This Month’s Highlights

A survey conducted just before the Affordable Care Act (ACA) was implemented on January 1, 2014, indicated that most psychiatrists were aware of the new service models that were being introduced by the ACA and that many were prepared to practice in such models. Joyce C. West, Ph.D., M.P.P., and colleagues report survey findings from a probability sample of nearly 1,100 U.S. psychiatrists who took part in the Study of Psychiatric Practice Under Health Care Reform, fielded in the fall of 2013. Almost a third of respondents (29%) reported that they were already practicing in an integrated care setting. Most (64%) reported already undertaking at least one of the roles identified in the survey instrument as integral to successful ACA implementation: participating on a team service delivery model; treating a caseload of patients with more severe mental illness and coordinating with a primary care clinician; providing consultation to primary care and mental health clinicians caring for psychiatric patients with diagnostic or therapeutic challenges; or providing leadership and supervision for team delivery of psychiatric and general medical care for psychiatric patients. However, achieving more widespread adoption of integrated models will be challenging, the authors conclude, because more than half of the psychiatrists’ patients were treated in solo or group office settings, where patients are more likely to pay out of pocket or have private insurance (page 1292).

Psychiatrists in the RAISE Connection Program adhered closely to the program’s prescribing guidelines, according to a chart review conducted between 2011 and 2013. The Connection Program, implemented in Manhattan and Baltimore over two years, was part of the NIMH-funded RAISE (Recovery After an Initial Schizophrenia Episode) initiative that tested models of coordinated specialty care for individuals with first-episode psychosis. Julie A. Kreyenbuhl, Pharm.D., Ph.D., and colleagues found that in line with program guidelines, 92% of participants were prescribed an antipsychotic medication and that dosages were within the recommended ranges. Recommended frequencies for weight monitoring and glucose and lipid level evaluations, however, were not met. Program psychiatrists, who received two days of training and ongoing consultation with a psychopharmacology expert, were expected to implement the medication management guidelines by using a shared decision-making approach with patients and families. Use of this approach may have contributed to the high rate of engagement and retention of program participants, the authors note (1300).

The American Psychiatric Association and the Academy of Child and Adolescent Psychiatry have urged members to use caution when prescribing second-generation antipsychotics to children, but the practice continues to grow. Haiden A. Huskamp, Ph.D., and colleagues used monthly physician-level prescribing data from IMS Health’s Xponent database to examine factors that influence antipsychotic prescribing to young children (ages zero to nine). The sample included all U.S. psychiatrists and a random sample of 5% of family medicine physicians who wrote at least ten antipsychotic prescriptions per year (N=31,713). During the three-year period, 42% of the sample had written at least one antipsychotic prescription for a young child, and nearly two-thirds of this group (64%) had written a prescription for a medication with no FDA-approved indications for a child of that age. These prescribing patterns were more common among physicians with a larger share of prescriptions paid for by Medicaid fee-for-service programs (page 1307).

Studies in two European countries examined initiatives to reduce the use of coercive measures during inpatient care. In Germany, the Supreme Court temporarily halted forced medication of involuntary psychiatric inpatients from July 2012 until February 2013 in the state of Baden-Wuerttemberg. Erich Flammer, Dr.Biol.Hum., and Tilman Steinert, Prof.Dr.Med., analyzed data from seven hospitals and showed that although the proportion of admissions involving seclusion or restraint (SR) remained nearly the same, the number of SR interventions rose significantly during admissions that involved at least one SR intervention (page 1315). In 2006, the Dutch government set a goal of reducing inpatient seclusion by at least 10% each year. Eric O. Noorthoorn, M.D., Ph.D., and colleagues found that from 2008 to 2013, psychiatric hospitals nationwide achieved an average yearly reduction of about 9%. Some hospitals where seclusion decreased saw an increase in forced medication use (page 1321).