Showing papers in "Psychiatric Services in 2009"

Prevalence of Serious Mental Illness Among Jail Inmates

Abstract: Objective: This study estimated current prevalence rates of serious mental illness among adult male and female inmates in five jails during two time periods (four jails in each period). Methods: During two data collection phases (2002–2003 and 2005–2006), recently admitted inmates at two jails in Maryland and three jails in New York were selected to receive the Structured Clinical Interview for DSM-IV (SCID). Selection was based on systematic sampling of data from a brief screen for symptoms of mental illness that was used at admission for all inmates. The SCID was administered to a total of 822 inmates—358 during phase I and 464 during phase II. To determine the current (past-month) prevalence of serious mental illness (defined as major depressive disorder; depressive disorder not otherwise specified; bipolar disorder I, II, and not otherwise specified; schizophrenia spectrum disorder; schizoaffective disorder; schizophreniform disorder; brief psychotic disorder; delusional disorder; and psychotic disorder not otherwise specified), interview data were weighted against strata constructed from the screening samples for male and female inmates by jail and study phase. Results: Across jails and study phases the rate of current serious mental illness for male inmates was 14.5% (asymmetric 95% confidence interval [CI]=11.0%–18.9%) and for female inmates it was 31.0% (asymmetric CI=21.7%–42.1%). Conclusions: The estimates in this study have profound implications in terms of resource allocation for treatment in jails and in community-based settings for individuals with mental illness who are involved in the justice system. Psychiatric Services 60:761–765, 2009)

County-Level Estimates of Mental Health Professional Shortage in the United States

Abstract: Objective: This study examined shortages of mental health professionals at the county level across the United States. A goal was to motivate discussion of the data improvements and practice standards required to develop an adequate mental health professional workforce. Methods: Shortage of mental health professionals was conceptualized as the percentage of need for mental health visits that is unmet within a county. County-level need was measured by estimating the prevalence of serious mental illness, then combining separate estimates of provider time needed by individuals with and without serious mental illness derived from National Comorbidity Survey Replication, U.S. Census, and Medical Panel Expenditure Survey data. County-level supply data were compiled from professional associations, state licensure boards, and national certification boards. Shortage was measured for prescribers, nonprescribers, and a combination of both groups in the nation’s 3,140 counties. Ordinary least-squares regression identified county characteristics associated with shortage. Results: Nearly one in five counties (18%) in the nation had unmet need for nonprescribers. Nearly every county (96%) had unmet need for prescribers and therefore some level of unmet need overall. Rural counties and those with low per capita income had higher levels of unmet need. Conclusions: These findings identified widespread prescriber shortage and poor distribution of nonprescribers. A caveat is that these estimates of need were extrapolated from current provider treatment patterns rather than from a normative standard of how much care should be provided and by whom. Better data would improve these estimates, but future work needs to move beyond simply describing shortages to resolving them. (Psychiatric Services 60:1323–1328, 2009)

What did STAR*D teach us? Results from a large-scale, practical, clinical trial for patients with depression

Abstract: The authors provide an overview of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study (www.star-d.org), a large-scale practical clinical trial to determine which of several treatments are the most effective "next-steps" for patients with major depressive disorder whose symptoms do not remit or who cannot tolerate an initial treatment and, if needed, ensuing treatments. Entry criteria were broadly defined and inclusive, and patients were enrolled from psychiatric and primary care clinics. All participants began on citalopram and were managed by clinic physicians, who followed an algorithm-guided acute-phase treatment through five visits over 12 weeks. At the end of each sequence, patients whose depression had not fully remitted were eligible for subsequent randomized trials in a sequence of up to three clinical trials. In general, remission rates in the study clinics were lower than expected, suggesting the need for several steps to achieve remission for most patients. There was no clear medication "winner" for patients whose depression did not remit after one or more aggressive medication trials. Both switching and augmenting appeared to be reasonable options when an initial antidepressant treatment failed, although these two strategies could not be directly compared. Further, the likelihood of remission after two vigorous medication trials substantially decreased, and remission would likely require more complicated medication regimens for which the existing evidence base is quite thin. STAR*D demonstrated that inclusion of more real-world patients in clinical trials is both feasible and informative. Policy implications of the findings, as well as the study's limitations, are discussed.

Perceived Stigma and Barriers to Mental Health Care Utilization Among OEF-OIF Veterans

Abstract: Objective: This study examined whether social support and beliefs about mental health care are associated with stigma, barriers to care, and mental health care utilization in a sample of veterans of Operation Enduring Freedom in Afghanistan and Operation Iraqi Freedom (OEF-OIF). Methods: A sample of 272 predominantly reservist and National Guard OEF-OIF veterans in Connecticut completed a needs assessment survey. Results: Negative beliefs about mental health care, particularly psychotherapy, and decreased perceived unit support predicted increased perceptions of stigma and barriers to care. Negative beliefs about mental health care were also associated with decreased likelihood of mental health counseling and medication visits in the past six months, even after adjustment for demographic characteristics, psychiatric disorders, and support variables. Conclusions: Educational interventions for modifying negative beliefs about mental health care and bolstering unit support may help decrease stigma and barriers to care and increase mental health treatment seeking among OEF-OIF veterans. (Psychiatric Services 60: 1118–1122, 2009)

Dropout From Outpatient Mental Health Care in the United States

Abstract: Objectives—Although mental health treatment dropout is common, patterns and predictors of dropout are poorly understood. This study explores patterns and predictors of mental health treatment dropout in a nationally representative sample. Methods—Data come from the National Comorbidity Survey Replication (NCS-R), a nationally representative household survey. Respondents in mental health treatment in the 12 months (n=1,664) before interview were asked about dropout defined as quitting treatment before the provider wanted. Cross-tabulation and discrete-time survival analyses were used to identify predictors. Results—Approximately one-fifth (22.4%) of patients quit treatment prematurely. The highest dropout rate was from the general medical sector (31.6%) and the lowest was from psychiatrists (15.1%). Dropout rates were intermediate in the human service sector (19.7%) and among patients seen by non-psychiatrist mental health professionals (18.9%). Over 70% of all dropout occurred after the first or second visits. Mental health insurance was associated with low odds of dropout (0.6, 0.4– 0.9). Psychiatric comorbidity was associated with a trend towards dropout. Several patient characteristics differentially predicted dropout across treatment sectors and in early and later phases of treatment. Conclusions—Roughly one-fifth of adults in mental health treatment each year drop out before completing the recommended course of treatment. Dropout is most common in the general medical sector and varies by patient characteristics across treatment sectors. Interventions focused on highrisk patients and sectors will likely be required to reduce the high proportion of patients who prematurely terminate treatment.

Provider attitudes toward evidence-based practices: are the concerns with the evidence or with the manuals?

Abstract: Objective: Studies examining therapists’ attitudes toward evidencebased practices, which have at times become conflated with “manualized treatments,” have indicated a number of concerns regarding perceived inflexibility, a lack of attention to the therapeutic alliance between provider and client, and a lack of emphasis on clinical judgment. This investigation examined the effect of training in two different formats of evidence-based treatments (standard treatment manuals versus modular assembly of treatment procedures) and with the use of two measures of attitudes. Methods: As part of a randomized clinical effectiveness trial, the attitudes of 59 therapists were assessed before and after training for a standard evidence-based treatment protocol and for a modular evidence-based treatment protocol. Attitudes were also assessed across two attitude measures that differentially emphasize the use of treatment manuals. Results: Results showed that compared with the standard condition, in the modular condition therapists’ attitudes became significantly more favorable toward evidence-based practices but only on the attitude measure that did not refer specifically to the use of manuals. Conclusions: The findings of this investigation have implications for dissemination of evidence-based practices and policy change. Contextual adaptations in evidence-based practice design and training may result in wider adoption of innovative and efficacious treatment practices. (Psychiatric Services 60:677–681, 2009)

Premature Mortality From General Medical Illnesses Among Persons With Bipolar Disorder: A Review

Abstract: Objective: Despite recent evidence that patients with bipolar disorder are at increased risk of premature mortality resulting from general medical disorders, there has been no systematic review of published studies. The authors reviewed the literature to determine whether there is evidence of increased risk of mortality from general medical causes among patients with bipolar spectrum disorders. Methods: MEDLINE was searched from 1959 to 2007 with a focus on bipolar disorder and medical mortality. Published studies in English with more than 100 patients were included. Results: Seventeen studies were identified involving 331,000 patients with bipolar disorder, affective psychosis, affective disorder severe enough to require inpatient psychiatric care or treatment with lithium, or schizoaffective disorder (that is, bipolar spectrum disorders) meeting the inclusion criteria. Compared with age- and sex-matched control samples without mental illness in the general population, mortality ratios for death from natural causes and from specific general medical conditions, such as cardiovascular, respiratory, cerebrovascular, and endocrine disorders, were significantly higher among patients with bipolar spectrum disorders in most studies. This finding was more consistent in larger studies with more than 2,500 patients with bipolar spectrum disorders. Cumulatively, cardiovascular disorder appeared to be the most consistent cause of excess mortality in larger studies. Conclusions: The available evidence suggests that bipolar spectrum disorders are associated with increased premature mortality secondary to general medical illnesses. Unhealthy lifestyle, biological factors, adverse pharmacologic effects, and disparities in health care are possible underlying causes for this excess mortality. (Psychiatric Services 60:147–156, 2009)

Risk Factors for Homelessness: Evidence From a Population-Based Study

Abstract: OBJECTIVE: This study examined factors associated with lifetime experience of homelessness among young adults. METHODS: Data were analyzed for 14,888 young adults (mean±SD age 21.97±1.77; 7,037 men and 7,851 women) who participated in the National Longitudinal Study of Adolescent Health (Add Health), a U.S. nationally representative, population-based sample. Data were collected from young adults through computer-assisted interviews six years after they had enrolled in the study as adolescents. Variables that have been associated with lifetime homelessness in at least one service sample were mapped to Add Health survey items. Data were analyzed by logistic regression. RESULTS: A total of 682 respondents (4.6%) were classified as ever being homeless. Several factors related to childhood experiences of poor family functioning, socioeconomic disadvantage, and separation from parents or caregivers were independently associated with ever being homeless. Other significant independent factors included current socioeconomic difficulty, mental health problems, and addiction problems. Indicators of involvement in crime and addiction problems with gambling and alcohol were not independently associated with homelessness. CONCLUSIONS: The findings underscore the relationship between specific indicators of adversity in childhood and risk of homelessness and point to the importance of early intervention efforts. Consistent with the extant research literature, mental health problems also appear to be associated with homelessness, highlighting the potentially complex service needs of this population.

Public Awareness Campaigns About Depression and Suicide: A Review

Abstract: Objective: Numerous institutions, including the World Health Organization, recommend education campaigns targeted at the general public to improve awareness of suicidal crises and, more broadly, of depression; to improve access to care; and to combat the stigma associated with these illnesses and discrimination against people who have them. The purpose of this literature review was to gather information on campaigns about depression or suicide awareness and summarize data on the impact and effectiveness of these campaigns. Methods: A search was conducted of MEDLINE, the Cochrane Library, PsycINFO, HDA (Health Development Agency) Evidence Base, DARE (Database of Abstracts of Reviews of Effects), and the ISI Web of Science to identify articles written in English and published between 1987 and 2007 that described depression or suicide awareness programs that targeted the public. Results: Among the 200 publications for which references were found, 43 publications that described 15 programs in eight countries met inclusion criteria. Comparing the programs was difficult because of the diversity of their objectives and the methods used to deliver the programs and to evaluate them. Results suggest that these programs contributed to a modest improvement in public knowledge of and attitudes toward depression or suicide, but most program evaluations did not assess the durability of the attitude changes. No study has clearly demonstrated that such campaigns help to increase care seeking or to decrease suicidal behavior. Conclusions: Developing guidelines for assessment of public education campaigns to improve knowledge about suicide and depression is essential for the sharing of knowledge among scientists and stakeholders. (Psychiatric Services 60:1203–1213, 2009)

Cognitive Enhancement Therapy for Early Course Schizophrenia: Effects of a Two-Year Randomized Controlled Trial

Abstract: Objective The early application of cognitive rehabilitation may afford long-term functional benefits to patients with schizophrenia. This study examined the two-year effects of an integrated neurocognitive and social-cognitive rehabilitation program, cognitive enhancement therapy (CET), on cognitive and functional outcomes in early course schizophrenia.

A Randomized Controlled Trial of Culturally Relevant, Brief Interpersonal Psychotherapy for Perinatal Depression

Abstract: Objectives—Depression during pregnancy is one of the strongest predictors of postpartum depression, which, in turn, has deleterious, lasting effects on infant and child well-being and on the mother’s and father’s mental health. The primary question guiding this randomized controlled trial was, Does culturally relevant, enhanced brief interpersonal psychotherapy (IPT-B) confer greater advantages to low-income, pregnant women than those that accrue from enhanced usual care in treating depression in this population? Enhanced IPT-B is a multicomponent model of care designed to treat antenatal depression and consists of an engagement session, followed by eight acute IPT-B sessions before the birth and maintenance IPT up to six months postpartum. IPT-B was specifically enhanced to make it culturally relevant to socioeconomically disadvantaged women. Methods—Fifty-three non–treatment-seeking, pregnant African-American and white patients receiving prenatal services in a large, urban obstetrics and gynecology clinic and meeting criteria for depression on the Edinburgh Postnatal Depression Scale (score >12 on a scale of 0 to 30) were randomly assigned to receive either enhanced IPT-B (N=25) or enhanced usual care (N=28), both of which were delivered in the clinic. Participants were assessed before and after treatment on depression diagnoses, depressive symptoms, and social functioning.

Patients' Depression Treatment Preferences and Initiation, Adherence, and Outcome: A Randomized Primary Care Study

Abstract: Objective: The authors examined the association of treatment preferences with treatment initiation, adherence, and clinical outcome among nonsenior adult and senior primary care patients with depression. Methods: Sixty primary care participants meeting DSM-IV criteria for major depression were randomly assigned to receive treatment congruent or incongruent with their primary stated preference. Participants received either 20 weeks of escitalopram, with monitoring by a care manager, or 12 weekly sessions of interpersonal psychotherapy followed by two monthly booster sessions. Adherence to treatment and depression severity were reassessed at weeks 4, 8, 12, and 24. Results: Participants expressed stronger preferences for psychotherapy than for antidepressant medication. Preference strength was a more sensitive measure of outcome than was congruence versus incongruence of preference with the assigned treatment. Across age groups, preference strength was significantly associated with treatment initiation and 12week adherence rate but not with depression severity or remission. Conclusions: A continuous measure of preference strength may be a more useful measure in clinical practice than preferences per se. Future research should focus on whether and how greater facilitation of the treatment decision-making process between patient and clinician influences clinical outcome. (Psychiatric Services 60:337–343, 2009)

Unmet Need for Treatment of Major Depression in the United States

Abstract: Objective: This study examined the extent and correlates of perceived unmet need for treatment among individuals with depression in the U.S. general population. Methods: Analyses were based on a representative sample of 6,510 adult participants in the 2005 and 2006 National Surveys on Drug Use and Health who reported a major depressive episode in the past 12 months. Results: A total of 3,568 (62.4%) participants had sought mental health treatment in the past 12 months, and 2,942 (37.6%) had not; 34.9% and 26.8% of these groups, respectively, reported unmet need for treatment. In both groups, older age was associated with a lower likelihood of reporting unmet need for treatment, whereas greater distress and impairment and higher education were associated with a greater likelihood of reporting unmet need. Among treatment seekers, treatment from general medical providers was associated with greater likelihood of unmet need, and more outpatient visits and insurance coverage for the full year were associated with a lower likelihood of unmet need. The most common reason for not seeking needed treatment was a concern about costs (cited as a reason by 46.0% of the total sample). Conclusions: Even though rates of treatment seeking have increased, many persons with major depression continue to experience unmet need for treatment, which in this study was mainly attributable to concerns about treatment costs. (Psychiatric Services 60: 297–305, 2009)

Off-Label Use of Antipsychotic Medications in the Department of Veterans Affairs Health Care System

Abstract: Objective: This study aimed to determine the prevalence of prescribing antipsychotics to adults without schizophrenia or bipolar disorder and to identify factors associated with such off-label use. Methods: Patients with at least one prescription for an antipsychotic medication from the Department of Veterans Affairs (VA) during fiscal year (FY) 2007 were identified in national VA administrative databases. Rates of off-label antipsychotic use were determined along with average doses. Multivariate logistic regression models identified sociodemographic and clinical characteristics associated with off-label use. Results: Of the 279,778 individuals in FY 2007 who received an antipsychotic medication, 168,442 (60.2%) had no record of a diagnosis for which these drugs are approved. The most common mental illness diagnoses among patients given prescriptions for antipsychotics off label were posttraumatic stress disorder (PTSD, 41.8%), minor depression (39.5%), major depression (23.4%), and anxiety disorder (20.0%). Among VA patients with mental illness other than schizophrenia or bipolar disorder, the proportion who received prescriptions for antipsychotic medications ranged from a low of 9.1% among patients with adjustment reaction; to about 20% for those with depression, dementia, or PTSD; and to a high of 40.7% among patients with other psychoses. Doses were low, with over half of patients who received off-label quetiapine, risperidone, or first-generation antipsychotics receiving doses below those recommended for schizophrenia. In logistic regression models, patients diagnosed as having other psychosis or dementia had the highest odds of receiving an antipsychotic medication off label. Conclusions: Off-label use of antipsychotic medications was common. Given that these drugs are expensive, have potentially severe side effects, and have limited evidence supporting their effectiveness for off-label usage, they should be used with greater caution. (Psychiatric Services 60:1175–1181, 2009)

Use of a critical time intervention to promote continuity of care after psychiatric inpatient hospitalization.

Abstract: Objectives: This study assessed the effectiveness of a brief three-month critical time intervention (B-CTI) model in improving continuity of psychiatric outpatient care for individuals with serious mental illness who are discharged from inpatient psychiatric treatment facilities. Methods: A total of 135 consenting veterans who were diagnosed as having serious mental illness and were discharged from an acute inpatient unit were randomly assigned to receive either B-CTI or usual care. The three-month B-CTI intervention begins before discharge. A B-CTI clinician meets with the patient, assesses needs, and maintains a high level of patient contact after discharge. Participants completed interviews at baseline and three months later. Chart reviews provided data on service utilization in the six months postdischarge. Results: Compared with the control group, the B-CTI group had significantly fewer days between their hospital discharge and their first outpatient service. B-CTI participants were more likely to have had an outpatient visit and to have had more total mental health and substance abuse visits within 30 and 180 days of discharge. They had greater continuity of care as evidenced by a greater number of two-month blocks with two or more outpatient visits over 180 days. Participants in the B-CTI group reported receiving more help in making and keeping medical and mental health appointments, making family contact and community connections, and receiving information on prescribed medications. Conclusions: This study provides evidence that a B-CTI targeted at the point of inpatient discharge can be helpful in promoting postdischarge continuity of care for persons with serious mental illness. The limited association of improved continuity of care with patient outcomes in this brief intervention demands further study. (Psychiatric Services 60:451–458, 2009)

Datapoints: psychotropic drug prescriptions by medical specialty.

Abstract: 1167 T important role of general practitioners in prescribing antidepressant medications and treating depression has been documented. However, the extent to which general practitioners are prescribing other types of psychotropic medications has received less emphasis. This study used data from August 2006 to July 2007 from the National Prescription Audit (NPA) Plus database of IMS to examine this question. IMS collects transaction information each month from approximately 36,000 retail pharmacies, representing about 70% of all retail pharmacies, which when weighted represent all prescriptions filled in retail outlets in the United States. Using a separate sample of retail pharmacy transactions that includes the physician’s Drug Enforcement Administration number, IMS assigns physician specialty information to obtain an estimate of the total number of prescriptions filled in retail pharmacies by medical specialty. As shown Figure 1, of the 472 million prescriptions for psychotropic medications, 59% were written by general practitioners, 23% by psychiatrists, and 19% by other physicians and nonphysician providers. General practitioners wrote prescriptions for 65% of the anxiolytics in the sample, 62% of the antidepressants, 52% of the stimulants, 37% of the antipsychotics, and 22% of the antimania medications. Conversely, psychiatrists and addiction specialists wrote prescriptions for 66% of the antimania medications, 49% of the antipsychotics, 34% of the stimulants, 21% of the antidepressants, and 13% of the anxiolytics. Pediatricians were included as general practitioners and wrote 25% of all stimulant prescriptions but only 3% of all other types of psychotropic medications (data not shown). Prescribing of psychotropic medications by nonpsychiatrists improves access to treatment. However, concerns remain about whether patients treated in the general medical setting are receiving treatment concordant with evidence-based guidelines, psychotherapy, adequate medication monitoring, and appropriate intensity of treatment. Psychotropic Drug Prescriptions by Medical Specialty

Initial outcomes of a mental illness self-management program based on wellness recovery action planning

Abstract: Objective: This study examined changes in psychosocial outcomes among participants in an eightweek, peer-led, mental illness self-management intervention called Wellness Recovery Action Planning (WRAP). Methods: Eighty individuals with serious mental illness at five Ohio sites completed telephone interviews at baseline and one month after the intervention. Results: Paired t tests of pre- and postintervention scores revealed significant improvement in self-reported symptoms, recovery, hopefulness, selfadvocacy, and physical health; empowerment decreased significantly and no significant changes were observed in social support. Those attending six or more sessions showed greater improvement than those attending fewer sessions. Conclusions: These promising early results suggest that further research on this intervention is warranted. Confirmation of the efficacy and effectiveness of peer-led self-management has the potential to enhance self-determination and promote recovery for people with psychiatric disabilities. (Psychiatric Services 60:246–249, 2009)

Cultural Competence: A Literature Review and Conceptual Model for Mental Health Services

Abstract: This article presents a conceptual model of organizational cultural competence for use in mental health services that resulted from a comprehensive review of the research literature. The model identifies four factors associated with cultural competence in mental health services (community context, cultural characteristics of local populations, organizational infrastructure, and direct service support) and redefines cultural competence as the degree of compatibility among these factors. A strength of this model of organizational cultural competence is that it facilitates future research and practice in psychiatric services settings and links culturally competent practices to service parity.

Psychiatrists' use of shared decision making in the treatment of schizophrenia: patient characteristics and decision topics.

Abstract: Objective: Shared decision making is advocated as a way of involving patients in medical decisions, but it can be achieved only when both patients and physicians commit to sharing decisions. This study explored psychiatrists’ views of shared decision making in schizophrenia treatment. Method: A structured questionnaire was given to 352 psychiatrists at the 2007 congress of the German Society of Psychiatry, Psychotherapy, and Nervous Diseases to determine their self-reported decisionmaking styles. Approximately half of the psychiatrists (N=181) were then asked to rate how 19 patient characteristics would influence whether they would share in decision making, and the other half (N=171) were asked whether 19 decision topics would be suitable for shared decision making. Results: Of the 352 participating psychiatrists, 51% reported regularly applying shared decision making, but decisionmaking styles were tailored to individual patients and decision topics. Shared decision making was seen as useful for well-informed and compliant patients and for those who currently dislike their antipsychotic, but it was not seen as useful in cases of potentially reduced decisional capacity. Psychosocial matters (for example, work therapy, future housing, and psychotherapy) were considered more suitable for shared decision making than were medical and legal decisions (for example, hospitalization, prescription of antipsychotics, and diagnostic procedures). Conclusions: It should be clarified whether and how patients with schizophrenia can be empowered and educated so they can share important treatment decisions. (Psychiatric Services 60:1107–1112, 2009)

The long-term impact of employment on mental health service use and costs for persons with severe mental illness.

Abstract: Objective: Stable employment promotes recovery for persons with severe mental illness by enhancing income and quality of life, but its impact on mental health costs has been unclear. This study examined service cost over ten years among participants in a co-occurring disorders study. Methods: Latent-class growth analysis of competitive employment identified trajectory groups. The authors calculated annual costs of outpatient services and institutional stays for 187 participants and examined group differences in ten-year utilization and cost. Results: A steady-work group (N=51) included individuals whose work hours increased rapidly and then stabilized to average 5,060 hours per person over ten years. A late-work group (N=57) and a no-work group (N=79) did not differ significantly in utilization or cost outcomes, so they were combined into a minimumwork group (N=136). More education, a bipolar disorder diagnosis (versus schizophrenia or schizoaffective disorder), work in the past year, and lower scores on the expanded Brief Psychiatric Rating Scale predicted membership in the steady-work group. These variables were controlled for in the outcomes analysis. Use of outpatient services for the steadywork group declined at a significantly greater rate than it did for the minimum-work group, while institutional (hospital, jail, or prison) stays declined for both groups without a significant difference. The average cost per participant for outpatient services and institutional stays for the minimum-work group exceeded that of the steady-work group by $166,350 over ten years. Conclusions: Highly significant reductions in service use were associated with steady employment. Given supported employment’s well-established contributions to recovery, evidence of long-term reductions in the cost of mental health services should lead policy makers and insurers to promote wider implementation. (Psychiatric Services 60: 1024–1031, 2009)

Approval Ratings of Inpatient Coercive Interventions in a National Sample of Mental Health Service Users and Staff in England

Abstract: Objective: To ascertain the degree of approval amongst service users and staff for various coercive measures commonly used in acute mental health care. Methods: A cross-sectional design was adopted. The Attitudes to Containment Measures Questionnaire (ACMQ) was completed by 1,361 service users and 1,226 staff in acute care mental health services from three regions of England. This provided evaluation of eleven coercive measures (e.g. seclusion) on six dimensions of approval (e.g. indignity, safety) in a large national sample. Comparisons between groups were tested using independent samples t-tests, χ2 or Spearman correlations. Results: Both service users and staff disapproved strongly of mechanical restraint and expressed a relative preference for compulsory intramuscular medication and seclusion. Male staff, older service users and staff who had been involved in implementing coercion expressed greater approval of coercive measures. Conclusion: Mechanical restraint remains highly objectionable to staff and service users in English mental health services despite its widespread acceptance elsewhere in the world.

The Role of Social Network and Support in Mental Health Service Use: Findings From the Baltimore ECA Study

Abstract: Objective: A significant number of people with mental illness do not use mental health services to receive treatment for their symptoms. This study examined the hypothesis that social network and social support affect mental health service use. Methods: Data were from the Baltimore cohort of the Epidemiologic Catchment Area study, a prospective cohort study that gathered data over four time points. This study examined data gathered in 1993–1996 (N=1,920) and 2004–2005 (N=1,071). The study examined indicators of social network and social support in relation to four types of service use (general medical, mental health within general medical, specialty psychiatric, and other human services) with multivariate logistic regression. Examples of other human services include a selfhelp group or crisis center for help with any psychological problem. Weighted generalized estimating equations were used for the analyses. Results: Among persons with major depressive disorder, generalized anxiety disorder, panic disorder, or alcohol use disorder in the past year or psychological distress in the past few weeks, general medical service use was reduced when the frequency of contact with relatives or friends occurred less than daily, but it was increased by about 40% when there was a higher than median level of spousal support. In contrast, receiving general medical services for mental health problems was reduced by about 50% when there was a higher than median level of social support from relatives. Specialty psychiatric service use was reduced when there was regular contact with six or more relatives and there was a higher than median level of social support from friends and relatives. None of the social network or social support measures were significantly (p≤.01) associated with use of other human services. Conclusions: Increased contact with the social network and higher levels of social support were associated with greater use of general medical services. However, more social support was associated with use of fewer services within the specialty psychiatric sector. (Psychiatric Services 60:1222–1229, 2009)

Does One Size Fit All? What We Can and Can't Learn From a Meta-analysis of Housing Models for Persons With Mental Illness

Abstract: Objective: Numerous studies have evaluated the impacts of community housing models on outcomes of persons with severe mental illness. The authors conducted a meta-analysis of 44 unique housing alternatives described in 30 studies, which they categorized as residential care and treatment, residential continuum, permanent supported housing, and nonmodel housing. Outcomes examined included housing stability, symptoms, hospitalization, and satisfaction. Methods: Outcome scores were converted to effect size measures appropriate to the data. Effect sizes were combined to estimate random effects for housing models, which were then compared. Results: All models achieved significantly greater housing stability than nonmodel housing. This effect was greatest for permanent supported housing (effect size=.63, p<.05). No differences between housing models were significant. For reduction of psychiatric symptoms, only residential care and treatment differed from nonmodel housing (effect size=.65, p<.05). For hospitalization reduction, both residential care and treatment and permanent supported housing differed from nonmodel housing (p<.05). Permanent supported housing achieved the highest effect size (.73) for satisfaction and differed from nonmodel housing and residential care and treatment (p<.001 and p<.05, respectively). Conclusions: The meta-analysis provides quantitative evidence that compared with nonmodel housing, housing models contribute to stable housing and other favorable outcomes. The findings also support the theory that different housing models achieve different outcomes for different subgroups. Data were not sufficient to fully answer questions designed to enable program planners and providers to better meet consumers’ needs. It is important to answer these questions with research that uses common measures and adheres to scientific conventions. (Psychiatric Services 60:473–482, 2009)

Implementing the Illness Management and Recovery Program in Community Mental Health Settings: Facilitators and Barriers

Abstract: Objective: There is little research on how to effectively implement the illness management and recovery program for people with severe mental illness in community mental health settings. This study aimed to examine which factors promote or hinder successful implementation of illness management and recovery in these settings. Methods: Twelve community mental health centers implemented illness management and recovery over a two-year period. They were supported in this endeavor by an implementation resource kit and regular meetings with a consultant trainer. Implementation efforts at each center were monitored by a supervised researcher (an implementation monitor) over the two years. This researcher conducted qualitative interviews with key informants every six months and conducted more frequent observations of routine activity in order to discern the implementation progress. These qualitative data were gathered into a database that was examined by the authors to discern key cross-site barriers to and facilitators of the implementation of illness management and recovery. Results: Through content analysis of the qualitative data, four broad cross-site themes emerged that appear to meaningfully determine success or failure of implementation. These were leadership, organizational culture, training, and staff and supervision. These overlapping themes worked synergistically to effect implementation. Conclusions: Implementation of illness management and recovery in community mental health settings is facilitated through strong leadership, an organizational culture that embraces innovation, effective training, and committed staff. Where these factors are lacking, strategies may need to be developed to effectively implement and sustain illness management and recovery. (Psychiatric Services 60:202–209 2009)

The STAR*D trial: revealing the need for better treatments.

Abstract: STAR * D (Sequenced Treatment Alternatives to Relieve Depression) continues to stimulate debate. The landmark trial demonstrated the feasibility of large-scale, community-based studies conducted without pharmaceutical company support. The results provided insight into nonresponse to initial treatment with selective serotonin reuptake inhibitors and alternatives for second- and third-line treatment options and suggested opportunities for personalized approaches to depression care. However, initial and one-year remission rates (28% and 70%, respectively) suggest that important goals for treatment of this disabling disease remain out of reach and that the bar for antidepressants has been set far too low.

Apples Don't Fall Far From the Tree: Influences on Psychotherapists' Adoption and Sustained Use of New Therapies

Abstract: Objective: The purpose of this investigation was to identify influences on the current clinical practices of a broad range of mental health providers as well as influences on their adoption and sustained use of new practices. Methods: U.S. and Canadian psychotherapists (N=2,607) completed a Web-based survey in which they rated factors that influence their clinical practice, including their adoption and sustained use of new treatments. Results: Empirical evidence had little influence on the practice of mental health providers. Significant mentors, books, training in graduate school, and informal discussions with colleagues were the most highly endorsed influences on current practice. The greatest influences on psychotherapists’ willingness to learn a new treatment were its potential for integration with the therapy they were already providing and its endorsement by therapists they respected. Clinicians were more often willing to continue to use a new treatment when they were able to effectively and enjoyably conduct the therapy and when their clients liked the therapy and reported improvement. Conclusions: Implications for dissemination and sustained use of new psychotherapies by community psychotherapists are discussed. For example, evidence-based treatments may best be promoted through therapy courses and workshops, beginning with graduate studies; to ensure future use of new therapies, developers of training workshops should emphasize ways to integrate their approaches into clinicians’ existing practices. (Psychiatric Services 60:671–676, 2009)

Perceptions of Need and Help Received for Substance Dependence in a National Probability Survey

Abstract: Objective: Most individuals with alcohol or other substance use disorders do not seek help for these problems. This study examined the factors associated with perceptions of need for help and receipt of help among individuals with alcohol or other substance dependence disorders in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Methods: The 2001–2002 NESARC surveyed a representative sample of the noninstitutionalized population in the United States. Individuals with a past-year substance dependence diagnosis (N=1,602) were classified into one of three groups: received help in the past year (14.7%), perceived a need for help but did not receive it (8.5%), or perceived no need and received no help (76.8%). Multinomial logistic regression with population weights was used to examine the influence of predisposing, enabling, and need-related factors on help seeking in the past year. Results: Factors that increased the receipt of help included older age, drug dependence (versus alcohol dependence only), longer time since the onset of dependence, co-occurring mood disorder, and more problems associated with substance use. Nonwhites were about twice as likely as whites (odds ratio=2.2) to perceive a need for help but not receive it. Similarly, more problems associated with substance use increased the odds of both receiving help and perceiving a need for help but not receiving it. None of the enabling characteristics were associated with help seeking or perceived need, after analyses controlled for predisposing and need-related factors. Conclusions: Increasing the recognition of problems associated with substance dependence, particularly alcohol, may facilitate help seeking, although barriers persist in regard to age and race-ethnicity. (Psychiatric Services 60:1068–1074, 2009)