Showing papers in "Psychiatric Services in 2010"

Reintegration Problems and Treatment Interests Among Iraq and Afghanistan Combat Veterans Receiving VA Medical Care

Abstract: Objective The objectives of this study were to describe the prevalence and types of community reintegration problems among Iraq and Afghanistan combat veterans who receive U.S. Department of Veterans Affairs (VA) medical care, identify interests in interventions or information to promote readjustment to community life, and explore associations between probable posttraumatic stress disorder (PTSD) and reintegration problems and treatment interests. Methods A national, stratified sample of Iraq-Afghanistan combat veterans receiving VA medical care responded to a mailed survey focused on community reintegration. Of 1,226 veterans surveyed, 754 (62%) responded. Prevalence and proportions were adjusted for potential nonresponse bias. Results An estimated 25% to 56% of combat veterans who use VA services reported "some" to "extreme" difficulty in social functioning, productivity, community involvement, and self-care domains. At least one-third reported divorce, dangerous driving, increased substance use, and increased anger control problems since deployment. Almost all (96%) expressed interest in services to help readjust to civilian life (95% confidence interval [CI]=93%-99%). The most commonly preferred ways to receive reintegration services or information were at a VA facility, through the mail, and over the Internet. An estimated 41% (95% CI=36%-46%) screened positive for PTSD, and probable PTSD was associated with reporting more readjustment difficulties and expressing interest in more types of services, including traditional mental health services. Conclusions Iraq-Afghanistan combat veterans who already receive VA medical care reported multiple current reintegration problems and wanted services and information to help them readjust to community life. These concerns were particularly prevalent among those with probable PTSD. Research is needed to explore nontraditional modes of service delivery, including the Internet.

Stigma, Barriers to Care, and Use of Mental Health Services Among Active Duty and National Guard Soldiers After Combat

Abstract: Objective: This study examined rates of utilization of mental health care among active duty and National Guard soldiers with mental health problems three and 12 months after they returned from combat in Iraq. Stigma and barriers to care were also reported for each component (active duty and National Guard). Methods: Cross-sectional, anonymous surveys were administered to 10,386 soldiers across both time points and components. Mean scores from 11 items measuring stigma and barriers to care were computed. Service utilization was assessed by asking soldiers whether they had received services for a mental health problem from a mental health professional, a medical doctor, or the Department of Veterans Affairs in the past month. Risk of mental problems was measured using the Patient Health Questionnaire, the PTSD Checklist, and items asking about aggressive behaviors and “stress, emotional, alcohol, or family” problems within the past month. Results: A higher proportion of active duty soldiers than National Guard soldiers reported at least one type of mental health problem at both three months (45% versus 33%) and 12 months (44% versus 35%) postdeployment. Among soldiers with mental health problems, National Guard soldiers reported significantly higher rates of mental health care utilization 12 months after deployment, compared with active duty soldiers (27% versus 13%). Mean stigma scores were higher among active duty soldiers than among National Guard soldiers. Conclusions: Active duty soldiers with a mental health problem had significantly lower rates of service utilization than National Guard soldiers and significantly higher endorsements of stigma. Current and future efforts to improve care for veterans should work toward reducing the stigma of receiving mental health care. (Psychiatric Services 61:572–588, 2010)

Use of Coercive Measures During Involuntary Hospitalization: Findings From Ten European Countries

Abstract: Objective: Involuntary treatment in mental health care is a sensitive but rarely studied issue. This study was part of the European Evaluation of Coercion in Psychiatry and Harmonization of Best Clinical Practice (EUNOMIA) project. It assessed and compared the use of coercive measures in psychiatric inpatient facilities in ten European countries. Methods: The sample included 2,030 involuntarily admitted patients. Data were obtained on coercive measures (physical restraint, seclusion, and forced medication). Results: In total, 1,462 coercive measures were used with 770 patients (38%). The percentage of patients receiving coercive measures in each country varied between 21% and 59%. The most frequent reason for prescribing coercive measures was patient aggression against others. In eight of the countries, the most frequent measure used was forced medication, and in two of the countries mechanical restraint was the most frequent measure used. Seclusion was rarely administered and was reported in only six countries. A diagnosis of schizophrenia and more severe symptoms were associated with a higher probability of receiving coercive measures. Conclusions: Coercive measures were used in a substantial group of involuntarily admitted patients across Europe. Their use appeared to depend on diagnosis and the severity of illness, but use was also heavily influenced by the individual country. Variation across countries may reflect differences in societal attitudes and clinical traditions. (Psychiatric Services 61: 1012-1017, 2010)

Recovery: a dimensional approach.

Abstract: Various definitions, dimensions, and components of recovery have been posited. Building on existing work, the authors propose five superordinate dimensions of recovery: clinical recovery, experiencing improvements in symptoms; existential recovery, having a sense of hope, empowerment, agency, and spiritual well-being; functional recovery, obtaining and maintaining valued societal roles and responsibilities, including employment, education, and stable housing; physical recovery, pursuing better health and a healthy lifestyle; and social recovery, experiencing enhanced and meaningful relationships and integration with family, friends, and the wider community. The model also identifies lay, professional, and systemic resources that promote each recovery dimension.

Mental Health Care for Children With Disruptive Behavior Problems: A View Inside Therapists' Offices

Abstract: Objectives: In the United States, more money is spent on treatment for children’s mental health problems than for any other childhood medical condition, yet little is known about usual care treatment for children. Objectives of this study were to characterize usual care outpatient psychotherapy for children with disruptive behavior problems and to identify consistencies and inconsistencies between usual care and common elements of evidence-based practices in order to inform efforts to implement evidence-based practices in usual care. Methods: Participants included 96 psychotherapists and 191 children aged four to 13 who were presenting for treatment for disruptive behavior to one of six usual care clinics. An adapted version of the Therapy Process Observational Coding System for Child Psychotherapy—Strategies scale (TPOCS-S) was used to assess psychotherapy processes in 1,215 randomly selected (out of 3,241 collected) videotaped treatment sessions; treatment sessions were recorded for up to 16 months. Results: Most children received a large amount of treatment (mean number of sessions=22, plus children received other auxiliary services), and there was great variability in the amount and type of care received. Therapists employed a wide array of treatment strategies directed toward children and parents within and across sessions, but on average all strategies were delivered at a low intensity. Several strategies that were conceptually consistent with evidence-based practices were observed frequently (for example, affect education and using positive reinforcement); however, others were observed rarely (for example, assigning or reviewing homework and role-playing). Conclusions: Usual care treatment for these youths reflected great breadth but not depth. The results highlight specific discrepancies between evidence-based care and usual care, thus identifying potentially potent targets for improving the effectiveness of usual care. (Psychiatric Services 61:788–795, 2010)

Web-Based Psychoeducational Intervention for Persons With Schizophrenia and Their Supporters: One-Year Outcomes

Abstract: Objective: This study examined the use of a uniquely designed Web site and home computers to deliver online multifamily psychoeducational therapy to persons with schizophrenia and their informal supports (family and friends). Web site usage and outcome benefits are reported. Methods: Thirty-one persons with schizophrenia or schizoaffective disorder and 24 support persons were randomly assigned to the online intervention (telehealth) or treatment as usual (usual care) condition. At three, six, and 12 months, interviewer-administered assessments were conducted with participants. Intention-to-treat analyses compared persons with schizophrenia in the two study conditions on severity of positive symptoms and knowledge of schizophrenia. Support persons in the two study conditions were compared on knowledge of schizophrenia. Each participant’s usage of the Web site was logged. Results: Persons with schizophrenia in the telehealth condition had a large and significant reduction in positive symptoms (p=.042, d=–.88) and a large and significant increase in knowledge of schizophrenia compared with their counterparts in the usual care condition. Support persons in the telehealth condition showed a large and significant increase in knowledge about prognosis compared with those in the usual care condition (p=.036, d=1.94). Persons with schizophrenia used the Web site to a much greater extent (pages viewed and time spent) than support persons. Conclusions: These findings suggest that online delivery of psychotherapeutic treatment and educational resources to consumers’ homes has considerable potential to improve consumer well-being and offers several advantages over standard clinic-based delivery models. (Psychiatric Services 61:1099–1105, 2010)

Lifestyle Interventions for Adults With Serious Mental Illness: A Systematic Literature Review

Abstract: Objective: The promotion of healthy lifestyles among persons with serious mental illness is an integral part of their recovery. The aims of this systematic literature review were to rate the methodological quality of lifestyle intervention outcome studies for persons with serious mental illness, summarize intervention strategies, examine physical health outcomes, and evaluate the inclusion of racial and ethnic minority groups in these studies. Methods: Electronic bibliographic database searches were performed to locate studies conducted in the United States. Articles written in English and published in peer-reviewed journals between 1980 and 2009 were included. The authors used a standardized instrument to rate studies’ methodological quality. Results: Twenty-three articles were reviewed. Based on studies’ methodological quality, three levels of evidence were found: single-group reports, quasi-experimental studies, and randomized controlled trials. Most interventions used behavioral techniques to improve dietary habits and increase physical activity. Twelve studies reported significant improvements in either weight loss or metabolic syndrome risk factors associated with receiving a lifestyle intervention. Persons from racial and ethnic minority groups were underrepresented, especially Hispanics and Asian Americans. Only one study included non– English-speaking participants. Conclusions: Lifestyle interventions adapted to persons with serious mental illness show promise in reducing weight loss and some risk factors for metabolic syndrome. The underrepresentation of persons from racial or ethnic minority groups in this literature limits its generalizability. Implications for research and practice are discussed. (Psychiatric Services 61:774–782, 2010)

Impact of Patient Language Proficiency and Interpreter Service Use on the Quality of Psychiatric Care: A Systematic Review

Abstract: Objective This literature review examined the effects of patients' limited English proficiency and use of professional and ad hoc interpreters on the quality of psychiatric care. Methods PubMed, PsycINFO, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) were systematically searched for English-language publications from inception of each database to April 2009. Reference lists were reviewed, and expert sources were consulted. Among the 321 articles identified, 26 met inclusion criteria: peer-reviewed articles reporting primary data on clinical care for psychiatric disorders among patients with limited proficiency in English or in the provider's language. Results Evaluation in a patient's nonprimary language can lead to incomplete or distorted mental status assessment. Although both untrained and trained interpreters may make errors, untrained interpreters' errors may have greater clinical impact, compromising diagnostic accuracy and clinicians' detection of disordered thought or delusional content. Use of professional interpreters may improve disclosure in patient-provider communications, referral to specialty care, and patient satisfaction. Conclusions Little systematic research has addressed the impact of language proficiency or interpreter use on the quality of psychiatric care in contemporary U.S. settings. Findings are insufficient to inform evidence-based guidelines for improving quality of care among patients with limited English proficiency. Clinicians should be aware of the ways in which quality of care can be compromised when they evaluate patients in a nonprimary language or use an interpreter. Given U.S. demographic trends, future research should help guide practice and policy by addressing deficits in the evidence base.

Coercion and Treatment Satisfaction Among Involuntary Patients

Abstract: Objective: This study aimed to assess involuntary inpatients’ satisfaction with treatment and explore how coercion and other factors are associated with satisfaction Methods: An observational prospective study was conducted in 67 acute wards in 22 hospitals in England A total of 778 involuntary inpatients were recruited, and their satisfaction with treatment was assessed a week after admission and at the one-month, three-month, and one-year follow-ups Perceived and documented coercion at admission and during hospital treatment, sociodemographic and clinical characteristics, and clinical improvement were tested as potential predictors of satisfaction Results: Mean scores on the Client’s Assessment of Treatment Scale measuring satisfaction with treatment ranged from 55 to 60 (on a scale with possible scores ranging from 0 to 10) at different time points and improved significantly from admission to the follow-ups Patients who perceived less coercion at admission and during hospital treatment were more satisfied overall, whereas coercive measures documented in the medical records were not linked to satisfaction Patients with more symptom improvement expressed higher levels of treatment satisfaction Conclusions: Satisfaction with treatment among involuntary patients was associated with perceptions of coercion during admission and treatment, rather than with the documented extent of coercive measures Interventions to reduce patients’ perceived coercion might increase overall treatment satisfaction (Psychiatric Services 61:286–292, 2010)

Analyzing Offense Patterns as a Function of Mental Illness to Test the Criminalization Hypothesis

Abstract: Objective: Programs for offenders with mental illness seem to be based on a hypothesis that untreated symptoms are the main source of criminal behavior and that linkage with psychiatric services is the solution. This study tested this criminalization hypothesis, which implies that these individuals have unique patterns of offending. Methods: Participants were 220 parolees; 111 had a serious mental illness, and 109 did not. Interview data and records were used to reliably classify offenders into one of five groups, based on their lifetime pattern of offending: psychotic, disadvantaged, reactive, instrumental, or gang- or drug-related affiliation. The distributions of those with and without serious mental illness were compared. Results: A small but important minority of offenders with a mental illness (7%, N=8) fit the criminalization hypothesis, in that their criminal behavior was a direct result of psychosis (5%, N=6) or comprised minor “survival” crimes related to poverty (2%, N=2). However, the reactive group contained virtually all offenders with a mental illness (90%, N=100) and the vast majority of offenders without a mental illness (68%, N=74), suggesting that criminal behavior for both groups chiefly was driven by hostility, disinhibition, and emotional reactivity. For most offenders with a mental illness in the reactive group, crime was also driven by substance dependence. Conclusions: Offenders with serious mental illness manifested heterogeneous patterns of offending that may stem from a variety of sources. Although psychiatric service linkage may reduce recidivism for a visible minority, treatment that targets impulsivity and other common criminogenic needs may be needed to prevent recidivism for the larger group. (Psychiatric Services 61:1217–1222, 2010)

Mental Health Aspects of Women's Reproductive Health: A Global Review of the Literatureby the World Health Organization; Geneva, Switzerland, WHO Press, 2009, 170 pages, $30.

Abstract: The World Health Organization and the United Nations Population Fund in collaboration with the Key Centre for Womens Health in Society in the School of Population Health at the University of Melbourne Australia are pleased to present this joint publication of available evidence on the intricate relationship between womens mental and reproductive health. The review comprises the most recent information on the ways in which mental health concerns intersect with womens reproductive health. It includes a discussion of the bio-psycho-social factors that increase vulnerability to poor mental health those that might be protective and the types of programmes that could mitigate adverse effects and promote mental health. This review is our unique contribution towards raising awareness on an emerging issue of major importance to public health. Its purpose is to provide information on the often neglected interlinks between these two areas so that public health professionals planners policy makers and programme managers may engage in dialogue to consider policies and interventions that address the multiple dimensions of reproductive health in an integrated way. (Excerpt)

Certified peer specialist roles and activities: results from a national survey.

Abstract: Objective: In 2001 Georgia became the first state to allow services provided by certified peer specialists (CPSs) to be reimbursed by Medicaid. Six other states have since followed Georgia’s lead, with many others in the process of doing so. This study examined where CPSs work and what they do. Methods: CPSs (N=291) from 28 states completed an online survey. Results: CPSs primarily did their work within the agency rather than in the community and worked most often with individuals rather than groups. CPSs frequently provided peer support and focus on self-determination, health and wellness, hope, communication with providers, illness management, and stigma. They spent the least amount of time supporting people’s family, parenting, dating, or spiritual relationships. Conclusions: CPS work settings and modalities varied greatly, although a core set of activities was identified. Implications for developing and refining CPS roles in the system are discussed, along with suggestions for additional training and supervision. (Psychiatric Services 61:520–523, 2010) eer support initiatives have historically occurred outside traditional mental health services. They typically consist of self-help or mutual-aid groups or small, localized independent programs modestly funded by states and counties. A dramatic change occurred in 2001 when Georgia approved peer support services provided by certified peer specialists (CPSs) for Medicaid reimbursement. This pioneering event officially recognized experience in recovery from mental illness as a valuable source of knowledge and peer relationships as a powerful and unique source of support. It also guaranteed stable funding and brought peer support squarely within the system of care. An additional six states have since approved peer support as a Medicaid-reimburseable service; many more states are moving toward similar policies. On a national level, the Veterans Health Administration has also proceeded in hiring CPSs. These efforts represent a milestone in mental health service delivery and are a concrete step toward system transformation as outlined in the President’s New Freedom Com

Treatment Receipt by Veterans After a PTSD Diagnosis in PTSD, Mental Health, or General Medical Clinics

Abstract: Objective: Despite the high prevalence of posttraumatic stress disorder (PTSD) among veterans treated at Department of Veterans Affairs (VA) facilities, rates of initiation of mental health treatment and persistence in treatment are unknown. This study examined outpatient treatment participation among veterans with a recent PTSD diagnosis and treatment differences according to the VA sector in which they received the diagnosis (PTSD specialty treatment program, general mental health clinic, and general medical clinic). Methods: Administrative data for 20,284 veterans who had received a diagnosis of PTSD at VA facilities were analyzed to determine rates of treatment initiation (any psychotropic prescription, an antidepressant prescription, behavioral counseling, and either a prescription or counseling) and maintenance of pharmacotherapy (at least four 30-day supplies), and counseling (at least eight visits) for the six months after diagnosis. Results: Approximately two-thirds of the sample initiated treatment: 50% received a psychotropic medication and 39% received some counseling; 64% received either medication or counseling. About half of those given medication (54%) received at least a four-month supply, and 24% of those given counseling had at least eight sessions. Overall, 33% received minimally adequate treatment. Initiation, type, and duration varied by treatment sector: receipt of a diagnosis in a PTSD specialty program or a mental health clinic conferred small but significant benefits over receipt in a general medical clinic. Conclusions: Greater availability of mental health specialty services, particularly PTSD services, may be needed to ensure that veterans receive minimally adequate treatment after a PTSD diagnosis. (Psychiatric Services 61:58–63, 2010)

Validating the Empowerment Scale With a Multisite Sample of Consumers of Mental Health Services

Abstract: Objective Empowerment is a key aspect of recovery and a common term in the mental health field, but there are few consistent definitions or validated measures of the construct. This study conducted psychometric testing on the Empowerment Scale, a widely used measure in the field. Methods As part of the Consumer-Operated Multi-Site study funded by the Substance Abuse and Mental Health Services Administration, consumers with a psychiatric disability were administered the Empowerment Scale along with several other scales to measure clinical status and psychosocial factors. Results Analyses produced five factors with acceptable fit statistics. The total scale demonstrated excellent reliability and validity. Conclusions Analyses provide additional evidence that the total Empowerment Scale score is a reliable, valid measure; subscales of the scale appear less robust. Empowerment is considered an essential factor in recovery-oriented programs and systems, and the use of psychometrically sound measures such as the Empowerment Scale therefore may be useful to evaluators.

Age of Diagnosis Among Medicaid-Enrolled Children With Autism, 2001-2004

Abstract: Objective: This study examined child- and county-level factors associated with age of diagnosis of autism among Medicaid-enrolled children and the change in age of diagnosis over time. Methods: National Medicaid claims from 2002 to 2004 were used to identify age of diagnosis and characteristics of children younger than ten years old with a diagnosis of autism (ICD-9 codes 299, 299.0x, or 299.8x). These data were linked to county-level education and health care variables. Linear regression with random effects for state and county was used to examine associations between these variables and age of diagnosis. Results: A total of 28,722 Medicaid-enrolled children newly diagnosed with an autism spectrum disorder were identified. Their average age of diagnosis was 64.9 months. Adjusted average age of diagnosis dropped 5.0 months for autistic disorder and 1.8 months for other spectrum disorders during the study period. Asian children were diagnosed earlier than children in other racial or ethnic groups, although these differences were much more pronounced for other spectrum disorders than for autistic disorder. Children eligible for Medicaid through the poverty category were diagnosed earlier, on average, than children who were eligible through disability, foster care, or other reasons, although this difference decreased over time. Children in large urban or rural counties were diagnosed later than children in small urban or suburban counties. Conclusions: Findings showed that diagnosis of autism occurs much later than it should among Medicaid-enrolled children, although timeliness is improving over time. Analyses suggest that most of the observed variation is accounted for by child-level variables, rather than county-level resources or state policies. (Psychiatric Services 61:822–829, 2010)

Reasons and determinants for not receiving treatment for common mental disorders.

Abstract: Objectives: This study focused on patients in the general population whose anxiety or depressive disorder is untreated. It explored reasons for not receiving treatment and compared four groups of patients— three that did not receive treatment for different reasons (no problem perceived, no perceived need for care, and unmet need for care) and one that received treatment—regarding their predisposing, enabling, and need factors. Methods: Cross-sectional data were used for 743 pri- mary care patients with current anxiety or depressive disorder from the Netherlands Study of Depression and Anxiety (NESDA). Diagnoses were confirmed with the Composite International Diagnostic Inter- view. Patients' perception of the presence of a mental problem, per- ceived need for care, service utilization, and reasons for not receiving treatment were assessed with the Perceived Need for Care Question- naire. Results: Forty-three percent of the respondents with a six-month anxiety or depression diagnosis did not receive treatment. Twenty-one percent of all respondents with depression or anxiety expressed a need for care but did not receive any. Preferring to manage the problem themselves was the most common reason for respondents to avoid seeking treatment. There were no significant differences in clinical need factors between treated patients and untreated patients with a perceived need for care. Compared with patients in the other two un- treated groups, untreated patients with a perceived need for care were more hindered in regard to symptom severity, functional disability, and psychosocial functioning. Conclusions: General practitioners should pay considerable attention to patients whose need for care is unmet. Furthermore, findings support the implementation of patient empow- erment in mental health care in order to contribute to easily accessible and patient-centered care. (Psychiatric Services 61:250-257, 2010)

Treatment Engagement: A Neglected Aspect in the Psychiatric Care of Suicidal Patients

Abstract: Objective: Suicide remains a serious health problem in the United States and worldwide. Despite changing distributions in sex, race-ethnicity, and age and considerable efforts to reduce the incidence rate, the number of suicides has remained relatively stable. The transition from emergency services to outpatient services is a crucial but often neglected step in treating suicidal individuals. Up to 50% of attempters refuse recommended treatment, and up to 60% drop out after only one session. This point of intervention is crucial for patients at elevated risk of suicide to reduce imminent danger and to increase the chances that patients will follow up on recommended treatment. Methods: PubMed, MEDLINE, and PsycINFO databases were searched for empirical investigations of treatment engagement of suicide attempters. Keywords searched included treatment, intervention, engagement, adherence, compliance, utilization, participation, and suicide attempt. Mapped terms were also included. Thirteen articles were selected. Results: Studies that have examined the effectiveness of postdischarge contact with suicide attempters (phone, letter, and in-person visits) to increase treatment adherence have found some immediate effects after substantial contact that were not sustained. Simple referrals to outpatient care were not effective. Family group interventions for adolescents have improved adherence, as have brief interventions in the emergency department. Conclusions: Despite greater public awareness of suicide, heightened prevention effort, and increased efficacy of treatment interventions, success in reducing suicidal behavior has been limited. Developing brief interventions for use in emergency settings that can reduce suicide risk and enhance treatment follow-up has been a neglected aspect of suicide prevention and may help to reduce suicidal behavior. (Psychiatric Services 61:1183–1191, 2010)

Stigmatizing experiences of parents of children with a new diagnosis of ADHD

Abstract: ADHD diagnosis, including their decisions to seek treatment. All interviews were recorded, transcribed, and analyzed using grounded theory methods. Codes were identified using a constant comparative approach, which led to theoretically defined thematic constructs of stigma. Results: Stigmatizing experiences were noted by 77% of the sample. Nearly half (N=21, 44%) were concerned about how society would label their child, 40% (N=19) felt social isolation and rejection, and 21% (N=10) perceived health care professionals and school personnel as being dismissive of their concerns. Parents’ own attitudes about ADHD treatment were shaped by their exposure to negative media (N=10, 21%), their mistrust of medical assessments (N=8, 17%), and the influence of general public views (N=3, 6%). These stigmatizing views were related to parental concerns about the impact that diagnosis and treatment would have on their child’s self-esteem and opportunities for future success. Conclusions: The range of ways in which parents in the study experienced stigma highlights the need for multiple perspectives for community outreach and public health programs that are aimed at addressing and eliminating mental health stigma. Even though stigma is a well-established barrier to mental health service use, the anticipated benefits of treatment may outweigh parents’ experiences with stigma. (Psychiatric Services 61:811–816, 2010)

Determining prevalence and correlates of psychiatric treatment with Andersen's behavioral model of health services use.

Abstract: Objective: This study examined the prevalence and correlates of use of health professional services for the treatment of mental or emotional problems by using Andersen’s Behavioral Model of Health Services Use. Methods: In the 2007 Behavioral Risk Factor Surveillance System 169,546 community-dwelling respondents from 35 states, the District of Columbia, and Puerto Rico answered questions about their sociodemographic characteristics; perceived need; nonspecific psychological distress, as measured with the Kessler-6 scale; and use of professional treatment of mental or emotional problems. Results: Evaluated need (psychological distress) was significantly associated with receipt of treatment for mental or emotional problems, as were predisposing factors (age, gender, race or ethnicity, marital status, and education), enabling and impeding factors (income, health insurance, and emotional support), and perceived need (number of mentally and physically unhealthy days and self-rated health). Conclusion: Constituents in the public mental health system should seriously consider that health services utilization is socially patterned and not just an individual behavior. (Psychiatric Services 61:524– 528, 2010)

Arrests two years after exiting a well-established mental health court.

Abstract: Objective: Relatively few studies have evaluated whether mental health courts reduce criminal recidivism. This study evaluated an established court and followed for two years defendants who exited the program in the court’s fifth year of operation. Methods: Court administrative data and state arrest records for 99 defendants who exited a mental health court in 2005 were used to determine whether the proportion arrested and number of arrests were lower in the two years after court exit than in the two years before court entry and whether the reduction was greater for those who completed the court process. Logistic regression was used to examine completion’s effect on recidivism with controls for other predictors. Survival analysis was used to discern how long court effects were sustained after exit. Results: Defendants had significantly reduced recidivism from precourt entry to postcourt exit. Completers (N=60) and those ejected from the program (N=31) had fewer rearrests, but completers were much less likely to be rearrested (odds ratio=.12), even with confounds controlled for, and they had a much longer period before rearrest. Conclusions: This study adds to the evidence that mental health courts can reduce criminal recidivism among offenders with mental illness and shows that this effect was sustained for two years, even though defendants were no longer being monitored by the court or receiving court-mandated treatment. The results show that the mental health court program studied had a greater impact on defendants who completed the program than on defendants who did not. (Psychiatric Services 61:463–468, 2010)

Health Care Reform and Care at the Behavioral Health—Primary Care Interface

Abstract: The historic passage of the Patient Protection and Affordable Care Act in March 2010 offers the potential to address long-standing deficits in quality and integration of services at the interface between behavioral health and primary care. Many of the efforts to reform the care delivery system will come in the form of demonstration projects, which, if successful, will become models for the broader health system. This article reviews two of the programs that might have a particular impact on care on the two sides of that interface: Medicaid and Medicare patient-centered medical home demonstration projects and expansion of a Substance Abuse and Mental Health Services Administration program that colocates primary care services in community mental health settings. The authors provide an overview of key supporting factors, including new financing mechanisms, quality assessment metrics, information technology infrastructure, and technical support, that will be important for ensuring that initiatives achieve their potential for improving care.

Stigma and Depression Treatment Utilization Among Latinos: Utility of Four Stigma Measures

Abstract: Objectives: Stigma associated with mental illness is an important yet understudied issue among Latinos. This study examined the psychometric properties of four stigma measures with a sample of Spanish-speaking Latino primary care patients. The study evaluated the scale for Perceived Discrimination Devaluation (PDD), the Stigma Concerns About Mental Health Care (SCMHC) scale, the Latino Scale for Antidepressant Stigma (LSAS), and the Social Distance (SD) scale. Methods: Participants (N=200) were low-income Latinos who were screened for depression with the Patient Health Questionnaire (PHQ-2) and asked about their depression treatment history, and they completed the four stigma measures at two time points (25 and 30 months from baseline). The four stigma measures were examined for internal consistency, convergent validity, construct validity, and criterion-related validity. Results: The factor-analytic results generally provided support for the construct validity of the measures. The four stigma measures also demonstrated internal consistency between two time points. Patients who reported greater social distance from individuals with depression were more likely to have been receiving treatment for emotional care in the past three months (odds ratio [OR]=.70, p<.05). Also, Latinos who scored high on the SCMHC (OR=.64, p<.05) and LSAS (OR=.77, p<.05) were less likely to have been taking antidepressant medications. Conclusions: The SCMHC, LSAS, and SD scales received support for their reliability and construct validity. Results also showed some support for their criterionrelated validity. A more mixed picture emerged for the PDD. Stigma ratings were associated with depression treatment utilization. Stigma ratings changed over time and were associated with treatment experiences. (Psychiatric Services 61:373–379, 2010)

Health reform and the scope of benefits for mental health and substance use disorder services.

Abstract: The Patient Protection and Affordable Care Act will expand insurance coverage to millions of Americans with mental disorders. One particularly important implementation issue is the scope of mental health and substance abuse services under expanded health insurance coverage. This article examines current public and commercial insurance coverage of the range of services used by individuals with mental illnesses and substance use disorders and assesses the implications of newly mandated standards for benefit packages offered by public and private plans. The authors note that many services needed by individuals with mental or substance use disorders fall outside the scope of benefits currently covered by a typical private insurance plan. Compared with other insurers, Medicaid currently covers a broader range of behavioral health services; however, individuals moving into Medicaid under new eligibility pathways will receive "benchmark" or "benchmark-equivalent" coverage rather than full Medicaid benefits. If behavioral health benefits are set at those currently available in typical private plans or in benchmark coverage, some newly insured individuals with mental illnesses or substance use disorders who are covered by private plans or Medicaid expansions are still likely to face gaps in covered services. Policy makers have several options for addressing these likely gaps in coverage, including requiring states to maintain coverage of some support services, including certain behavioral health services in the "essential benefits package," and expanding eligibility for full Medicaid benefits.

Assessing Outcomes for Consumers in New York's Assisted Outpatient Treatment Program

Abstract: Objective: This study examined whether New York State’s assisted outpatient treatment (AOT) program, a form of involuntary outpatient commitment, improves a range of policy-relevant outcomes for court-ordered individuals. Methods: Administrative data from New York State’s Office of Mental Health and Medicaid claims between 1999 and 2007 were linked to examine whether consumers under a court order for AOT experienced reduced rates of hospitalization, shorter hospital stays, and improvements in other outcomes. Multivariable analyses controlling for relevant covariates were used to examine the likelihood that AOT produced these effects. Results: On the basis of Medicaid claims and state reports for 3,576 AOT consumers, the likelihood of psychiatric hospital admission was significantly reduced by approximately 25% during the initial six-month court order (odds ratio [OR]=.77, 95% confidence interval [CI]=.72–.82) and by over one-third during a subsequent six-month renewal of the order (OR=.59, CI=.54–.65) compared with the period before initiation of the court order. Similar significant reductions in days of hospitalization were evident during initial court orders and subsequent renewals (OR=.80, CI=.78–.82, and OR=.84, CI=.81–.86, respectively). Improvements were also evident in receipt of psychotropic medications and intensive case management services. Analysis of data from case manager reports showed similar reductions in hospital admissions and improved engagement in services. Conclusions: Consumers who received court orders for AOT appeared to experience a number of improved outcomes: reduced hospitalization and length of stay, increased receipt of psychotropic medication and intensive case management services, and greater engagement in outpatient services. (Psychiatric Services 61:976–981, 2010)

Perceived Need for Care, Help Seeking, and Perceived Barriers to Care for Alcohol Use Disorders in a National Sample

Abstract: Objective: The aims of this study were to examine the rates and correlates of help seeking, perceived need for care, and perceived barriers to care among people with an alcohol use disorder in a large nationally representative sample. Methods: Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions for persons 18 years and older (N=43,093). Three main groups were defined: people who sought help, people who perceived a need for care but did not seek help, and people who neither perceived a need nor sought help. Results: Almost one-third (N=11,843, or 28%) of survey respondents met DSM-IV criteria for a lifetime alcohol use disorder. Most individuals with an alcohol use disorder (81%) did not report seeking care or perceiving a need for help. Those who were younger, were married, had higher income, had higher education, and did not have an adverse general medical condition were significantly less likely to perceive a need for help or to seek help for an alcohol use disorder. Respondents who did not perceive a need for help or seek it were significantly less likely to have an additional axis I or axis II disorder. Conclusions: Knowledge of the factors that influence perceived need for help could aid in developing interventions directed toward increasing the rates of help seeking among people with an alcohol use disorder. Regular screening for alcohol use disorders in primary health care settings is recommended. (Psychiatric Services 61:1223–1231, 2010)

Findings of a U.S. national cardiometabolic screening program among 10,084 psychiatric outpatients.

Abstract: Objective: A national cardiometabolic screening program for patients in a variety of public mental health facilities, group practices, and community behavioral health clinics was funded by Pfizer Inc. between 2005 and 2008. Methods: A one-day, voluntary metabolic health fair in the United States offered patients attending public mental health clinics free cardiometabolic screening and same-day feedback to physicians from a biometrics testing third party that was compliant with the Health Insurance Portability and Accountability Act. Results: This analysis included 10,084 patients at 219 sites; 2,739 patients (27%) reported having fasted for over eight hours. Schizophrenia or bipolar disorder was self-reported by 6,233 (62%) study participants. In the overall sample, the mean waist circumference was 41.1 inches for men and 40.4 inches for women; 27% were overweight (body mass index [BMI] 25.0–29.9 kg/m 2 ), 52% were obese (BMI ≥30.0 kg/m 2 ), 51% had elevated triglycerides (≥150 mg/dl), and 51% were hypertensive (≥130/85 mm Hg). In the fasting sample, 52% had metabolic syndrome, 35% had elevated total cholesterol (≥200 mg/dl), 59% had low levels of high-density lipoprotein cholesterol (<40 mg/dl for men or <50 mg/dl for women), 45% had elevated triglycerides (≥150 mg/dl), and 33% had elevated fasting glucose (≥100 mg/dl). Among the 1,359 fasting patients with metabolic syndrome, 60% were not receiving any treatment. Among fasting patients who reported treatment for specific metabolic syndrome components, 33%, 65%, 71%, and 69% continued to have elevated total cholesterol, low levels of high-density lipoprotein, high blood pressure, and elevated glucose levels, respectively. Conclusions: The prevalence of metabolic syndrome and cardiometabolic risk factors, such as overweight, hypertension, dyslipidemia, and glucose abnormalities, was substantial and frequently untreated in this U.S. national mental health clinic screening program. (Psychiatric Services 61:892–898, 2010)

Ten-year use of mental health services by patients with borderline personality disorder and with other axis II disorders.

Abstract: Objective: The study determined the prevalence of use of three treatment modalities (individual therapy, medication, and hospitalization) reported over a ten-year period by patients with borderline personality disorder and by those in a comparison group with other axis II disorders. Time to cessation and time to resumption for each modality among patients with borderline personality disorder were also determined. Methods: Treatment history of inpatients with a reliable diagnosis of borderline personality disorder (N=290) and of other axis II disorders (N=72) was assessed with an interview of proven reliability during the index admission. Treatment history was reassessed at two-year intervals for ten years. Results: For all three treatment modalities, prevalence of use declined significantly among patients with borderline personality disorder and among those in the comparison group. Among patients with borderline personality disorder, 52% reported having stopped individual therapy and 44% reported having stopped medication at one or more of the follow-up interviews over ten years. However, 85% of those who had stopped psychotherapy and 67% of those who stopped taking medication resumed these treatments during a subsequent two-year period. In contrast, 88% had experienced at least one two-year period without a psychiatric hospitalization by the time of the ten-year followup; however, almost half of these patients were subsequently rehospitalized. Conclusions: The results suggest that patients with borderline personality disorder tend to use outpatient treatments without interruption over prolonged periods. They also suggest that inpatient treatment is used far more intermittently by patients with borderline personality disorder. (Psychiatric Services 61:612–616, 2010)

Consequences of receipt of a psychiatric diagnosis for completion of college

Abstract: Objective The purpose of this study was to evaluate the independent associations between DSM-IV psychiatric disorders and the failure to complete college among college entrants. Methods Data were from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). The sample included 15,800 adults, aged 22 years and older, who at least entered college. Diagnoses were made with the NESARC survey instrument, the Alcohol Use Disorder and Associated Disability Interview Schedule-DSM-IV Version. The large sample permitted analysis of multiple psychiatric disorders in the same multivariable logistic regression models. Given the frequent comorbidity of these disorders, this approach is an important step toward disentangling the independent roles of disorders in postsecondary educational outcomes. Results Evaluation of the independent associations between specific psychiatric disorders and postsecondary educational attainment showed that five diagnoses were positively and significantly associated with the failure to graduate from college. Four were axis I diagnoses: bipolar I disorder, marijuana use disorder, amphetamine use disorder, and cocaine use disorder. One was an axis II diagnosis: antisocial personality disorder. Conclusions This study provides new data on DSM-IV diagnoses associated with the failure to complete postsecondary education. The findings suggest that psychiatric factors play a significant role in college academic performance, and the benefits of prevention, detection, and treatment of psychiatric illness may therefore include higher college graduation rates.

Pharmacotherapy of Alcohol Use Disorders in the Veterans Health Administration

Abstract: Objective: Acamprosate, oral and long-acting injectable naltrexone, and disulfiram are approved for treatment of alcohol dependence. Their availability and consideration of their use in treatment are now standards of high-quality care. This study determined rates of medication initiation among Veterans Health Administration (VHA) patients. Methods: VHA pharmacy and administrative data were used to identify patients with alcohol use disorder diagnoses in fiscal years (FY) 2006 and 2007 and the proportion (nationally and by facility) who received each medication. Patient characteristics associated with receipt were also examined. Results: Among more than a quarter-million patients with alcohol use disorder diagnoses, the percentage receiving any of the medications increased from 2.8% in FY 2006 to 3.0% in FY 2007. Receipt of these medications was more likely among patients who received specialty addiction care, those with alcohol dependence (compared with abuse), those younger than 55 years, and females. In the patient subgroups examined, the largest proportion to receive any of the medications was 11.6%. Across 128 VHA facilities, rates of use among patients in the sample who had received past-year specialty addiction treatment ranged from 0% to 20.5%; rates ranged from 0% to 4.3% among those with no specialty treatment. Patient preferences and medical contraindications could not be determined from the data. Conclusions: Findings suggest the need to better understand systemwide variation in use of these medications and their use as a rough proxy for availability and consideration of pharmacotherapy—a standard of care with strong organizational support. (Psychiatric Services 61:392–398, 2010)