Showing papers in "Psychiatric Services in 2013"
TL;DR: Responses to item 9 of the PHQ-9 for depression identified outpatients at increased risk of suicide attempt or death, indicating that suicidal ideation was an enduring vulnerability rather than a short-term crisis.
Abstract: Can asking one question accurately assess suicide risk? If the question is item 9 on the Patient Health Questionnaire (PHQ-9), the answer may be yes. Researchers in a large integrated health system examined outcomes for more than 84,000 outpatients who completed the PHQ-9 at every visit for depression between 2007 and 2011. Patients who reported thoughts of death or self-harm “more than half the days” or “nearly every day” experienced a markedly increased risk of subsequent suicide attempt and suicide death. For this high-risk group, additional assessment is clearly indicated, the authors said.
398 citations
TL;DR: There may be multiple pathways through which stigma and discrimination lead to negative outcomes, suggesting that interventions to reduce internalized stigma need to target multiple points along these pathways in order to be effective.
Abstract: ObjectivesThe investigators aimed to examine the prevalence of internalized stigma among individuals with serious mental illness and to construct and test a hypothesized model of the interrelationships among internalized stigma, self-concept, and psychiatric symptoms.MethodsOne hundred individuals, most of whom were African American and had a diagnosis of serious mental illness, were receiving mental health services from one of three community outpatient mental health programs or one Veterans Affairs medical center. They completed an interview that included measures of internalized stigma, psychiatric symptoms, self-esteem, self-efficacy, and recovery orientation. Structural equation modeling (SEM) was used to examine the interrelationships among these variables.ResultsThirty-five percent of participants reported moderate to severe levels of internalized stigma, which was not significantly associated with any demographic variable or diagnosis. However, greater internalized stigma was associated with lower...
210 citations
TL;DR: Treatment for veterans may be improved by increasing awareness of gender differences, integrating mental health and pastoral services, and recognizing that alcohol misuse may reduce utilization.
Abstract: Many studies of Iraq and Afghanistan veterans with mental disorders document low rates of service use. However, most studies look at use in the first year after returning from a deployment. Do rates of use rise as time since deployment increases? In the National Post-Deployment Adjustment Survey, the median time since deployment was four years, and two-thirds of veterans with probable PTSD or major depression reported past-year use of mental health services. The finding of these notably higher rates is “a valuable message to communicate to veterans,” the authors conclude, and may reduce some veterans’ ambivalence about seeking treatment.
180 citations
TL;DR: No recovery measure can currently be unequivocally recommended, although the QPR most closely maps to the CHIME framework of recovery and the RAS is most widely published.
Abstract: The definition and measurement of personal recovery remain somewhat amorphous, but a rubric called CHIME has emerged as a useful standard to identify the essential elements of this very personal process. This review identified 13 measures of recovery and compared how well they assessed the five domains of recovery identified by the CHIME framework—connectedness, hope and optimism, identity, meaning and purpose, and empowerment. Although several measures showed a range of range of psychometric properties, none could be considered a gold standard.
172 citations
TL;DR: Although the intervention showed promise in improving fitness, optimizing weight loss may require additional intensive, multicomponent dietary interventions.
Abstract: Overweight persons with severe mental illness tripled their attendance at fitness clubs and were more engaged in vigorous physical activity after joining a fitness health mentor program called In SHAPE. Participants were provided a one-year fitness club membership and paired with a health mentor who provided weekly personal training and nutrition counseling. A one-year controlled trial comparing outcomes with a control group that was given a free gym membership but no mentoring found that twice as many In SHAPE participants had made significant improvements in cardiovascular health.
147 citations
TL;DR: Barriers associated with the decision not to seek treatment for symptoms of combat-related posttraumatic stress disorder were examined and suggest areas for intervention efforts to minimize barriers to treatment for PTSD for OEF/OIF veterans.
Abstract: Objectives:Barriers associated with the decision not to seek treatment for symptoms of combat-related posttraumatic stress disorder (PTSD) were examined.Methods:Participants were 143 military men and women who served in Operation Enduring Freedom or Operation Iraqi Freedom (OEF/OIF) and who screened positive for posttraumatic stress disorder (PTSD), as assessed by the PTSD Checklist–Military Version, and who had not sought treatment for PTSD. During a cognitive-behavioral telephone intervention, participants were asked about their beliefs concerning seeking PTSD treatment.Results:Four categories of beliefs were associated with the decision to seek treatment, including concerns about treatment (40%), emotional readiness for treatment (35%), stigma (16%), and logistical issues (8%).Conclusions:This work suggests areas for intervention efforts to minimize barriers to treatment for PTSD for OEF/OIF veterans.
127 citations
127 citations
TL;DR: Students who experience depressive symptoms or seek treatment for depression during college might be at risk of interruptions in their college enrollment, and cannabis use and heavy drinking appear to add to this risk.
Abstract: ObjectiveThis study examined the prospective relationship of substance use and mental health problems with risk of discontinuous enrollment in college.MethodsParticipants were 1,145 students at a large public university who were interviewed annually for four years beginning at college entry in 2004 (year 1). Discontinuous enrollment was defined as a gap in enrollment of one or more semesters during the first two years (early discontinuity) or the second two years (late discontinuity) versus continuous enrollment throughout all four years. Explanatory variables measured in year 1 were scores on the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory, childhood conduct problems, cannabis use, number of illicit drugs used, and alcohol consumption. In years 3 and 4, participants reported lifetime history of clinically diagnosed attention-deficit hyperactivity disorder, depression, and anxiety, including age at diagnosis. Multinomial logistic regression models were developed to evaluate the associat...
124 citations
TL;DR: Seclusion and restraint were prevented without an increase of violence in wards for men with schizophrenia and violent behavior and a similar reduction may also be feasible under less extreme circumstances.
Abstract: ObjectiveThis randomized controlled trial studied whether seclusion and restraint could be prevented in the psychiatric care of persons with schizophrenia without an increase of violence.MethodsOver the course of a year, 13 wards of a secured national psychiatric hospital in Finland received information about seclusion and restraint prevention. Four high-security wards (N=88 beds) for men with psychotic illness were then stratified by coercion rates and randomly assigned to two equal groups. In the intervention wards, staff, patients, and doctors were trained for six months in applying six core strategies to prevent seclusion-restraint; six months of supervised intervention followed. Poisson’s regression analyses compared monthly incidence rate ratios (IRRs) of coercion and violence (per 100 patient-days).ResultsThe proportion of patient-days with seclusion, restraint, or room observation declined from 30% to 15% for intervention wards (IRR=.88, 95% confidence interval [CI]=.86–.90, p<.001) versus from 25...
113 citations
TL;DR: Unmet need is widespread, particularly among the uninsured, and expansion of coverage under the ACA, in conjunction with federal parity, should improve access, but ongoing monitoring of access is a research and policy priority.
Abstract: ObjectivesThis study estimated unmet need for mental health services, identified population risk factors related to unmet need, and established baseline data to assess the impact of the Affordable Care Act (ACA) and the Mental Health Parity and Addiction Equity Act.MethodsNational Health Interview Survey data (1997–2010) were analyzed.ResultsUnmet need increased from 4.3 million in 1997 to 7.2 million in 2010. Rates in 2010 were about five times higher for uninsured than for privately insured persons. In a multivariate logistic model, likelihood was higher among children (age two to 17), working-age adults (age 18–64), women, uninsured persons, persons with low incomes, in fair or poor health, and with chronic conditions.ConclusionsUnmet need is widespread, particularly among the uninsured. Expansion of coverage under the ACA, in conjunction with federal parity, should improve access, but ongoing monitoring of access is a research and policy priority.
111 citations
TL;DR: Use of enhanced levels of care, such as that offered by the Care Programme Approach, may play a strong role in preventing suicide within two weeks of discharge, as were older age and comorbid psychiatric disorders.
Abstract: ObjectiveSuicide risk after discharge from psychiatric inpatient care is high, particularly in the first few weeks. The aim of the study was to identify risk factors and protective factors (that is, factors associated with a reduced risk of suicide), including variation in health care received, for suicide among patients in the two-week postdischarge period.MethodsThis was a national population-based retrospective case-control study of 100 psychiatric patients in England (2004–2006), age 18–65, who died by suicide within two weeks of hospital discharge. These patients were matched on discharge date with 100 living control group patients.ResultsFifty-five percent of suicides occurred within a week of discharge, 49% of whom died before their first follow-up appointment. Conditional logistic regression analyses indicated that recent adverse life events and a short (less than one week) final admission were independently associated with postdischarge suicide, as were older age and comorbid psychiatric disorder...
TL;DR: Policies aimed at expanding insurance coverage and mental health parity would likely benefit individuals with major depression and substance dependence comorbidity even more than those without such comor bidity.
Abstract: ObjectiveThe study explored mental health service use patterns and barriers to care among individuals with comorbid mental and substance use disorders.MethodsUsing data from the National Survey on Drug Use and Health (2005–2010) for 18,972 adults with past-year major depressive episodes, the study compared mental health service use and perceived barriers to care among participants with and without co-occurring alcohol dependence, nonalcohol drug dependence, and both alcohol and drug dependence.ResultsCompared with participants without comorbid substance dependence, participants with alcohol dependence or both alcohol and nonalcohol drug dependence used more mental health services of all types, and participants with only comorbid alcohol dependence used more medication treatments. Participants with comorbid substance dependence were significantly more likely than those without comorbid substance dependence to report unmet mental health treatment need. However, barriers to mental health care were remarkably...
TL;DR: Living Well shows promise in helping mental health consumers more effectively manage chronic general medical conditions and experience improved functioning and well-being.
Abstract: ObjectiveIndividuals with serious mental illness have elevated rates of comorbid chronic general medical conditions and may benefit from interventions designed to support illness self-management. This study examined the effectiveness of a modified version of the Chronic Disease Self-Management Program called Living Well for individuals with serious mental illness.MethodsA total of 63 mental health consumers with serious mental illness and at least one concurrent chronic general medical condition were randomly assigned to receive the 13-session peer-cofacilitated Living Well intervention or usual care. Participants were evaluated on attitudinal, behavioral, and functional outcomes at baseline, at the end of the intervention, and at a two-month follow-up.ResultsLiving Well participants showed significant postintervention improvements across a range of attitudinal (self-efficacy and patient activation), behavioral (illness self-management techniques), and functional (physical and emotional well-being and gen...
TL;DR: In this article, the authors describe three ongoing studies anchored in research partnerships to improve the implementation of effective practices within various service systems, specifically in light of recent initiatives led by the National Institutes of Health.
Abstract: This column describes the essential role of partnerships in the conduct of dissemination and implementation (D&I) research. This research field, which develops knowledge to support the integration of health information and evidence-based practices, has thrived in recent years through research initiatives by federal agencies, states, foundations, and other funders. The authors describe three ongoing studies anchored in research partnerships to improve the implementation of effective practices within various service systems. Inherent in the challenge of introducing evidence-based practices in clinical and community settings is the participation of a wide range of stakeholders who may influence D&I efforts. Opportunities to enhance partnerships in D&I research are described, specifically in light of recent initiatives led by the National Institutes of Health. Partnerships remain a crucial component of successful D&I research. The future of the field depends on the ability to utilize partnerships to conduct more rigorous and robust research.
TL;DR: Evidence supported the efficacy of collaborative care for depression as an engagement enhancement intervention among underserved racial-ethnic populations and the effect of the interventions on clinical outcomes, such as symptom improvement and rehospitalization, was mixed.
Abstract: Two key steps in reducing racial-ethnic disparities are to make treatments more widely available and to improve access to them. But unless underserved groups are engaged in treatment, improving availability and access is not enough. What strategies work to enhance engagement in mental health treatments? This systematic review examined ten randomized trials in which patients from underserved racial-ethnic groups made up at least half the sample. Collaborative care for depression was the only approach that could be designated as efficacious for engagement of underserved groups.
TL;DR: Early implementation experiences of PBHCI grantees may inform other programs that seek to integrate primary care into behavioral health settings as part of new, large-scale government initiatives, such as specialty mental health homes.
Abstract: ObjectiveThis article describes the characteristics and early implementation experiences of community behavioral health agencies that received Primary and Behavioral Health Care Integration (PBHCI) grants from the Substance Abuse and Mental Health Services Administration to integrate primary care into programs for adults with serious mental illness.MethodsData were collected from 56 programs, across 26 states, that received PBHCI grants in 2009 (N=13) or 2010 (N=43). The authors systematically extracted quantitative and qualitative information about program characteristics from grantee proposals and semistructured telephone interviews with core program staff. Quarterly reports submitted by grantees were coded to identify barriers to implementing integrated care.ResultsGrantees shared core features required by the grant but varied widely in terms of characteristics of the organization, such as size and location, and in the way services were integrated, such as through partnerships with a primary care agenc...
TL;DR: Compared with labels for nonpsychotic disorders, schizophrenia elicited more negative stereotyping and the at-risk label invoked greater social distance and less willingness to help, while the psychosis risk label alone appeared to evoke greater status loss and discrimination.
Abstract: Objectives:This study compared stigma associated with the psychosis risk label and diagnostic labels for nonpsychotic and psychotic mental disorders among young adult peers.Methods:Urban college respondents (N=153) read an experimental vignette describing a young adult experiencing prodromal symptoms who was randomly assigned a diagnostic label (major depression, generalized anxiety disorder, schizophrenia, or psychosis risk with and without accurate information about the psychosis risk label) and answered questions about stigma toward the individual in the vignette.Results:Compared with labels for nonpsychotic disorders, schizophrenia elicited more negative stereotyping and the at-risk label invoked greater social distance and less willingness to help. Any increased social distance appeared to be reduced by accurate information about the at-risk state. No differences in stigma were found for the psychosis risk and schizophrenia labels.Conclusions:The psychosis risk label alone appeared to evoke greater s...
TL;DR: Routine outpatient treatment, including medication and outpatient services, may reduce the likelihood of arrest among adults with serious mental illness, and medication possession over a 90-day period after hospitalization appears to confer additional protection.
Abstract: ObjectiveThis study examined whether possession of psychotropic medication and receipt of outpatient services reduce the likelihood of posthospitalization arrest among adults with serious mental illness. A secondary aim was to compare service system costs for individuals who were involved with the justice system and those who were not.MethodsClaims data for prescriptions and treatments were used to describe patterns and costs of outpatient services between 2005 and 2012 for 4,056 adult Florida Medicaid enrollees with schizophrenia or bipolar disorder after discharge from an index hospitalization. Multivariable time-series analysis tested the effects of medication and outpatient services on arrest (any, felony, or misdemeanor) in subsequent 30-day periods.ResultsA total of 1,263 participants (31%) were arrested at least once during follow-up. Monthly medication possession and receipt of outpatient services reduced the likelihood of any arrests (misdemeanor or felony) and of misdemeanor arrests. Possession ...
TL;DR: A manageable list of 32 evidence-based components of first-episode psychosis services can form a foundation for developing a fidelity scale for such services and may also be helpful to funders and providers as a summary of essential services.
Abstract: ObjectiveThe purpose of this study was to identify essential evidence-based components of first-episode psychosis services.MethodsThe study was conducted in two stages. In the first stage a systematic review of both peer-reviewed and gray literature (January 1980 to April 2010) was conducted. Databases searched included MEDLINE, PsycINFO, and EMBASE. In the second stage, a consensus-building technique, the Delphi, was used with an international panel of experts. The panelists were presented the evidence-based components identified in the review, together with the level of supporting evidence for each component. They rated the importance of each component on a 5-point scale. A score of 5 was required to determine that a component was essential.ResultsThe review identified 1,020 citations; abstracts were reviewed for relevance. A total of 280 peer-reviewed articles met criteria for relevance. Two researchers independently reviewed these articles and identified 75 unique service components. Each component wa...
TL;DR: Little evidence was found that psychotic symptoms are "idioms of distress"; respondents who reported lifetime psychotic symptoms were prone to a higher lifetime prevalence of distress, and this association was not specific to any racial-ethnic group.
Abstract: ObjectiveThis study determined the prevalence of psychotic symptoms among racial-ethnic groups in a representative sample of American adults and explored the relationship of these symptoms with race-ethnicity, psychological distress, and dysfunction.MethodsData from the Collaborative Psychiatric Epidemiology Surveys were used, which combines three nationally representative surveys: the National Comorbidity Survey Replication, National Survey of American Life, and National Latino and Asian American Study. The sample comprised 16,423 respondents, and the analysis adjusted for design effects.ResultsThe adjusted lifetime and 12-month prevalence rates of psychotic symptoms were 11.6% and 1.4%, respectively. Latinos and blacks had higher lifetime rates (13.6% and 15.3%, respectively) than whites (9.7%) and Asians (9.6%). In logistic regression analysis, lifetime reports of psychotic symptoms were associated with Latino ethnicity, a lifetime diagnosis of a substance use disorder or posttraumatic stress disorder,...
TL;DR: In this article, patients who participated in a randomized controlled trial comparing subjective distress and traumatic impact after seclusion or mechanical restraint were interviewed about the coercive measure about one year later, with higher scores indicating greater distress.
Abstract: ObjectivePatients who participated in a randomized controlled trial comparing subjective distress and traumatic impact after seclusion or mechanical restraint were interviewed about the coercive measure about one year later.MethodsBetween May and December 2006, patients were interviewed about one year after experiencing seclusion or mechanical restraint as an inpatient. Items from the Coercion Experience Scale (CES) were used in the original and the follow-up studies to assess distress on a 5-point scale, with higher scores indicating greater distress. Patients were also asked about subjective feelings about the coercive measure and completed the Impact of Event Scale–Revised (IES-R) to assess symptoms of posttraumatic stress disorder (PTSD).ResultsSixty (59%) of the 102 patients in the original sample were included for follow-up. Although the original study found no differences between patients who experienced seclusion or mechanical restraint, the follow-up study found significantly higher mean scores f...
TL;DR: Evidence is provided that the mindfulness-based education program can improve Chinese schizophrenia sufferers' psychosocial functioning and reduce their illness relapse.
Abstract: ObjectivesThis study tested the effectiveness of a mindfulness-based psychoeducation program for Chinese outpatients with schizophrenia over an 18-month follow-up. The program is a psychoeducational program that addresses patients’ awareness and knowledge of schizophrenia and builds skills for illness management.MethodsA multisite controlled trial was conducted with 96 Chinese patients with schizophrenia in Hong Kong. They were randomly assigned to either the mindfulness-based psychoeducation program or usual psychiatric care. The patients’ mental and psychosocial functioning, insights into illness, and rehospitalization rates were measured at recruitment and at three and 18 months postintervention.ResultsCompared with those in usual care, the patients in the mindfulness psychoeducation program showed significantly greater improvements in their illness insights, symptom severity, functioning, and number and length of rehospitalizations at the 18-month follow-up.ConclusionsThe findings provide evidence tha...
TL;DR: Person-centered planning and collaborative documentation were associated with greater engagement in services and higher rates of medication adherence within community mental health centers (CMHCs).
Abstract: ObjectiveTailoring service planning to clients’ personal life goals, or person-centered planning, has emerged as a recovery-oriented practice. This study examined the impact of person-centered planning and collaborative documentation on service engagement and medication adherence within community mental health centers (CMHCs).MethodsTen CMHCs were assigned randomly to receive training in person-centered planning and collaborative documentation or provide usual treatment. Medication adherence and service engagement were measured for 11 months (May 2009–March 2010) for 367 clients. Models compared changes in medication adherence and service engagement among clients of CMHCs in the control and experimental conditions.ResultsMedication adherence increased significantly at CMHCs in the experimental condition (B=.022, p≤.01) but showed no significant change at CMHCs in the control condition (B=.004, p=.25). Appointment no-shows at CMHCs in the experimental condition were reduced (odds ratio=.74, p=.001).Conclus...
TL;DR: A framework of acceptable, accessible, and available services identifies opportunities for providers to adjust practices and maximize engagement in services among individuals with serious mental illness who are in high need of treatment.
Abstract: ObjectiveThis study sought to describe reasons for disengagement from services and practical guidelines to enhance engagement among individuals with serious mental illness and high need for treatment.MethodsQualitative interviews were conducted with 56 individuals with serious mental illness and 25 providers recruited from a larger project that used administrative data to identify individuals with serious mental illness who had disengaged from care. Individuals with serious mental illness and providers described reasons for disengagement and effective provider engagement strategies.ResultsIndividuals with serious mental illness and providers differed in reported reasons for disengagement. Reasons reported by individuals with serious mental illness included services that were not relevant to their needs, inability to trust providers, and a belief that they were not ill. Providers cited lack of insight, stigma, and language and cultural barriers as common reasons for disengagement. Strategies for increasing...
TL;DR: The expansion of antipsychotic use was most prominent among youths who were Medicaid eligible because of low family income (SCHIP) and reflects increased medication use for behavioral problems.
Abstract: Use of antipsychotics by children and adolescents has increased markedly. To identify contributing factors, this study analyzed 1997 and 2006 Medicaid data for more than 450,000 youths. The rate of antipsychotic use rose from 1.2% to 3.2%. A strong contributing factor was the notable growth in the size of the group covered by Medicaid because of their low family income (State Children's Health Insurance Program and Temporary Assistance for Needy Families). In 1997, these youths accounted for 20% of antipsychotic users, compared with 46% in 2006. Another “paramount” factor, note the authors, is treatment of externalizing behavior symptoms with antipsychotics.
TL;DR: The findings illustrate the value of participatory methods to understand what recovery signified to people with serious mental illness and how understanding the interrelationships between recovery dimensions can inform recovery-oriented services.
Abstract: To better understand the dimensions of recovery, staff at two supported housing agencies invited consumers to participate in photovoice, in which people use cameras to document their daily realities and create narratives about them to promote dialog and inform social action. For six weeks, the consumers took pictures of persons and events that reflected recovery and wellness and also met for 90-minute sessions to present and discuss their photographs. Analysis of the narrative and visual data revealed the complex interplay of spiritual, educational, social, and other resources that support recovery.
TL;DR: Findings suggest that Medicaid insurance expansions under the ACA will reduce unmet need for substance use disorder treatment.
Abstract: In states that opt to expand Medicaid, individuals with household income less than 138% of the poverty level will gain access to treatment. To assess unmet need for substance abuse treatment among newly eligible adults, researchers analyzed data from two groups of respondents to the National Survey on Drug Use and Health: low-income Medicaid enrollees and uninsured individuals who will become Medicaid eligible. The rate of substance use disorders was significantly higher in the latter group. Findings suggest that Medicaid expansion will reduce unmet need for treatment.
TL;DR: The DSM-5 approach was feasible and clinically useful in a wide range of routine practice settings and favorably received by both clinicians and patients.
Abstract: The fifth edition of the Diagnostic and Statistical Manual (DSM-5) attempts to capture the latest scientific advances and to enhance the reliability of diagnostic criteria. Among the new manual's most noticeable differences is the inclusion of patient-reported measures to identify initial clinical status and monitor progress. In 2011 and 2012, clinicians and their patients from the United States, Canada, Australia, and the United Kingdom undertook to assess the clinical utility and feasibility of the new manual. The results of the field trials are reported.
TL;DR: In addressing the needs of high-cost, high-risk patients to meet quality and expenditure targets, an ACO should examine the quality of mental health care it provides as well as medical quality for patients with mental illness.
Abstract: The Centers for Medicare and Medicaid Services (CMS) is promoting formation of accountable care organizations (ACOs). In these population-based models, CMS aligns a Medicare beneficiary population to an ACO with associated expenditure and quality targets, transitioning away from purely volume-based revenue of fee-for-service Medicare. Patients with mental illness are among high-cost Medicare beneficiaries, but this population has received little attention in ACO implementation. Although the ACO goals of providing chronic and preventive care in a coordinated, patient-centered manner are consistent with what some mental health providers have long advocated, the population-based orientation may be unfamiliar. In addressing the needs of high-cost, high-risk patients to meet quality and expenditure targets, an ACO should examine the quality of mental health care it provides as well as medical quality for patients with mental illness. In addition, federal agencies should invest to ensure understanding of the im...
TL;DR: There was substantial variation in lifetime treatment contact and delays in initial treatment contact by mental disorder, and Lifetime treatment contact, delays in treatment seeking, and receipt of helpful treatment did not vary by educational level.
Abstract: ObjectiveThis study examined lifetime treatment contact and delays in treatment seeking, including rates for receipt of helpful treatment, after the onset of specific mental disorders and evaluated factors that predicted treatment seeking and delays in treatment seeking.MethodsData were from the Netherlands Mental Health Survey and Incidence Study−2, a nationally representative, face-to-face survey of the general population aged 18–64 (N=6,646). DSM-IV diagnoses, treatment contact, and respondents' perception of treatment helpfulness were assessed with the Composite International Diagnostic Interview 3.0.ResultsThe proportion of respondents with lifetime mental disorders who made lifetime treatment contact ranged from 6.5% to 56.5% for substance use disorders and from 75.3% to 91.4% for mood disorders. Delays in initial treatment contact varied among persons with mood disorders (median=0 years), substance use disorders (0–4 years), impulse-control disorders (4–8 years), and anxiety disorders (0–19 years)....