Psychiatric Services Current Issue

This Month’s Highlights

Sat, 01 Jun 2013 00:00:00 GMT

The Promise of Large, Longitudinal Data Sets

Valenstein M. — Sat, 01 Jun 2013 00:00:00 GMT

In a study in this issue, Gören and colleagues used longitudinal data to assess whether providers followed guidelines when prescribing antipsychotics. This is an advance over studies that have assessed the quality of care with cross-sectional data. The point prevalence of antipsychotic polypharmacy may be of interest when assessing the quality of care. However, starting a patient with schizophrenia on antipsychotic polypharmacy immediately, rather than reserving it until other treatments have failed, has different implications.

Antipsychotic Prescribing Pathways, Polypharmacy, and Clozapine Use in Treatment of Schizophrenia

Gören JL, Meterko M, Williams S, et al. — Sat, 01 Jun 2013 00:00:00 GMT

Objective

To ensure optimal care for patients with schizophrenia, antipsychotic medications must be appropriately prescribed and used. Therefore, the primary objectives of this study were to identify and describe pathways for antipsychotic prescribing, assess the consistency of observed pathways with treatment guidelines, and describe variability across facilities.

Methods

Data from Veterans Affairs administrative data sets from fiscal year (FY) 2003 to FY 2007 were gathered for analysis in this retrospective cohort study of antipsychotic prescribing pathways among 13 facilities across two regional networks. Patients with a new episode of care for schizophrenia or schizoaffective disorder in FY 2005 were identified, and antipsychotic prescribing history was obtained for two years before and after the index diagnosis. Demographic characteristics and distribution of comorbidities were assessed. Median medical center rates of polypharmacy were calculated and compared with Fisher’s exact test.

Results

Of 1,923 patients with a new episode of schizophrenia care, 1,003 (52%) had complete data on prescribing pathways. A majority (74%) of patients were prescribed antipsychotic monotherapy, and 19% received antipsychotic polypharmacy. Of patients receiving antipsychotic polypharmacy, 65% began polypharmacy within 90 days of starting any antipsychotic treatment. There was a fourfold difference in polypharmacy across facilities. Antipsychotic polypharmacy was not associated with geographic location or medical center patient volume. Clozapine utilization was low (0%–2%).

Conclusions

Retrospective examination of longitudinal prescribing patterns identified multiple antipsychotic prescribing pathways. Although most patients received guideline-concordant care, antipsychotic polypharmacy was commonly used as initial treatment, and there was substantial variability among facilities. Study findings suggest the utility of secondary data to assess treatment adaptation or switching for practical clinical trials.

Changes in VA Psychiatrists’ Attitudes About Work Environment and Turnover During Mental Health Service Enhancement

Mohr DC, Bauer MS, Penfold RB. — Sat, 01 Jun 2013 00:00:00 GMT

Objective

The Veterans Health Administration (VHA) has undergone significant organizational transformation as part of a comprehensive strategic plan to enhance mental health services. Organizational change can create stress and decrease employee morale, even if the change is beneficial for patients and the organization. The study examined whether psychiatrists’ work satisfaction and work environment perceptions changed during a period of transformation. Facility-level turnover rate was also examined.

Methods

Data were analyzed from 7,218 psychiatrists who responded to an annual organizational survey between 2004 and 2010 (excluding 2005) conducted with 139 facilities. Survey ratings were regressed on individual and facility-level characteristics in a multilevel model. Adjusted mean scores for the measures were compared with Tukey post hoc tests to identify significant differences by year.

Results

Most satisfaction ratings on measures improved after the initial actions for strategic reform and stabilized in 2006. Turnover rates and intention to leave were also consistent during this time. Positive linear trends over time were observed for pay satisfaction, management for achievement, skill development, workplace civility, and satisfaction with senior management.

Conclusions

Extensive reorganization of VHA mental health services was associated with improvements in psychiatrists’ workplace satisfaction, and these increases were sustained over time. In the current climate of rapid transformation under health care reform nationally, the VHA experience may inform the broader national process and organizational strategies to improve and maintain the morale of the health care workforce.

Characteristics of Adults With Substance Use Disorders Expected to Be Eligible for Medicaid Under the ACA

Busch SH, Meara E, Huskamp HA, et al. — Sat, 01 Jun 2013 00:00:00 GMT

Objectives

Provisions in the Affordable Care Act (ACA) are likely to expand access to substance use disorder treatment for low-income individuals. The aim of the study was to provide information on the need for substance use disorder treatment among individuals who may be eligible for Medicaid under the ACA.

Methods

The 2008 and 2009 National Survey on Drug Use and Health provided data on demographic characteristics, health status, and substance use disorders for comparison of current low-income Medicaid enrollees (N=3,809) with currently uninsured individuals with household incomes that may qualify them for Medicaid coverage beginning in 2014 (N=5,049). The incomes of the groups compared were 138% of the federal poverty level (133% provided in the ACA plus a 5% income “disregard” allowed by the law).

Results

The rate of substance use disorders among currently uninsured income-eligible individuals was slightly higher than the rate among current Medicaid enrollees (14.6% versus 11.5%, p=.03). Although both groups had significant unmet need for substance use disorder treatment, the treatment rate among those who needed treatment was significantly lower in the income-eligible group than in the currently enrolled group (31.3% versus 46.8%, p<.01). When the analysis excluded informal care received outside the medical sector, treatment rates among those with treatment needs were much lower in both groups (12.8% in the income-eligible group and 30.7% among current enrollees).

Conclusions

Findings suggest that Medicaid insurance expansions under the ACA will reduce unmet need for substance use disorder treatment.

Comparison of Outcomes for African Americans, Hispanics, and Non-Hispanic Whites in the CATIE Study

Arnold J, Miller AL, Cañive JM, et al. — Sat, 01 Jun 2013 00:00:00 GMT

Objective

Medication outcome literature in schizophrenia across racial-ethnic groups is sparse, with inconsistent findings. The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study provided an opportunity for exploratory analyses of racial-ethnic outcomes. The study objective was to examine race-ethnicity outcomes for CATIE's main outcome (study discontinuation) and secondary outcomes.

Methods

CATIE participants included whites (non-Hispanic) (N=722), African Americans (N=506), and Hispanics (N=170). Survival analyses and mixed-effects regression modeling were conducted, with adjustment for baseline sociodemographic differences and baseline scores of the secondary outcomes.

Results

Racial-ethnic groups had unique patterns of outcomes. Hispanics were much more likely to discontinue for lack of efficacy from perphenazine (64% versus 42% non-Hispanic whites and 24% African Americans) and ziprasidone (71% versus 40% non-Hispanic whites and 24% African Americans); Hispanics' quality of life also declined on these medications. Non-Hispanic whites were more likely to discontinue for lack of efficacy in general (averaging olanzapine, quetiapine, and risperidone discontinuation rates). African Americans were less likely to continue after the first phase (32% continuing versus 40% for non-Hispanic whites and 41% Hispanics). Discontinuations were driven by research burden, personal issues, and unspecified loss to follow-up. Non-Hispanic whites had higher depression scores during the follow-up period. African Americans had fewer side effects.

Conclusions

CATIE results did not show disparities favoring non-Hispanic whites. CATIE may have provided state-of-the-art treatment and thus reduced disparate treatments observed in community clinics. African Americans discontinued even after consideration of socioeconomic differences. Why perphenazine and ziprasidone may be less effective with Hispanics should be explored.

Current and Future Funding Sources for Specialty Mental Health and Substance Abuse Treatment Providers

Levit KR, Stranges E, Coffey RM, et al. — Sat, 01 Jun 2013 00:00:00 GMT

Objectives

Goals were to describe funding for specialty behavioral health providers in 1986 and 2005 and examine how the recession, parity law, and Affordable Care Act (ACA) may affect future funding.

Methods

Numerous public data sets and actuarial methods were used to estimate spending for services from specialty behavioral health providers (general hospital specialty units; specialty hospitals; psychiatrists; other behavioral health professionals; and specialty mental health and substance abuse treatment centers).

Results

Between 1986 and 2005, hospitals—which had received the largest share of behavioral health spending—declined in importance, and spending shares trended away from specialty hospitals that were largely funded by state and local governments. Hospitals’ share of funding from private insurance decreased from 25% in 1986 to 12% in 2005, and the Medicaid share increased from 11% to 23%. Office-based specialty providers continued to be largely dependent on private insurance and out-of-pocket payments, with psychiatrists receiving increased Medicaid funding. Specialty centers received increased funding shares from Medicaid (from 11% to 29%), and shares from other state and local government sources fell (from 64% to 46%).

Conclusions

With ACA’s full implementation, spending on behavioral health will likely increase under private insurance and Medicaid. Parity in private plans will also push a larger share of payments for office-based professionals from out-of-pocket payments to private insurance. As ACA provides insurance for formerly uninsured individuals, funding by state behavioral health authorities of center-based treatment will likely refocus on recovery and support services. Federal Medicaid rules will increase in importance as more people needing behavioral health treatment become covered.

Implementation of Multifamily Group Treatment for Veterans With Traumatic Brain Injury

Perlick DA, Straits-Troster K, Strauss JL, et al. — Sat, 01 Jun 2013 00:00:00 GMT

Objective

This study evaluated the initial efficacy and feasibility of implementing multifamily group treatment for veterans with traumatic brain injury (TBI).

Methods

Veterans at two Veterans Affairs medical centers were prescreened by their providers for participation in an open trial of multifamily group treatment for TBI. Enrollment was limited to consenting veterans with a clinical diagnosis of TBI sustained during the Operation Enduring Freedom–Operation Iraqi Freedom era, a family member or partner consenting to participate, and a score ≥20 on the Mini-Mental State Examination. The nine-month (April 2010–March 2011) trial consisted of individual family sessions, an educational workshop, and bimonthly multifamily problem-solving sessions. Interpersonal functioning and symptomatic distress among veterans and family burden, empowerment, and symptomatic distress among families were assessed before and after treatment.

Results

Providers referred 34 (58%) of 59 veterans screened for the study; of those, 14 (41%) met criteria and consented to participate, and 11 (32%) completed the study. Severity of TBI, insufficient knowledge about the benefits of family involvement, and access problems influenced decisions to exclude veterans or refuse to participate. Treatment was associated with decreased veteran anger expression (p≤.01) and increased social support and occupational activity (p≤.05), with effect sizes ranging from .6 to 1.0. Caregivers reported decreased burden (p≤.05) and increased empowerment (p≤.01).

Conclusions

The results supported implementation of a randomized controlled trial, building in education at the provider and family level.

Inpatient Psychiatric Care Experience and Its Relationship to Posthospitalization Treatment Participation

Bowersox NW, Bohnert AB, Ganoczy D, et al. — Sat, 01 Jun 2013 00:00:00 GMT

Objective

This study used factor analysis of a Veterans Health Administration (VHA) survey to identify factors that measure satisfaction with inpatient treatment and to examine the factors’ utility in evaluating treatment participation following discharge.

Methods

The Survey of Healthcare Experiences of Patients (inpatient version) (I-SHEP) was mailed to 34,237 veterans who were discharged from inpatient to outpatient care in the VHA during fiscal year 2009 and was completed by 7,408 patients. A factor analysis of survey responses identified underlying I-SHEP factors and evaluated relationships between the factors, patient characteristics, and attendance at VHA mental health appointments within seven and 30 days of discharge.

Results

The factor analysis identified three domains of satisfaction: respect and caring by nurses–overall hospital impression; involvement and information about care; and respect and caring by doctors. These factors demonstrated good internal consistency (Cronbach’s α=.93, .90, and .94, respectively) and accounted for a moderate amount of variance in patient responses (r²=.167). Only the care involvement and information factor was associated with participation in follow-up care: increased satisfaction (one standard deviation change in scale score) was associated with improved odds of a mental health visit within seven and 30 days of discharge (odds ratio=1.14 and 1.17, respectively, p<.01).

Conclusions

After discharge, persons may not generalize satisfaction about the respect and caring shown by inpatient treatment teams toward their decision to attend outpatient care. Providing patients with information about treatment and involving them in care decisions during inpatient care may help facilitate the transition to outpatient settings.

Relationships Among Veteran Status, Gender, and Key Health Indicators in a National Young Adult Sample

Grossbard JR, Lehavot K, Hoerster KD, et al. — Sat, 01 Jun 2013 00:00:00 GMT

Objective

Although many risk behaviors peak during young adulthood, little is known about health risk factors and access to care. This study assessed health indicators and health care access in a national sample of young adult veterans and civilians.

Methods

Data were from the 2010 Behavioral Risk Factor Surveillance System, a national telephone survey. Of 27,471 participants, ages 19–30 years, 2.2% were veterans (74.6% were male) and 97.7% were civilians (37.6% were male). Gender-stratified comparisons assessed health indicators and health care access by veteran status. Multivariate logistic regression was used to examine health indicators and health care access as a function of gender and veteran status.

Results

In the overall sample, women were more likely than men to have insurance, to have a regular physician, and to have had a routine checkup and yet were more likely to report financial barriers to care. Women also were more likely than men to report general medical and mental distress and higher lifetime anxiety and depressive disorders, whereas men were more likely to be overweight or obese and to report tobacco use and high-risk drinking. Adjusted analyses revealed a higher likelihood of general medical distress and higher rates of lifetime anxiety disorders among veterans compared with civilians, although there were no differences between veterans and civilians regarding health care utilization and hazardous drinking.

Conclusions

Findings extend the literature on health care status and modifiable risk factors for young adults by identifying differences between men and women and between veterans and civilians. Interventions may need to be tailored on the bases of gender and veteran status because of several differences in mental health and general health needs.

Use of Intervention Strategies by Assertive Community Treatment Teams to Promote Patients’ Engagement

Manuel JI, Appelbaum PS, Le Melle SM, et al. — Sat, 01 Jun 2013 00:00:00 GMT

Objective

This study explored the range of interventions and the use of more intrusive techniques by staff of assertive community treatment (ACT) teams to promote engagement, manage problem behaviors, and reinforce positive behaviors among patients. Individual and organizational characteristics that may be associated with these practices were identified.

Methods

Between January and March 2006, clinicians (N=239) from 34 ACT teams participated in a one-time survey about their intervention strategies with patients, perceptions about the ACT team environment, and beliefs about persons with severe mental illness.

Results

Significant variation existed in the types of interventions employed across teams. The less intrusive strategies, including positive inducements and verbal guidance, were the most common. Other strategies that placed limits on patients but that were still considered less intrusive—such as medication monitoring and money management—were also common. Clinicians who reported working in more demoralized climates and having negative perceptions of mental illness were more likely to endorse leveraged or intrusive interventions.

Conclusions

The findings of this study suggest significant variation across teams in the use of intervention strategies. Both perceptions of a demoralized organizational climate and stigmatizing beliefs about mental illness were correlated with the use of more intrusive intervention strategies. Future research on the role and appropriateness of more intrusive interventions in mental health treatment and the impact of such interventions on patient outcomes is warranted.

Economic Grand Rounds: Financing First-Episode Psychosis Services in the United States

Goldman HH, Karakus M, Frey W, et al. — Sat, 01 Jun 2013 00:00:00 GMT

Adequate financing is essential to implementing services for individuals experiencing a first episode of a psychotic illness. Recovery After an Initial Schizophrenia Episode (RAISE), a project sponsored by the National Institute of Mental Health, is providing a practical test of the implementation and effectiveness of first-episode services in real-world settings. This column describes approaches to financing early intervention services that are being used at five of 18 U.S. sites participating in a clinical trial of a team-based, multielement RAISE intervention. The authors also describe new options for financing that will become available as the Affordable Care Act (ACA) is implemented more fully. The ACA will rationalize coverage of first-episode services, but the all-important Medicaid provisions will also require individual state action to implement services optimally.

Research and Services Partnerships: Partnership: A Fundamental Component of Dissemination and Implementation Research

Chambers DA, Azrin ST. — Sat, 01 Jun 2013 00:00:00 GMT

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.

Research to Reduce the Suicide Rate Among Older Adults: Methodology Roadblocks and Promising Paradigms

Szanto K, Lenze EJ, Waern M, et al. — Sat, 01 Jun 2013 00:00:00 GMT

The National Institute of Mental Health and the National Action Alliance for Suicide Prevention have requested input into the development of a national suicide research agenda. In response, a working group of the American Association for Geriatric Psychiatry has prepared recommendations to ensure that the suicide prevention dialogue includes older adults, a large and fast-growing population at high risk of suicide. In this Open Forum, the working group describes three methodology roadblocks to research into suicide prevention among elderly persons and three paradigms that might provide directions for future research into suicide prevention strategies for older adults.

Behavioral Health and Social Correlates of Reincarceration Among Hispanic, Native American, and White Rural Women

Willging C, Malcoe L, St. Cyr S, et al. — Sat, 01 Jun 2013 00:00:00 GMT

Objective

To identify community reentry needs, this study examined mental illness, substance dependence, and other correlates of reincarceration in an ethnically diverse, rural population of women prisoners.

Methods

A purposive, cross-sectional sample of 98 women in a New Mexico state prison completed structured interviews. Analyses examined associations of substance dependence, mental illness, lifetime trauma, and sociodemographic variables with previous incarceration.

Results

Eighty-five percent screened positive for substance dependence, 50% for current mental disorders, and 46% for both. Exposure to trauma was pervasive (100%), especially physical or sexual trauma (83%). In adjusted analyses, previous incarceration was associated with precarious housing before imprisonment (odds ratio [OR]=2.19, p=.038) and with having co-occurring mental illness and substance dependence (OR=2.68, p=.019).

Conclusions

Findings support those of similar studies in urban areas and with other ethnic groups. Wraparound programs focusing on harm reduction, housing, and treatment and support services are needed for successful reentry of these underserved women.

Health Care Utilization Prior to Loss to Care Among Veterans With Serious Mental Illness

Abraham KM, Lai Z, Bowersox NW, et al. — Sat, 01 Jun 2013 00:00:00 GMT

Objective

This study examined the association between utilization of Veterans Affairs (VA) health services and the probability of treatment dropout among veterans with serious mental illness.

Methods

Utilization of VA health services in the fiscal year (FY) before treatment dropout among veterans with serious mental illness who were lost to care for at least 12 months beginning in FYs 2008 or 2009 (N=6,687) was compared with utilization in FYs 2007 or 2008 among veterans with serious mental illness who remained in care (N=6,687).

Results

The veterans (mean age=54) were predominantly male (91%) and Caucasian (76%). After accounting for demographic and clinical variables, the analyses found that more primary care and mental health outpatient visits and fewer general medical and mental health hospitalizations were associated with lower odds of dropout.

Conclusions

Engagement in outpatient health care was associated with lower odds of loss to care among veterans with serious mental illness.

Primary Care Providers’ Views on Metabolic Monitoring of Outpatients Taking Antipsychotic Medication

Mangurian C, Giwa F, Shumway M, et al. — Sat, 01 Jun 2013 00:00:00 GMT

Objective

The purpose of this study was to evaluate attitudes of primary care providers toward barriers to metabolic monitoring and to characterize their beliefs about providers’ responsibility for monitoring and reducing cardiovascular risk for people with severe mental illness.

Methods

An anonymous survey was administered to 214 primary care providers working in 23 public community health clinics in San Francisco.

Results

The response rate was 77% (164 of 214). Nearly 40% of primary care providers were unaware of consensus guidelines for metabolic monitoring of people who take second-generation antipsychotic medications. Responses showed variation in providers’ beliefs about who should monitor patients’ metabolic risk. The major barriers to metabolic monitoring were severity of psychiatric illness, difficulty collaborating with psychiatrists, and difficulty arranging psychiatric follow-up.

Conclusions

Primary care providers believed that better communication between primary care providers and psychiatrists would facilitate metabolic monitoring and promote better treatment for patients with severe mental illness who are taking antipsychotic medications.

IOM Committee Assesses Current and Long-Term Needs of Returning Service Members and Veterans

Sat, 01 Jun 2013 00:00:00 GMT

More than 2.2 million men and women have served in the wars in Iraq and Afghanistan. Although most have readjusted well to postdeployment life, a large proportion (44%) have reported difficulties resuming home life, reconnecting with family members, finding employment, and returning to school. To better understand and address the needs of these individuals, Congress requested the National Academies to undertake a comprehensive assessment of the physical, psychological, social, and economic effects of deployment on service members and their families and communities and identify gaps in care.

News Briefs

Sat, 01 Jun 2013 00:00:00 GMT

AHRQ series on PCMH research methods: The patient-centered medical home (PCMH) is a promising model for organizing care to improve quality and accessibility and reduce costs. To refine the PCMH model, evaluators and researchers need methods that yield robust evidence. The PCMH Research Methods Series, funded by the Agency for Healthcare Research and Quality (AHRQ) and developed by Mathematica Policy Research, is designed to “expand the toolbox” of methods used to evaluate PCMH models and other health care interventions. Each of the ten briefs in the series describes a research method, outlines advantages and limitations, and lists resources for researchers to learn more. The topics cover both “evolutionary” ways to improve evaluations—by using traditional research methods—and “revolutionary” approaches that draw on methods from anthropology, organizational analysis, engineering, and political science. The goal is to ensure that evaluations focus not only on “Does it work?” but also on “How does it work?” For example, Efficient Orthogonal Designs describes a tool for use at the outset of a study to compare the effectiveness of different ways of deploying each PCMH component, as well as how the effects of individual components interact. The series is available on the AHRQ Web site at pcmh.ahrq.gov.