care
professional compliance with nationally costs within each 12-month period after
recognized guidelines for the process of care. program initiation. As noted above, these
Another domain is health care system calculations can be very problematic.
performance, as assessed using industrial- With behavioral health services, favorable
type measures of quality, consistency, and cost-effectiveness, as calculated above, can
efficiency of administrative, logistical, and be reliably secured for services related to
support services. Yet other domains include tobacco, drugs, and alcohol for pregnant
member health outcomes, member and women, and for early detection and
physician satisfaction, employer-as-a-client treatment of depression in patients with
satisfaction, and financial performance. diabetes, asthma, congestive heart failure,
Because of the impact of preventive/disease and other major chronic illnesses. The
162 Special Report

services to pregnant women reduce the need hidden burden of illness that has not yet
for costly newborn intensive care unit been diagnosed but is present within the
(NICU) services. The services to persons enrolled population. For behavioral
with chronic illness reduce emergency room disorders and diseases such as hypertension
and hospital use. Another service that the and diabetes, the number of not-yet-
literature shows would almost certainly be diagnosed cases may equal or exceed those
cost-effective within 12 months of program known to the plan through claims data. The
initiation is psychoeducation for patients purpose of screening programming is to aid
scheduled for surgery. the early diagnosis of these diseases so that
they may be inexpensively managed before
Image/Reputation of Health Care System the progress to a more severe stage of illness.
The image/reputation of the health care Screening programming increases incidence
system is important for recruiting employers, and prevalence while reducing average
members, and medical staff. Voluntary severity of illness and future costs. In many
certifying agencies, such as the National cases, the “future” is only 6 to 24 months
Committee for Quality Assurance (NCQA), away, creating a situation where such
the Joint Commission on Accreditation of programming often can pay for itself within
Healthcare Organizations (JCAHO), and the 12 to 24 months.
Utilization Review Accreditation
Commission, track preventive programming Case Identification
and selected health outcomes as measures of Both individuals and groups with priority
health care quality. Thus, preventive needs can be identified in many ways. For
programming that does not offer immediate some, claims or pharmacy data can be used
cost-effectiveness still can have substantial to identify persons with diabetes, asthma,
favorable fiscal impact by virtue of its value and other chronic diseases who may need
for health plan marketing. priority screening for depression and other
mental illnesses. Others can be identified
Need through chart review. For some, however,
Incidence and Period Prevalence identification will be difficult because the
For practical purposes, in a managed care member may not be forthright about
setting, incidence can be considered the rate behaviors seen as stigmatizing, or out of a
of new cases per 100 or per 1,000 members desire to please the doctor who may be seen
per year. New cases can arise from initial as an authority figure. This frequently is seen
diagnosis/onset of new illness in previously relative to tobacco use and alcohol and illicit
enrolled members, and through enrollment drugs, where less than half of those using
of persons with preexisting illness. Period these substances may voluntarily admit to
prevalence is the percentage of members their use. Some research protocols have
known to have a specified disease within any included blood or urine tests. With rare
given year. There is interplay among exceptions, blood or urine screening for
incidence, prevalence, and severity of illness these substances is not appropriate for
that needs to be understood. routine medical care. As a result, from a
When dealing with behavioral disorders health care delivery perspective, there is no
and major chronic diseases, there always is a easy or complete solution for this problem.
Severity of Illness higher risk members. High-quality case
Behavioral and chronic medical illnesses management and preventive programs,
have a natural history of progressing from including psychoeducation, can be very
asymptomatic to symptomatic, to more effective in reaching out to these higher risk
severely ill stages, with or without medical members, eliminating barriers to their
complications. The purpose of both participation, and enabling their
preventive and therapeutic services is to participation.
delay or interrupt this progression—perhaps
delaying it for the remainder of the natural Efficacy
life of the person. Given this model of Projection and Modeling
illness, the secret to success is either Assessing the efficacy of preventive services
prevention of the illness or early involves projecting what would have
identification to prevent progression of happened had the service not been provided.
illness. Tracking onset and severity of illness In most cases, this is best done by estimating
will require data not found in most claims- likely outcomes based on the published
based data systems. Some of these data will literature and the experience of others.
not even be in the medical record and will Projection and modeling does not necessarily
require screening and follow-up imply reliance on elegant mathematical
questionnaires. modeling procedures.
The most practical ways involve use of
Severity of Risk carefully selected baselines and benchmarks.
For purposes of quality assurance and The usual baseline is incidence or prevalence
disease management programming, “severity data from within the health plan.
of risk” is a characteristic of each enrolled Benchmarks can be secured from a variety of
member separate from severity of illness, and sources, including but not limited to HEDIS,
not directly ascertainable from claims data. Healthy People 2010, the published
One major dimension of severity of risk can literature, and databases presenting State and
be defined in terms of a member’s national averages and State and national
willingness and ability to adhere to survey data. Unfortunately, from the
prescribed regimens of lifestyle and perspective of managed care plans, many of
management of current illness. In this the most useful benchmarks are not
context, “high-risk” members are those who parameters discernable from claims data.
do not quit smoking, take their pills, control They require special surveys, medical record
their diet, etc. Basically, the higher the risk, reviews, or data that might be secured from
the more health plan resources need to be electronic medical record systems. Much of
invested to encourage and enable the the ascertainment of HEDIS compliance is
member to do what is needed to prevent based on highly structured reviews of
future illness and prevent deterioration of randomly sampled medical records.
current illness. The common practice of It is generally considered best to establish
developing educational and fitness the baseline and define the benchmarks and
programming, but not aggressively objectives prior to initiating new preventive
marketing it to those most in need of such services. Running the preventive program
programming, utterly fails to reach the first, then trying to reconstruct the baseline
164 Special Report

can be difficult and can significantly erode assurance, and utilization review.
confidence in the results. A review of the literature indicates the
Use of fixed baselines and benchmarks is following four major components as most
critical to maintaining preventive services promising for a health plan to develop and
after the stage has been reached in which maintain the best possible quality assurance
annual differences in process and outcome and preventive/disease management services:
measures no longer occur, or have been
substantially curtailed by the previous ■ Medical leadership, preferably with one
success of the preventive programming. or more physicians on a full-time or
part-time basis, with personnel who are
Effectiveness and Cost-Efficiency trained and experienced in epidemiology
Cost-efficiency generally is assessed in two and population-health management
stages. The first is limited to process ■ Management information support
measures (persons educated, calls, visits, services, surveillance and data systems
prescriptions filled, etc.) that usually are easy (MIS) for need ascertainment, program
to gather and track on a concurrent basis. management, and program evaluation
These measures will document the activity ■ Staff capacity to manage and interpret
needed to improve the outcomes. the quality assurance and
The second stage focuses on member preventive/disease management data
outcomes (cost-benefit). Given the delays ■ Financial support and staffing for
between the delivery of the preventive service screening and survey work, provider and
and the capture of the benefit in terms of patient health education, prevention-
reducing illness and reduction in hospital oriented case management, and
and emergency room utilization, total prevention-oriented outreach and home
reliance on outcome data can give distorted visitation.
pictures of program efficacy, both positive
and negative. Both process and outcome Research strongly suggests that universal
measures may be tracked and validly preventive services, both medical and
interpreted. Total reliance on cost- behavioral, will have to be implemented by
effectiveness calculations based on costs of primary care physicians and their staff
programming and claims-related health care assistance. These services represent an
use data can be distorted by changes in additional burden for them to carry and must
membership, delays in submission or be recognized in terms of clinical productivity
processing of health care claims, changes in expectations and reimbursement if such
rate structure, and movement between fee- services are to be effectively and universally
for-service and capitated billing. implemented. In the case of the universal
preventive behavioral screening procedures,
Infrastructure depending on the type of patient and whether
From a management perspective, similar one is dealing with an initial or follow-up
infrastructure elements are needed for visit, such screening can be expected to
preventive services (both medical and lengthen the clinical encounter between 30
behavioral), disease and demand seconds and approximately 2 or 3 minutes. A
management programming, quality percentage of the patients will give positive
responses to the screening questions and will appointments, etc. This would enable the
then require between 2 and 10 minutes of plan to follow up on missed appointments,
additional time for patient interview and in cue primary care physicians as to needed
some cases to arrange follow-up referrals to periodic diagnostic and treatment
other programs and professionals. procedures, track medication compliance,
Quality assurance (QA) and and flag those who may need special
preventive/disease management (DM) attention due to a deteriorating health or
services both require the same population- risk profile. Such information systems could
based approach and same types of data be created in-house for a single physician
systems. Since they both contribute to group for a single disease, then, after the
member outcomes, and since NCQA, bugs have been worked out of the system,
JCAHO, and peer-review organizations expanded to other physician groups and
consider them together, it is probably best to other diseases.
address them with a combined initiative.
Screening Policies and Procedures
Surveillance and Data Systems Screening is a process intended to identify
Surveillance is the process by which health preclinical illness so that it can be treated
care systems identify those in need of early. Sometimes reviewing claims data or
preventive services, then follow up to assess charts can do this. Most of the time,
the effectiveness of such services. Depending however, it requires direct member
on the disease, the surveillance system might participation to collect questionnaire data, x-
be entirely claims-based, might include rays, and/or laboratory specimens. Screening
detailed pharmacy and laboratory data, and programs and related health fairs are
might be by chart review, by member survey, widespread, but many fail to secure desired
or a combination of these measures. health benefits and cost savings for lack of
Not all health care delivery systems have adequate follow-up.
integrated and computerized claims and Screening for behaviors or disorders with
medical record systems. Given this social stigma raises the issue of invasion of
circumstance, the literature suggests that the privacy and the issue of unwanted
most cost-efficient approach to intrusiveness into the life of the member.
preventive/disease management data systems Such behaviors and disorders include use of
may be to have small, separate, dedicated tobacco, alcohol and drugs, presence of
systems that can be developed in-house, mental illness in the member or their family,
using spreadsheet or database software, AIDS, sexually transmitted diseases, self-
secured free of charge from selected inflicted injury, or injury due to criminal
pharmaceutical manufacturers or purchased behavior. When addressing these issues, some
from a variety of vendors. percentage of members voluntarily will
According to the research, the most provide this information on interview. For
practical approach in most cases will be to those who will not, proceeding with blood
develop a registry of patients to be or urine testing or other means of
considered for preventive services for each investigation may be warranted in selected
disease or health condition, then track cases. Such more intrusive screening
appropriate health status measures, probably does not appear justified on a
166 Special Report

routine basis. This situation, in turn, creates Psychoeducation
circumstances in which the health care Psychoeducation is health education
system knowingly will fail to identify a combined with behavioral counseling. The
substantial percentage of the cases. counseling component of psychoeducation
deals with emotions, perceptions, coping,
Follow-Up Protocols Postscreening relaxation, and self-care. Psychoeducation is
Research indicates that in the context of of value for high users of health care
preventive and disease management services, those with major chronic diseases,
programming, screening without well- and persons scheduled to undergo major
established postscreening follow-up surgical procedures. In the case of surgical
protocols is likely to be a waste of time (for patients, psychoeducation can enhance early
anything beyond marketing and community mobility and control of pain.
relations). Desired follow-up usually entails
more detailed clinical assessment, with Health Education (Individual, Group, and Web Site)
treatment in some form initiated for those Health education is the least intensive of
found to be “positive” for the disease. these ancillary services. Although it is
sometimes provided one-on-one, it is more
Counseling often provided as distribution of written
Counseling, which entails providing material or in group sessions at the health
objective information and helpful advice, is facility or a community site. The goal of
what every health professional does daily in health education is to provide the patient
his or her contact with patients. It is an with the information needed to secure and
essential part of the care process. maintain the best of health, and to motivate
Unfortunately, a quick and cursory the participants to adhere to the
explanation by the physician or nurse simply recommendations.
will not suffice, even when accompanied by With each passing year, more and more
written instructions. In addition, in most health education is being provided over the
health care systems, if the patient has a Internet, or by other self-paced electronic
question after they reach home, it is difficult, means. This can be highly effective and cost-
if not impossible, to secure the answer from efficient for patients with the computer
the provider. literacy and motivation to use these
Because the usual practice of modalities.
physician/nurse counseling often is Seeking health-related information is a
inadequate to assure patient adherence to major activity on the Internet. The problem
prescribed preventive measures and regimens from a physician and health-plan perspective
of care, each health care delivery system is that the information secured may be of
should consider its needs for health dubious quality, may conflict with physician
education, psychoeducation, case advice, or may simply be wrong. The research
management, call centers, and home indicates that for these reasons, health plans
visitation to improve patient adherence to are well advised to develop and maintain their
medical recommendations for selected own Web sites, contract with a vendor of such
groups of high-risk and chronic disease service, and provide health-education pages,
patients. with linkage to sources of health information
that they consider to be accurate, reliable, up- purchase this service from a national vendor
to-date, and consistent with what their who will customize it to meet the needs of
physicians are advising their members. the client health plan or medical center.
Case Management Home Visitation

Case management is a service usually Preventive/anticipatory home visitation for
provided by a nurse or social worker to high-risk pregnant women and infants was a
identify the full range of health needs for a common practice in many local health
given enrollee and to assure that the service departments and some public sector health
package is both complete and cost-efficient. care delivery systems through the mid-1970s.
The most common use of case managers is to Since then, it has all but disappeared in the
control the cost of care for persons with face of cost containment and a lack of peer-
exceptionally high health care costs. Case reviewed literature demonstrating the
management usually is conducted in efficacy of such services. Over the past 20
inpatient settings or for patients on long- years, a new body of literature has been
term home care. Prevention-oriented case published that clearly demonstrates the value
management, however, frequently is of such home visitation, provided that the
provided on an outpatient basis and consists mothers and infants are carefully selected,
of an occasional in-depth assessment and the services are provided in accordance with
relatively light continued contact with the strict protocols, and the goals of the service
patient and/or family to assure that are clearly articulated (Eckenrode et al.,
appointments are being kept, medications 2000; Kitzman et al., 1997, 2000; Olds et
are taken, and questions are answered. Such al., 1986, 1988, 1992, 1993, 1994, 1995,
case management usually is reserved for 1997, 1998).
those with very complex or severe illness, or Home visitation is the most expensive
those who need additional assistance and service discussed in this report. Research
motivation to reasonably comply with indicates that to be cost-efficient, it must be
prescribed regimens of care. reserved for only a small number of patients
whose specific needs and risk profiles justify
Call Centers this level of service. Home visitation allows
Call centers provide several types of services. the nurse or social worker to observe the
Most commonly, they provide members with home environment, and by doing so, does a
24-hour telephone access for health advice better job of providing counseling,
and guidance. Members can call any time of education, and case management to
the day or night with questions concerning empower and enable that patient and family
how to handle current medical situations or to better manage their risk profile. Routine
issues. These call centers also can be home visitation is recommended for low-
configured to place outgoing calls for income, economically and socially vulnerable
purposes of health education, case first-time pregnant women for prenatal and
management, gathering of survey data, etc. postnatal visits shortly after birth, their
Like most of the other components on this newborn infants, and infants born to
list, a health plan or medical center can mentally retarded mothers. Occasional home
either set up their own call center or visits may be helpful to support caregivers in
168 Special Report

the home caring for patients with dementia or to substitute for nursing home placement.
or other serious long-term mental or physical Home visitation uses nurses or social
ailments. The home visit option might also workers to provide in-home assessment and
be considered for all other classes of patients guidance in dealing with a wide range of
with extreme risk profiles and/or difficulty medical, social, financial, psychological, and
adhering to prescribed regimens of care. educational issues. This home visitation may
The home visitation envisioned herein is include physical examination and health
very different from the home health services assessment, but it does not involve giving
currently provided by most health care injections, changing bandages, or any other
systems to facilitate early hospital discharge hands-on therapeutic medical service.
170 Special Report
XV. Appendix C:
Billing for Preventive
Behavioral Services
M
ultiple sets of billing codes are provided—some for visits
completely devoted to preventive services, and some for primary
care physician use for mental health diagnosis and patient
management. For most visits, the screening will take less than 3 minutes.
Follow-up on screening results can then be billed as diagnosis and patient
management.
Benefit packages will differ among and use. Health Care Common Procedure System
between insurance carriers and different (HCPCS) codes are standardized nationally
policies offered by a single carrier. and are used in addition to CPT codes in
Practitioners will have to check with the Medicare and Medicaid Programs. However,
insurance carrier or managed care plan to there are “Level III HCPC” codes developed
decide which codes to use to provide specific by individual States for locally designated
services to specific patients. services. These are not yet standardized
It is important to note that billing codes nationally, although government agencies are
are expressed in terms of “encounters,” and currently reviewing them to standardize,
that an outpatient visit may include multiple reduce in number, and streamline. The
“encounters.” Here again, a provider must project to standardize the local Level III
inquire with his or her managed care plan or HCPC codes is being directed by the U.S.
insurance carrier to determine which Centers for Medicare and Medicaid Services
encounters, within a single outpatient visit, (CMS) in accordance with the
are to be “bundled,” and which are to be “Administrative Simplification” transactions
billed separately. provisions of the Health Insurance
Coding of diagnoses and medical Portability and Accountability Act (HIPAA)
procedures for billing and for other purposes of 1996, P.L. 104-191 (see
is a complex matter. International www.cms.gov/hipaa/hipaa2/regulations/trans
Classification of Disease (ICD-9 and ICD- actions/default.asp). Once the HIPAA billing
10) codes are most commonly used for codes become final, providers may bill for
diagnoses. Current Procedural Terminology mental health services in primary care as
(CPT) codes are most commonly used for well as specialty services in the specialty
visits, procedures, and billing—but there are sector (Tremper, 2003). Our appendix is
at least two other sets of codes in common limited to presentation of the CPT codes
most important to primary care practitioners counseling provided as a separate encounter
for preventive behavioral services. to promote health and prevent illness and
Although psychologists, nurses, and other injury for a patient without symptoms, and
nonphysicians have a strictly defined scope may be reimbursed using preventive
of practice limitations, physicians do not. A medicine codes (Agency for Healthcare
primary care physician may bill for Quality Research, 2003). These codes run
psychiatric services, since CPT code consecutively from 99401 for an
specifications for preventive services do not approximate 15-minute encounter, through
rule out prevention of mental illness. The 99404 for an approximate 60-minute
limitation, if any, would be based on the encounter.
interpretation of the State Medicaid office, a Another possible approach, using general
regional Medicare intermediary, or the preventive medicine codes, are the codes for
specific benefits offered by a private preventive medicine evaluation and
insurance company. Whether or not mental management of an individual, including a
health specialists can bill for screening for comprehensive history, a comprehensive
evidence of preclinical mental illness will examination, counseling/anticipatory
depend on the benefit packages of the guidance/risk factor reduction interventions,
managed care or other health insurance plan, and ordering appropriate
State Medicaid program, or Medicare laboratory/diagnostic procedures. There also
intermediary. Here again, primary care are preventive medicine codes for counseling
practitioners are urged to check the and risk factor interventions in group
resources available to them for patient settings, with code 99411 for sessions of
referral, based on the patients plan approximately 30 minutes, and 99412 for
membership or insurance policy. hour-long sessions.
The CPT coding for “Preventive Medicine, Code 99420 is specific to administration
Individual Counseling” specifies that this is and interpretation of health risk assessment
Table 8: Preventive Medicine, Individual Counseling,

and/or Risk Factor Reduction Intervention Provided to
an Individual as a Separate Procedure
CPT Code Approximate Duration

of Procedure
99401 15 minutes
99402 30 minutes
99403 45 minutes
99404 60 minutes
172 Special Report

Table 9: Preventive Medicine Comprehensive Evaluations
CPT Code for Initial CPT Code for

Evaluation of New Patient Periodic Reevaluation Age Range
99381 99391 Under 1 year

99382 99392 1–4
99383 99393 5–11
99384 99394 12–17
99385 99395 18–39
99386 99396 40–64
99387 99397 65 and over
instruments. Payers may or may not allow ■ 90804: Individual psychotherapy,

use of this code for behavior-related insight-oriented, behavior modifying
questionnaires such as the Pediatric and/or supportive, in an office or
Symptom Checklist or one of the longer outpatient facility, approximately 20 to
alcohol- or depression-related questionnaires. 30 minutes face-to-face with patient
Finally, the last of the preventive medicine ■ 90805–90804: With medical evaluation
codes is 99429, Unlisted Preventive Medicine and management services
Service. Practitioners are urged to check with ■ 90847: Family psychotherapy (conjoint
the managed care plan or insurance carrier psychotherapy) (with patient present)
before using this code. ■ 90862: Pharmacologic management,
There are a number of promising including prescription use and review of
psychiatric codes that may be accessible to medication with no more than minimal
primary care physicians for follow-up on medical psychotherapy
brief screening tests, especially for depression ■ 90887: Interpretation or explanation of
and any form of substance use. In these results of psychiatric, other medical
cases, the 1- or 2-minute screening interview examinations and procedures, or other
would not be reimbursed separately. The accumulated data to family or other
diagnostic interview, counseling, and responsible persons, or advising them
development of a treatment plan may be how to assist the patient.
billable in the same manner as billing for
diagnosis and management of a purely In addition, in the context of
physical chronic disease. psychoeducational interventions, including
simple biofeedback training for presurgical
The major codes of interest here are— patients—
■ 90801: Psychiatric interview ■ 90875: Individual psychophysiological

examination therapy incorporating biofeedback
training by any modality (face-to-face 2003 update (Hopkins & Kachur, 2002).
with the patient), with psychotherapy Additional guidance on codes to be used for
(e.g., insight-oriented, behavior Medicaid and Medicare can be secured from
modifying, or supportive psychotherapy); the U.S. Center for Medicaid and Medicare
approximately 20–30 minutes Services at http://cms.hhs.gov/.
■ 90901: Biofeedback training by any More detailed guidelines for Medicare
modality payments for Part B Mental Health Services can
be accessed at http://oig.hhs.gov/oei/reports/oei-
The material in this appendix was 03-99-00130.pdf
developed from the CPT 2000 Codebook of To secure CPT code books and related
the American Medical Association (AMA materials, a number of products and services
CPT Editorial Panel and AMA CPT may be found on the American Medical
Advisory Committee, 1999) and the Ingenix Association’s Web site at www.ama-
assn.org/ama/pub/category/3116.html.
174 Special Report

XVI. Appendix D:
Procedures for
Implementation and
Evaluation of
Preventive Services
P
reventive services, unlike therapeutic services, are provided to persons
who currently do not show evidence of disease. As a result, those
persons who might benefit from such services often cannot be identified
through claims data, but rather by identifying risk and protective factors. This
creates a situation where health care delivery systems need policies and
procedures for preventive services (both behavioral and medical) and quality
assurance services (both behavioral and medical) that rely on data systems
other than health care claims. This chapter provides general information
regarding the implementation of preventive behavioral services. Additional
information appears in Appendix B: Policy and Management Issues
Guidelines; and in Appendix C: Billing for Preventive Behavioral Services.
Basic Principles ■ Most of the preventive behavioral

■ Those most in need of preventive services intended to prevent onset of the
behavioral services often are those least behavioral disorder are provided in
likely to volunteer for such services. school and community settings.
Addressing this issue requires Preventive behavioral services offered in
assertiveness on the part of both the clinical settings tend to detect those at
health plan and provider. high risk or those who are in the early
■ Not all persons provided preventive stages of illness, and they tend to reduce
services will have experienced the disease health care costs of other illnesses.
or complication the service was intended ■ As with other preventive services and
to prevent. quality assurance programming, more
■ The literature indicates that interview and than claims data are needed to identify
counseling-based preventive services are far those in need of services. Most often,
less than 100 percent effective in securing the patient interview is required for case
desired risk modification or behavior change. finding, and record review and special
physician and patient surveys are needed value. The same is true when dealing
for program planning and evaluation. with screening and other preventive
services, as discussed in this report.
Steps To Be Taken at the Level of the
Health Care Delivery System The Role of the Primary Care Practitioner
■ Policies, procedures, and quality ■ The physician or other health care
assurance guidelines can be in place for provider can briefly screen each person
all clinical preventive behavioral services for all the topics for which screening is
that are to be implemented within the indicated on the basis of his or her life-
health care delivery system. cycle group (age and/or pregnancy).
■ When dealing with multiple screening ■ The initial set of screening questions for
procedures for a single age/life-cycle each life-cycle group may be organized
group, it may be helpful to have a single so that the screening can be completed in
policy statement/document dealing with less than 3 minutes.
the entire set of screening procedures for ■ Follow-up on positive findings may be
that group. considered a diagnostic activity and will
■ These policies and procedures can be take as long as required to rule out the
summarized in posters and other problem, treat the disorder, or identify
reminders to cue the clinical staff. the need for referral to a mental health
■ Physicians, nurses, and other staff as professional. Initial follow-up can be
appropriate can be trained in screening, done by the primary care practitioner.
follow-up, and other policies and Patients may be referred to mental health
procedures. practitioners with initial confirmation of
■ Printed informational materials specific the need to do so by the primary care
to preventive services can be distributed practitioner.
to all primary care providers. ■ Primary care practitioners can follow up
■ The health care system may wish to have at subsequent outpatient visits to
the capability to provide—directly or monitor behavioral change and assure
indirectly—all needed follow-up services. that mental health professionals have
■ Quality assurance programming can be provided appropriate services.
in place to track the provision of each ■ Provisions might be made for the
screening, preventive, and follow-up clinician to record the screening, the
intervention, and the impacts and findings, and the various levels and types
outcomes of each service on behaviors, of follow-up.
clinical outcomes, and use of other ● In health care systems with electronic
health care resources. medical records, specific fields can be
■ Each preventive service for each age/life- provided.
cycle group may be tracked separately. ● In health care systems without
Although the data to be tracked are electronic medical records—
similar for tobacco, alcohol, and illicit ▲ Dummy billing codes can be developed
drugs, separate data can be gathered for (to record the provision of the service
each substance. Data pooled across on the billing form, even though it is
multiple substances are of little practical not separately reimbursed).
176 Special Report

▲ Specific space can be provided on the Assessment of Program Efficacy
medical record to facilitate medical ■ Number and percentage of patients
record review. screened.
■ Percentage of those screened with
Assessment of Need for Programming positive findings.
■ Assessment of need may not be required ■ Percentage of patients counseled.
to initiate the preventive behavioral ■ Percentage offered post–initial-screening
services suggested for universal special education, extended counseling,
implementation. The needed data can be or other follow-up services.
secured in the process of identifying the ■ Documentation of use on each
number and percentage of patients who subsequent visit to document changes in
screen positive and require some form of behavior, outcomes, quit rates, and
follow-up service. relapse rates (medical record reviews).
■ Special assessment of needs can be done ■ Comparison of overall health care
by contacting the local or State health utilization, including those who screened
department and requesting data available positive and participated in follow-up,
on prevalence of substance use disorder those who screened positive and did not
within the community(ies) being served follow up, and those who screened
by the health care delivery system. All negative.
States and some localities will have such ■ Comparison of utilization data for
data, and some may have data specific to before-and-after implementation of the
substance use disorder in pregnancy new preventive behavioral programming.
through the Behavioral Risk Factor Medical records can be reviewed and
Surveillance Survey (BRFSS) and locally small surveys of both patients and
conducted surveys. providers can be conducted to assess the
■ Claims data can be reviewed for data preprogram screening for substance use
relating to the prevalence of substance disorder, depression, and behavioral
use disorders, depression, and behavioral disorders.
disorders. ■ Provider and patient surveys to address
■ Claims and medical records data can be behaviors, perceptions, and satisfaction
reviewed for patients with diabetes, asthma, with services.
and other chronic diseases to determine
whether it is appropriate to invest in
preventive behavioral programming to
improve patient compliance with prescribed
regimens of care.
178 Special Report
DHHS Publication No. (SMA) 04-3906
Printed 2004

DHHS Publication No. (SMA) 04-3906 Printed 2004

Uploaded by

Copyright:

Available Formats

DHHS Publication No. (SMA) 04-3906 Printed 2004

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

DHHS Publication No. (SMA) 04-3906 Printed 2004

Uploaded by

Copyright:

Available Formats

DHHS Publication No.

Public Domain Notice

Electronic Access and Copies of Publication

DHHS Publication No. (SMA) 04-3906

III. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

IV. Overview of Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

V. Pregnant Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

VI. High-Risk Pregnant Women and Children to Age 5 . . . . . . . . . . . . . . . . .39

VII. Screening Children and Adolescents (5–18 Years) . . . . . . . . . . . . . . . . . . .49

VIII. Adolescents (12–18 Years) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

IX. Adults (19 Years and Older) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

Clinical Preventive Services in Substance Abuse and Mental Health Update v

X. Psychoeducation for Three Categories of Patients . . . . . . . . . . . . . . . . . .101

XI. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107

XII. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109

XIII. Appendix A: Literature Search Methods and Results . . . . . . . . . . . . . .145

XIV. Appendix B: Policy and Management Issues and Guidelines . . . . . . . . .155

XV. Appendix C: Billing for Preventive Behavioral Services . . . . . . . . . . . . .171

XVI. Appendix D: Procedures for Implementation and Evaluation

Table 2: Summary of Selective Preventive Service Guidelines . . . . . . . . . . . . . .20

Table 3: Tabular Summary of Initial PubMed Search for 1998–2002 . . . . . . .146

Table 4: Notes on Randomized Controlled Trials in

Table 6: Preliminary Analysis of SAMHSA 2000 Monograph:

Table 7: Topics from SAMHSA 2000 Monograph Reflected in

Table 8: Preventive Medicine, Individual Counseling, and/or

Table 9: Preventive Medicine Comprehensive Evaluations . . . . . . . . . . . . . . .173

Clinical Preventive Services in Substance Abuse and Mental Health Update 1

Clinical Preventive Services in Substance Abuse and Mental Health Update 3

Figure 1. Continuum of Health Care

Clinical Preventive Services in Substance Abuse and Mental Health Update 5

Clinical Preventive Services in Substance Abuse and Mental Health Update 7

Clinical Preventive Services in Substance Abuse and Mental Health Update 9

Clinical Preventive Services in Substance Abuse and Mental Health Update 11

Scope of Review primary prevention AND mental

Clinical Preventive Services in Substance Abuse and Mental Health Update 13

The results of this advanced search are Exclusions

Clinical Preventive Services in Substance Abuse and Mental Health Update 15

Clinical Preventive Services in Substance Abuse and Mental Health Update 17

Table 1: Summary of Universal Preventive Service Guidelines

Pregnant Women General General General

Clinical Preventive Services in Substance Abuse and Mental Health Update 19

General: Psychoeducation for patients scheduled for surgical procedures

Targeted: Psychoeducation for patients with somatization

Clinical Preventive Services in Substance Abuse and Mental Health Update 21

Clinical Preventive Services in Substance Abuse and Mental Health Update 23

Clinical Preventive Services in Substance Abuse and Mental Health Update 25

Clinical Preventive Services in Substance Abuse and Mental Health Update 27

Clinical Preventive Services in Substance Abuse and Mental Health Update 29

In a 2002 review of alcohol problem- Evidence of Need

Clinical Preventive Services in Substance Abuse and Mental Health Update 31

Clinical Preventive Services in Substance Abuse and Mental Health Update 33

Clinical Preventive Services in Substance Abuse and Mental Health Update 35

■ Numbers of cases of illicit drug use

Clinical Preventive Services in Substance Abuse and Mental Health Update 37

Clinical Preventive Services in Substance Abuse and Mental Health Update 39

Clinical Preventive Services in Substance Abuse and Mental Health Update 41

Clinical Preventive Services in Substance Abuse and Mental Health Update 43

Clinical Preventive Services in Substance Abuse and Mental Health Update 45

Services to Infants Born to Mentally Retarded Other