This Month’s Highlights

Overcrowding of U.S. emergency departments (EDs) along with bed and staff shortages have led to long ED wait times for many patients with mental disorders—a practice called boarding. This month’s lead article reports on a study by Joseph L. Smith, M.P.H., and colleagues, who identified factors associated with boarding (defined as wait times of more than six hours) among nearly 600,000 patients with a primary psychiatric diagnosis who visited Florida EDs from 2010 to 2013. The mean length of stay for these patients was 7.7 hours. Those who were suicidal or had a schizophrenia diagnosis had the longest stays. Hispanic patients stayed more than two hours longer than Caucasian patients and more than one hour longer than African-American patients—differences that may have been attributable to insurance type. Commercial insurance was associated with the shortest stays. Most visits that ended in transfers to other facilities qualified as episodes of boarding. Three-quarters of the transferred patients were held for an average of nearly 16 hours (page 1169). In a Taking Issue commentary, Marvin S. Swartz, M.D., describes a simulation model used in North Carolina for generating useful estimates of bed need by using ED boarding times as a “key crisis capacity metric” (page 1163).

Two studies examined approaches to preventing costly inpatient readmissions, a key goal of providers, policy makers, and insurers. Analyzing data for more than 32,000 Medicaid enrollees who were hospitalized with a primary psychiatric diagnosis, Catherine Anne Fullerton, M.D., M.P.H., and colleagues found that in the week after discharge less than 5% received intermediate services (residential, partial hospital, intensive outpatient, and other rehabilitative services) and that, contrary to expectations, receipt did not lower readmissions significantly (page 1175). Joanna P. MacEwan, Ph.D., and colleagues analyzed Medicaid claims for more than 15,000 patients with schizophrenia and found that compared with oral antipsychotics, long-acting injectables were associated with a significantly reduced 60-day readmission rates (page 1183).

Although clozapine is superior to other antipsychotics for treatment-resistant schizophrenia, relatively few patients receive it. Two studies by Jessica L. Gören, Pharm.D., and her colleagues investigated clozapine use across Department of Veterans Affairs (VA) facilities. In 2013, 4% of veterans with schizophrenia received clozapine. Structured interviews with key informants at VA medical centers indicated that high use was associated with integration of nonphysician providers into clozapine clinics, clear organizational processes and infrastructure for treating severe mental illness, and transportation to the clinic. Low use was associated with a lack of champions for clozapine processes and limited-capacity care systems (page 1189). In the second study—a business case analysis—the authors found that simply doubling the use of clozapine could save the Veterans Health Administration up to $80 million in the first year and even more in later years, as initial costs involved in extra office visits and laboratory monitoring subside. Mortality associated with the drug’s serious potential side effects would be more than offset by prevention of suicides (page 1197).

Many adults with serious mental illness have one or more chronic general medical conditions. Integrated self-management interventions address both psychiatric and general medical illnesses. A literature review by Karen L. Whiteman, Ph.D., and colleagues looked at studies of nine such interventions: automated telehealth, Health and Recovery Peer program, Helping Older People Experience Success, Integrated Illness Management and Recovery, Life Goals Collaborative Care, Living Well, Norlunga Chronic Disease Self-Management program, Paxton House, and Targeted Training in Illness Management. The authors found evidence for the feasibility and acceptability of these interventions and preliminary evidence of their clinical effectiveness. High operating costs and workforce shortages are obstacles that could be overcome by use of technology and peer providers (page 1213).

Recognizing that integration of general medical care into community mental health centers (CMHCs) could improve outcomes for people with serious mental illness, SAMHSA began the Primary and Behavioral Health Care Integration (PBHCI) grants program in 2009. Deborah M. Scharf, Ph.D., and colleagues describe outcomes for early participants (2009 and 2010). Approximately one year of PBHCI treatment resulted in potentially clinically significant improvements in cholesterol but not in the other general medical outcomes examined (page 1226). At two PBHCI CMHCs, use of outpatient general medical services rose between 2011 and 2014, but reductions in hospitalization were achieved only by the clinic with a relatively long history of providing medical care, according to a study by Antoinette Krupski, Ph.D., and colleagues (page 1233).