Showing papers in "Psychiatric Services in 2003"
TL;DR: The education sector plays a central role as a point of entry into the mental health system for children and adolescents as well as patterns of movement through five service sectors: specialty mental health services, education, general medicine, juvenile justice, and child welfare.
Abstract: Objective: This study examined points of entry into the mental health service system for children and adolescents as well as patterns of movement through five service sectors: specialty mental health services, education, general medicine, juvenile justice, and child welfare. Methods: The data were from the Great Smoky Mountains Study, a longitudinal epidemiologic study of mental health problems and service use among youths. The sample consisted of 1,420 youths who were nine, 11, or 13 years old at study entry. Each youth and a parent were interviewed at baseline and every year thereafter about the use of services for mental health problems over the three-year study period. Results: Population estimates indicated that 54 percent of youths have used mental health services at some time during their lives. The education sector was the most common point of entry and provider of services across all age groups. The specialty mental health sector was the second most common point of entry for youths up to age 13 years, and juvenile justice was the second most common point of entry for youths between the ages of 14 and 16. Youths who entered the mental health system through the specialty mental health sector were the most likely to subsequently receive services from other sectors, and those who entered through the education sector were the least likely to do so. Conclusions: The education sector plays a central role as a point of entry into the mental health system. Interagency collaboration among three primary sectors—education, specialty mental health services, and general medicine—is critical to ensuring that youths who are in need of mental health care receive appropriate services. (Psychiatric Services 54:60–66, 2003)
616 citations
400 citations
TL;DR: This book is coming as the best seller book today, so, when you are really a good reader or you're fans of the author, it does will be funny if you don't have this book.
Abstract: Follow up what we will offer in this article about aggression and antisocial behavior in children and adolescents research and treatment. You know really that this book is coming as the best seller book today. So, when you are really a good reader or you're fans of the author, it does will be funny if you don't have this book. It means that you have to get this book. For you who are starting to learn about something new and feel curious about this book, it's easy then. Just get this book and feel how this book will give you more exciting lessons.
352 citations
291 citations
TL;DR: Supporting traditional cognitive-behavioral therapy for depression with clinical case management improves retention in traditional mental health outpatient care and can improve outcomes for Spanish-speaking patients.
Abstract: OBJECTIVE: The aim of this study was to determine whether supplementing traditional cognitive-behavioral therapy for depression with clinical case management would reduce the rate of dropout from care and improve outcomes for ethnically diverse, impoverished medical outpatients METHODS: The study was a randomized trial that compared cognitive-behavioral group psychotherapy alone (N=103) with the same therapy supplemented by clinical case management (N=96) RESULTS: The patients who received supplemental case management had lower dropout rates than those who received cognitive-behavioral group therapy alone Supplemental case management was associated with greater improvement in symptoms and functioning than cognitive-behavioral therapy alone for patients whose first language was Spanish (N=77) but was less effective for those whose first language was English (N=122) CONCLUSIONS: Supplemental case management improves retention in traditional mental health outpatient care and can improve outcomes for Span
288 citations
TL;DR: The findings support the structured professional judgment model of risk assessment as well as the HCR-20 specifically and suggest that clinical judgment, if made within a structured context, can contribute in meaningful ways to the assessment of violence risk.
Abstract: OBJECTIVE: This study tested the interrater reliability and criterion-related validity of structured violence risk judgments made by using one application of the structured professional judgment model of violence risk assessment, the HCR-20 violence risk assessment scheme, which assesses 20 key risk factors in three domains: historical, clinical, and risk management. METHODS: The HCR-20 was completed for a sample of 100 forensic psychiatric patients who had been found not guilty by reason of a mental disorder and were subsequently released to the community. Violence in the community was determined from multiple file-based sources. RESULTS: Interrater reliability of structured final risk judgments of low, moderate, or high violence risk made on the basis of the structured professional judgment model was acceptable (weighted kappa=.61). Structured final risk judgments were significantly predictive of postrelease community violence, yielding moderate to large effect sizes. Event history analyses showed that ...
285 citations
TL;DR: Clients with schizophrenia who have higher levels of cognitive impairment may require greater amounts of vocational support than those with lower levels of impairment and a variety of rehabilitation strategies may be required to improve vocational outcomes and reduce the amount of supported employment services needed by clients with schizophrenia.
Abstract: OBJECTIVES: This study examined the relationships of measures of cognitive functioning and psychiatric symptoms with work outcomes and use of vocational services for clients with schizophrenia in a supported employment program. METHODS: Thirty clients who were newly enrolled in a supported employment program were evaluated with cognitive and symptom measures at program entry and two years later. The clients' amounts of competitive work, wages earned, on-job support, and contact with employment specialists during the two-year follow-up period were documented. RESULTS: Predictors of clients' work outcomes included previous work history, amount of government entitlement income received, severity of negative symptoms, involvement in sheltered work activity at baseline, and level of cognitive functioning, including scores on measures of executive functioning and verbal learning and memory. The amounts of on-job support and contact with employment specialists were predicted by the cognitive domains of executive...
241 citations
TL;DR: Discrimination based on group characteristics other than mental illness does not diminish the impact of stigma associated with mental illness, and antistigma programs need to target not only discrimination related to mental illness but also that associated with other group characteristics, such as race, gender, sexual orientation, and physical disability.
Abstract: Objectives: The authors sought to gain further perspective on discrimination experienced by persons with mental illness by comparing selfreports of discrimination due to mental illness to self-reports of discrimination due to other group characteristics, such as race, gender, and sexual orientation. Methods: A total of 1,824 persons with serious mental illness who participated in a baseline interview for a multistate study on consumer-operated services completed a two-part discrimination questionnaire. The first part of the questionnaire assessed participants’ perceptions about discrimination due to mental illness as well as more than half a dozen other group characteristics. The second part of the questionnaire asked participants who reported some experience with discrimination to identify areas in which this discrimination occurred, such as employment, education, and housing. Results: More than half of the study participants (949 participants, or 53 percent) reported some experience with discrimination. The most frequent sources of this discrimination were mental disability, race, sexual orientation, and physical disability. Areas in which discrimination frequently occurred included employment, housing, and interactions with law enforcement. Areas in which discrimination was experienced did not significantly differ among groups of study participants characterized by mental disability, race, gender, sexual orientation, or physical disability. Conclusions: Discrimination based on group characteristics other than mental illness does not diminish the impact of stigma associated with mental illness. Antistigma programs need to target not only discrimination related to mental illness but also that associated with other group characteristics, such as race, gender, sexual orientation, and physical disability. (Psychiatric Services 54:1105–1110, 2003)
238 citations
TL;DR: Clinicians should consider the effect of weight gain on quality of life when prescribing antipsychotics and should help patients adopt weight maintenance behaviors, according to this study.
Abstract: Weight gain has been associated with the use of antipsychotic medications, and research has linked obesity with reduced quality of life. This study sought to assess the impact of weight gain on persons with schizophrenia who are taking antipsychotic medications. The Psychological Well-Being Index, a measure of quality of life, was distributed to individuals with schizophrenia who belonged to mental health associations. Among 286 respondents, 56 percent gained no weight over a six-month period while taking antipsychotic medications, 19 percent gained one to ten pounds, 12 percent gained 11 to 20 pounds, and 14 percent gained more than 20 pounds. When gender and use of antipsychotics were controlled for, weight gain was related to poorer quality of life and reduced well-being and vitality. Clinicians should consider the effect of weight gain on quality of life when prescribing antipsychotics and should help patients adopt weight maintenance behaviors.
234 citations
TL;DR: People with chronic mental disorders may be at risk of reduced access to medical treatment and poor quality of medical care, and their scores were significantly lower than those of the general population on all four domains used to assess the quality of primary medical care.
Abstract: People with chronic mental disorders may be at risk of reduced access to medical treatment and poor quality of medical care. The authors examined receipt of and barriers to medical treatment among patients at a community mental health center. Fifty-nine patients completed a validated instrument for measuring access to medical care and the quality of primary care. Their responses indicated problems with access to care, and their scores were significantly lower than those of the general population on all four domains used to assess the quality of primary medical care. The findings suggest the need for community mental health centers to better assess and address barriers to primary medical care.
187 citations
TL;DR: Overall, studies continued to support the notion that telepsychiatry assessments can produce reliable results, telepsychiatric services can lead to improved clinical status, and patients and clinicians are satisfied with treatment delivered via telePsychiatry.
Abstract: Objective In response to new developments and interest in the area of telepsychiatry, literature on this topic has greatly increased over the past three years. Because of this increase, the authors conducted a literature review of telepsychiatry to update a previously published review that covered the years 1970 to 2000. Methods A search was conducted on the MEDLINE, PsycINFO, and Telemedicine Information Exchange (TIE) databases for literature published from March 2000 to March 2003 on telepsychiatry applications, using the following terms: telepsychiatry, telepsychology, telemental health, videoconferencing, and video conferencing. Results Sixty-eight publications were identified over this three-year period, exceeding the 63 publications identified in the previous literature review. The authors summarize the results of findings in six areas: novel clinical demonstrations and current program descriptions; the reliability of clinical assessments; clinical outcomes; satisfaction of patients and clinicians; cost and cost-effectiveness; and legal, regulatory, and ethical issues. Studies describing existing programs and novel clinical applications support the belief that the use of telepsychiatry is expanding. Overall, studies continued to support the notion that telepsychiatry assessments can produce reliable results, telepsychiatric services can lead to improved clinical status, and patients and clinicians are satisfied with treatment delivered via telepsychiatry. Evidence supported the notion that telepsychiatry is a cost-effective means of delivering mental health services; however, this conclusion was based on limited studies of economic models of telepsychiatry programs. Also limited were papers on the topics of legal, regulatory, and ethical issues. Conclusions Despite the rapid increase in information on telepsychiatry, methodologically sound studies in the area of telepsychiatry are still infrequent.
TL;DR: A definitive relationship exists between compliance and the economic costs of schizophrenia and the authors suggest collection of data on longer-term clinical outcomes as a means to improve future economic evaluations of schizophrenia treatments.
Abstract: OBJECTIVES: The authors examined published economic evaluations of schizophrenia and antipsychotic therapies to determine the role of compliance with medication therapy in the economic cost of schizophrenia. METHODS: The authors reviewed studies published from 1995 to 2002 that evaluated compliance with treatment for schizophrenia. Literature searches were conducted for that period by using MEDLINE, EMBASE, and Current Contents. The primary search terms were "schizophrenia," "compliance," "relapse," and "economic costs." RESULTS AND CONCLUSIONS: A definitive relationship exists between compliance and the economic costs of schizophrenia. Lower rates of compliance lead to higher costs of treating schizophrenia. However, the full implications are difficult to surmise from the literature because of inadequacies in the reporting of compliance rates and outcomes of treatment over time. The authors suggest collection of data on longer-term clinical outcomes as a means to improve future economic evaluations of sc...
TL;DR: Prospective controlled trials are needed to substantiate perceptions that combination antipsychotic therapy is clinically beneficial and to provide guidelines on when and for whom antipsychotics polypharmacy should be considered.
Abstract: OBJECTIVE: Surveys have shown that antipsychotic drug combinations are frequently prescribed, yet few clinical studies have examined this practice. Experts have generally recommended antipsychotic combinations, especially those combining an atypical and a conventional antipsychotic, as a measure of last resort. A survey of prescribers was conducted to examine why combination antipsychotic therapy is being used in outpatient clinical practice. METHODS: Antipsychotic prescribing practices in the Department of Veterans Affairs Puget Sound Health System were reviewed for a six-month period during 1998-1999. Data on the use of atypical and conventional antipsychotics in combination were collected. RESULTS: A total of 1,794 patients received prescriptions for at least one antipsychotic medication during the study period, of which 715 (40 percent) received an atypical agent. Ninety-three patients (13 percent) who were treated with an atypical antipsychotic received a prescription for combination antipsychotic th...
TL;DR: In this article, the efficacy of a 12-week weight control program for patients taking atypical antipsychotics was evaluated and compared with those of 15 patients in a control group.
Abstract: This study assessed the efficacy of a weight control program for patients taking atypical antipsychotics. Thirty-one patients with schizophrenia or schizoaffective disorder participated in a 12-week weight control program that incorporated nutrition, exercise, and behavioral interventions. Changes in patients' weight and in body mass index (BMI) were recorded and compared with those of 15 patients in a control group. The intervention group had a mean weight loss of 2.7 kg (six pounds) and a mean reduction of .98 BMI points, compared with a mean weight gain of 2.9 kg (6.4 pounds) and a mean gain of 1.2 BMI points in the control group. These data suggest that the intervention was effective in this group of patients. Professionals treating persons who are taking atypical antipsychotics should encourage them to engage in weight control activities.
TL;DR: African-American urban ministers functioning as pastoral counselors constitute an engaging and useful group with experiences and skills that can be tapped by interested secular professionals.
Abstract: Objective: Little is currently known about the pastoral counseling work of pastors of African-American churches. The authors interviewed the pastors of nearly all African-American churches in a metropolitan area about their pastoral counseling work and related aspects of their ministry. Methods: Of 121 African-American pastors identified, 99 completed a semistructured interview describing their backgrounds, attitudes, concerns, and work. The interview included detailed queries about how they understood and carried out any pastoral counseling work. Results: The respondents averaged more than six hours of counseling work weekly and often addressed serious problems similar to those seen by secular mental health professionals, with whom they reported readily exchanging referrals. Many of the respondents reported having and maintaining specialized education for their counseling work, which they described as including both spiritual and psychological dimensions. Most of the pastors reported that they observe and address severe mental illness and substance abuse in their congregations and that they also counsel individuals outside their own denominations. Conclusions: African-American urban ministers functioning as pastoral counselors constitute an engaging and useful group with experiences and skills that can be tapped by interested secular professionals. Their work represents a significant mental health resource for persons who lack sufficient access to needed care. (Psychiatric Services 54:688–692, 2003)
TL;DR: A hybrid model is proposed to link efficacy and effectiveness research to foster broader use of empirically validated treatments in substance abuse treatment programs and enhance the scientific yield of effectiveness research.
Abstract: Many behavioral and pharmacologic treatments for which there is strong empirical support are rarely used in clinical practice in the treatment of substance dependence. In an effort to facilitate greater emphasis on issues such as utility, practicality, and cost earlier in the evaluation of promising therapies, the authors propose a hybrid model to link efficacy and effectiveness research. A hybrid model may foster broader use of empirically validated treatments in substance abuse treatment programs and enhance the scientific yield of effectiveness research. The hybrid model retains essential features of efficacy research (randomization, use of control conditions, independent assessment of outcome, and monitoring of treatment delivery) while expanding the research questions to also address issues of importance in effectiveness studies. Such issues include diversity in settings, clinicians, and patients; cost-effectiveness of treatment; training issues; and patient and clinician satisfaction.
TL;DR: The high levels of trauma and revictimization observed in the study highlight the need for the development of evidence-based interventions to treat trauma and its aftermath among women with schizophrenia or schizoaffective disorder.
Abstract: OBJECTIVE: The authors assessed the prevalence of traumatic life events and posttraumatic stress disorder (PTSD) among women with schizophrenia or schizoaffective disorder and co-occurring substance abuse or dependence. The association between PTSD and specific traumatic life events was also examined. METHODS: Fifty-four drug-addicted women with schizophrenia or schizoaffective disorder participated in the study. All women were psychiatric outpatients and completed a large battery of structured clinical assessments. RESULTS: High rates of trauma, particularly physical abuse (81 percent), and revictimization—being abused both as a child and as an adult—were reported. The average number of traumatic life events reported was eight, and almost three-quarters of the sample reported revictimization. Rates of current PTSD were considerably higher than those documented in previous study samples of persons with serious mental illness and of drug-addicted women in the general community. PTSD was significantly assoc...
TL;DR: Assessment of assaults among psychiatric inpatients revealed two psychosis-related factors related to positive psychotic symptoms and the other to psychotic confusion and disorganization, as well as a third factor that differentiated impulsive from psychopathic assaults.
Abstract: OBJECTIVE: The purpose of this study was to assess the extent to which psychosis, disordered impulse control, and psychopathy contribute to assaults among psychiatric inpatients. METHODS: The authors used a semistructured interview to elicit reasons for assaults from assailants and their victims on an inpatient research ward. Video monitoring provided supplemental information to confirm participants' identities and activities before and during the assault. RESULTS: Consensus clinical ratings indicated that approximately 20 percent of the assaults in this sample were directly related to positive psychotic symptoms. Factor analysis revealed two psychosis-related factors, one related to positive psychotic symptoms and the other to psychotic confusion and disorganization, as well as a third factor that differentiated impulsive from psychopathic assaults. CONCLUSIONS: Information obtained from interviews with assailants can reveal the underlying causes of specific assaults. This information is potentially usef...
TL;DR: The results of this analysis underscore the importance of clinical and administrative priorities in efforts to reduce the use of seclusion and restraint in public psychiatric hospitals.
Abstract: OBJECTIVE: The author reviews and evaluates a variety of interventions that were considered to have contributed to the successful reduction of reliance on the use of seclusion and restraint in a public psychiatric hospital for adult patients with severe and persistent psychiatric impairments. METHODS: A multiple regression analysis was applied to monthly seclusion and restraint data covering the period from 1997 to 2002. The independent variables were each of the component efforts to reduce reliance on seclusion and restraint at the hospital: changes in the criteria for administrative review of incidents of seclusion and restraint, changes in the composition of the case review committee, development of a behavioral consultation team, enhancement of standards for behavioral assessments and plans, and improvements in the staff-patient ratio. RESULTS: The use of seclusion and restraint was 75 percent lower during the final year of the five-year study period than it was during the first year. The only variabl...
TL;DR: Prescription benzodiazepine use was common among patients with co-occurring severe mental illness and a substance use disorder and was not associated with any of the measured outcomes other than increasing the likelihood of benzodiazine abuse.
Abstract: OBJECTIVES: Because use of benzodiazepines may exacerbate existing substance use disorders or become abused substances, prescription of benzodiazepines for patients with severe mental illness (schizophrenia or bipolar disorder) and co-occurring substance use disorders (abuse or dependence) is controversial. The authors examined benzodiazepine use and associated psychiatric, substance abuse, and institutional outcomes in a six-year longitudinal study of patients with co-occurring disorders. METHODS: At baseline and yearly follow-up for six years, 203 patients with co-occurring severe mental illness and substance use disorder were prospectively assessed for medication use, substance use, psychiatric symptoms, use of hospitalization, and quality of life. RESULTS: Almost one-half of the patients (43 percent) reported taking prescribed benzodiazepines at the time of at least one assessment. Patients taking prescribed benzodiazepines were more likely to have high scores on measures of overall symptoms and affec...
TL;DR: This study provided further evidence that VA disability compensation incentives influence the way some veterans report their symptoms when they are being evaluated for PTSD and suggested that current VA disability policies have problematic implications for the delivery of clinical care, evaluation of treatment outcome, and rehabilitation efforts within the VA.
Abstract: Objective: This study sought to further examine the relationship between compensation-seeking status and reporting of symptoms among combat veterans who were evaluated for posttraumatic stress disorder (PTSD). Methods: Archival data were drawn for 320 adult male combat veterans who were consecutively evaluated at a Department of Veterans Affairs (VA) PTSD outpatient clinic from 1995 to 1999. The veterans were compared on variables from their clinical evaluation, including diagnostic status and self-report measures such as the Minnesota Multiphasic Personality Inventory-2, which includes scales designed to detect feigned or exaggerated psychopathology. Results: Compensation-seeking veterans reported significantly more distress across domains of psychopathology, even after the effects of income had been controlled for and despite an absence of differences in PTSD diagnoses between groups. However, compensation-seeking veterans also were much more likely to overreport or exaggerate their symptoms than were non-compensation-seeking veterans. Conclusions: This study provided further evidence that VA disability compensation incentives influence the way some veterans report their symptoms when they are being evaluated for PTSD. These data suggest that current VA disability policies have problematic implications for the delivery of clinical care, evaluation of treatment outcome, and rehabilitation efforts within the VA. (Psychiatric Services 54:84–91, 2003)
TL;DR: The association of perceived safety with gender, the presence of PTSD, and increased alcohol use among survivors of the September 11, 2001, terrorist attack on the Pentagon warrants further study.
Abstract: OBJECTIVE: The authors examined posttraumatic stress disorder (PTSD), alcohol use, and perceptions of safety in a sample of survivors of the September 11, 2001, terrorist attack on the Pentagon. METHODS: Analyses were conducted to examine the effect of past traumatic experience, trauma exposure, initial emotional response, and peritraumatic dissociation on probable PTSD, substance use, and perceived safety among 77 survivors seven months after the attack. RESULTS: Eleven respondents (14 percent) had PTSD. Those with PTSD reported higher levels of initial emotional response and peritraumatic dissociation. Ten respondents (13 percent) reported increased use of alcohol. Women were more than five times as likely as men to have PTSD and almost seven times as likely to report increased use of alcohol. Persons with higher peritraumatic dissociation were more likely to develop PTSD and report increased alcohol use. Those with lower perceived safety at seven months had higher initial emotional response and greater...
TL;DR: Compared with patients who received conventional antipsychotics, those receiving atypical antipsychotic medications were significantly less likely to have a switch in medication and to use concomitant anticholinergic and anxiolytic medications.
Abstract: Objectives: Rates of medication adherence over a one-year period were assessed among outpatients with schizophrenia who initiated therapy with conventional or atypical antipsychotic agents. Methods: Data were drawn from paid medical and pharmacy claims for a random sample of 10 percent of all California Medicaid (“Medi-Cal”) recipients. Outpatients with schizophrenia who were aged 18 years or older and who initiated monotherapy with a conventional or atypical antipsychotic medication in the last quarter of 1997 were identified. The percentages of patients who discontinued antipsychotic therapy or who had a switch in medications over a one-year period were determined. The use of selected concomitant medications was also assessed. Data were analyzed by means of chi square tests and multivariate statistics that adjusted for demographic and clinical differences between medication groups. Results: A total of 298 patients who initiated therapy with a conventional (N=93) or atypical (N=205) antipsychotic medication were identified. The groups were similar in mean age (about 42 years) and gender distribution (about 54 percent were male). Compared with patients who received conventional antipsychotics, those receiving atypical antipsychotics were significantly less likely to have a switch in medication and to use concomitant anticholinergic and anxiolytic medications. In each group, antipsychotic medication was available for about 60 percent of days over one year of follow-up. Conclusions: Compared with the use of conventional antipsychotics, the use of atypical antipsychotic medications was associated with significantly less treatment switching and less use of concomitant medications. However, undertreatment, evidenced by a lack of prescription refills, occurred among patients taking both medication classes, which highlights the need for further research on nonadherence. (Psychiatric Services 54:719–723, 2003)
TL;DR: The arrival of atypical antipsychotics, with their lower rate of extrapyramidal effects, was greeted positively as an advance on the older drugs, and it was suggested that the lower rates of side effects would improve compliance, but few data to support this suggestion have been reported.
Abstract: Introduction by the column editor: The problem of noncompliance is one that affects all areas of medicine. Some opinion holds that it may be worse for psychiatric disorders, particularly the psychoses, and that the side effects of the older or conventional antipsychotics have played a major role in poor compliance. Side effects have also been proposed as the reason long-acting medications have been unpopular in the United States. This explanation, like many others, seems a bit simplistic and would not explain why European countries and Australia use ten times as many long-acting drugs as the United States.The arrival of atypical antipsychotics, with their lower rate of extrapyramidal effects, was greeted positively as an advance on the older drugs. It was suggested that the lower rate of side effects would improve compliance. However, few data to support this suggestion have been reported.
TL;DR: The rate of help seeking among persons with alcohol use problems is low, which is a public health concern, and multiple logistic regression analyses identified a number of subgroups who might have needed substance abuse services but did not receive them.
Abstract: OBJECTIVES: This study provided population estimates of mental syndromes and substance use problems and examined whether the co-occurrence of mental health and substance use problems was associated with the use of substance abuse treatment services. METHODS: Study data were drawn from the 1997 National Household Survey on Drug Abuse. RESULTS: Of the total sample of 16,661 adults, 2 percent reported using services for alcohol or drug use problems in the previous year. Among the 3,474 (17 percent) who reported at least one alcohol or drug use problem, 6 percent used substance abuse services. Only 4 percent of persons who reported substance use problems alone received any substance abuse treatment service in the previous year. Only 3 percent of persons who reported alcohol use problems alone received such services. Among persons with one or more substance use problems, the prevalence of service use was 11 percent among persons who reported one co-occurring mental syndrome and 18 percent among those who repor...
TL;DR: Multivariate logistic regression revealed that participants who received psychotropics, alone or in combination, were significantly more likely to be in state custody, male, and older than other participants and less likely to being African American or Hispanic.
Abstract: Objectives: The authors sought to determine the prevalence, patterns, and demographic correlates of multiple psychotropic pharmacotherapy in a statewide sample of low-income children and adolescents in community-based clinical care. Methods: The Medicaid managed care database of the Connecticut Department of Social Services was the source of linked encounter and pharmacy information for the one-year period ending June 30, 1999. Period prevalence was calculated for children and adolescents ranging in age from newborn through 18 years who had any psychotropic drug prescription claims during the study period. For each participant, multiple psychotropic pharmacotherapy was defined as having claims for prescriptions for medications in two or more different psychotropic drug classes during a seven-day period. Age, gender, race, and state custody status were examined across groups, and multiple psychotropic pharmacotherapy patterns were identified. Results: Of the 196,505 youths in Medicaid managed care, 9,447 received at least one psychotropic medication, yielding a period prevalence of 4.8 percent. Among youths who received psychotropics, 13.6 percent had received multiple psychotropic pharmacotherapy. Multivariate logistic regression revealed that participants who received psychotropics, alone or in combination, were significantly more likely to be in state custody, male, and older than other participants and less likely to be African American or Hispanic. Stimulants, antidepressants, and mood stabilizers were the most commonly dispensed agents. The most common drug class combinations were an antidepressant plus an antipsychotic, a stimulant plus an antidepressant, and a stimulant plus an alpha 2 agonist. Conclusions: Our findings revealed sociodemographic differences in psychopharmacological care among young Medicaid managed care enrollees and the common occurrence of multiple psychotropic pharmacotherapy. (Psychiatric Services 54:72–77, 2003)
TL;DR: Various changes, such as in contractual relationships, payment methods for primary care physicians, and performance measurement, can be made in existing institutional arrangements to better align them with emerging clinical technologies and evidence-based practice.
Abstract: Deficits in the quality of treatment of depression in the primary care sector have been documented in multiple studies. Several clinical models for improving primary care treatment of depression have been shown to be cost-effective in recent years but have not proved to be sustainable over time, partly because of barriers created by common organizational and financing arrangements such as managed behavioral health care carve-outs and risk-based provider payment mechanisms. These arrangements, which often distort relative costs that primary care physicians face when making treatment decisions for patients who have depression, can steer these decisions away from evidence-based practice. Various changes, such as in contractual relationships, payment methods for primary care physicians, and performance measurement, can be made in existing institutional arrangements to better align them with emerging clinical technologies and evidence-based practice.
TL;DR: The results of this study underscore the need for continuing concern about the use of case management and other mental health services by persons from ethnic minorities.
Abstract: OBJECTIVES: This study examined case management service use by ethnic group in a sample of 4,249 European-American, Latino, and African-American patients with a diagnosis of schizophrenia or schizoaffective disorder who were receiving services in the public mental health sector of San Diego County during fiscal year 1998-1999. METHODS: Data on demographic and clinical variables were obtained from the public mental health services database of the San Diego County Mental Health Department. Multivariate logistic regression analyses were used to determine the relationship between the demographic and clinical variables and use of case management services. RESULTS: The ethnic composition of the sample was 64 percent European American, 20 percent Latino, and 17 percent African American. Overall, 1,100 patients (26 percent) received case management services. A disproportionately greater percentage of service use occurred among European Americans (30 percent) than among patients from ethnic minorities (19 percent ...
TL;DR: National reforms and institutional efforts can lead to downward trends in the use of seclusion and restraint among psychiatrically hospitalized youths, and the active elements of these interventions warrant further study and replication.
Abstract: OBJECTIVES: This study examined characteristics associated with the use of seclusion and restraint among 442 psychiatrically hospitalized youths and sought to quantify changing trends in the rates of these modalities of treatment over time after the 1999 implementation of federal regulations and an institutional performance improvement program. METHODS: Demographic and clinical data related to all 5,929 incidents of seclusion and restraint that occurred during 2000 and 2001 at a child and adolescent state psychiatric hospital were analyzed. RESULTS: The two-year prevalence of use of seclusion was 61 percent and of restraint was 49 percent. Children and adolescents who were admitted on an emergency basis and those belonging to ethnic minority groups were more likely to undergo seclusion or restraint. Children aged 11 years and younger were more likely to undergo seclusion. The total number of episodes decreased by 26 percent and their cumulative duration decreased by 38 percent between the first quarter of...