Adequacy of treatment for serious mental illness in the United States

Impact of the Medicare Shared Savings Program on utilization of mental health and substance use services by eligibility and race/ethnicity

OBJECTIVE

To assess the impact of the Medicare Shared Savings Program (MSSP) ACOs on mental health and substance use services utilization and racial/ethnic disparities in care for these conditions.

DATA SOURCES

Five percent random sample of Medicare claims from 2009 to 2016.

STUDY DESIGN

We compared Medicare beneficiaries in MSSP ACOs to non-MSSP beneficiaries, stratifying analyses by Medicare eligibility (disability vs age 65+). We estimated difference-in-difference models of MSSP ACOs on mental health and substance use visits (outpatient and inpatient), medication fills, and adequate care for depression adjusting for age, sex, race/ethnicity, region, and chronic medical and behavioral health conditions. To examine the differential impact of MSSP on our outcomes by race/ethnicity, we used a difference-in-difference-in-differences (DDD) design.

DATA COLLECTION/EXTRACTION METHODS

Not applicable.

PRINCIPAL FINDINGS

MSSP ACOs were associated with small reductions in outpatient mental health (Coeff: -0.012, P < .001) and substance use (Coeff: -0.001, P < .01) visits in the disability population, and in adequate care for depression for both the disability- and age-eligible populations (Coeff: -0.028, P < .001; Coeff: -0.012, P < .001, respectively). MSSP ACO's were also associated with increases in psychotropic medications (Coeff: 0.007 and Coeff: 0.0213, for disability- and age-eligible populations, respectively, both P < .001) and reductions in inpatient mental health stays (Coeff:-0.004, P < .001, and Coeff:-0.0002, P < .01 for disability- and age-eligible populations, respectively) and substance use-related stays for disability-eligible populations (Coeff:-0.0005, P<.05). The MSSP effect on disparities varied depending on type of service.

CONCLUSIONS

We found small reductions in outpatient and inpatient stays and in rates of adequate care for depression associated with MSSP ACOs. As MSSP ACOs are placed at more financial risk for population-based treatment, it will be important to include more robust behavioral health quality measures in their contracts and to monitor disparities in care.

Role of cancer survivor health and health service use in spouses' use of mental health-related care

BACKGROUND

Spouses of cancer survivors are at an increased risk of poor mental health outcomes but are known to underuse supportive services. The objective of the current study was to determine how the health and health care use of cancer survivors were associated with depression and anxiety-related health care use in their spouses.

METHODS

The current observational study used data from the Medical Expenditure Panel Survey to identify married individuals with a cancer-related medical event or disability ("cancer survivors"), and linked health and health care use data across spousal dyads. Spouses reporting a prescription for an antidepressant or antianxiety medication or any psychotherapy were flagged as having used mental health care. Correlates of use were assessed, with a focus on the health and health care use of the cancer survivor.

RESULTS

Greater than 25% of the spouses of cancer survivors used mental health care over the approximately 2.5 years of follow-up. Controlling for their own predisposing, enabling, and need characteristics, spouses were found to be less likely to use mental health care if the cancer survivor reported more health conditions or elevated depressed mood compared with dyads in which the survivor reported low distress and depression. Spouses were nearly 3 times more likely to use mental health care if the cancer survivor themselves had used mental health care (odds ratio, 2.98; 95% confidence interval, 2.17-4.09).

CONCLUSIONS

The findings of the current study enhance understanding of how health outcomes are intertwined in families with cancer, and reinforce the importance of a family-centered approach to cancer care that facilitates psychosocial care.

LAY SUMMARY

The health and well-being of cancer survivors and their spouses are intertwined. The results of the current study demonstrated that this interrelationship extends to mental health care related to depression and anxiety. Spouses of cancer survivors were found to be less likely to receive mental health care when the survivor had more health care needs. Spouses were nearly 3 times more likely to receive care if the survivor also was receiving mental health care. Caregiving spouses may face more challenges finding the time, money, or energy to engage in their own self-care. However, providing supportive care to one partner may help the other partner access care as well.

Prevalence and correlates of diagnosed and undiagnosed epilepsy and migraine headache among people with severe psychiatric disorders in Ethiopia

BACKGROUND

There is a paucity of research on the prevalence of diagnosed as well as undiagnosed neurological disorders with episodic manifestations such as epilepsy and migraine headaches in people with severe psychiatric disorders (SPD). To the best of our knowledge, this is the first study analyzing and comparing the prevalence of diagnosed and undiagnosed chronic neurological disorders with episodic manifestations including epilepsy and migraine headache in people with SPD.

METHOD

This quantitative cross-sectional survey was undertaken among 309 patients with SPD selected by a systematic random sampling technique. The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) was used to confirm SPD among the participants. The International Classification of Headache Disorders (ICHD-3) and International League Against Epilepsy (ILAE) were used to define migraine headache and epilepsy, respectively]. Risk factors for chronic neurologic disorders were explored by using logistic regression models.

RESULT

In this study, the prevalence of overall neurological disorders, epilepsy, and migraine headache among people with SPD were found to be 5.2% (95%CI 3.2-8.3), 1.6% (95%CI 0.7-3.9), and 3.9% (95%CI 2.2-6.7), respectively. We found that a considerably higher proportion of people with SPD had undiagnosed overall neurological disorder (87.5%; 14/16), epilepsy (60%; 3/5), as well as migraine headaches (100%; 12/12). On the other hand, in this study, 12.5%, 40%, and 0% of patients with overall neurologic disorder, epilepsy, and migraine headaches respectively were diagnosed by the professionals. Higher disability score (WHODAS score) was associated with increased odds of having neurological disorders compared with the lower WHODAS score [OR = 1.30 (95% CI 1.02-1.66)].

CONCLUSION

Whilst the prevalence estimates of neurological disorders with episodic manifestations including epilepsy and migraine headache was high among people with SPD, the vast majority of them remained undiagnosed. The diagnosis rates of those disorders were significantly low, perhaps surprisingly zero for migraine headache. High WHODAS score was associated with increased odds of having neurological disorders. Routine screening and management of epilepsy and migraine headache are imperative among people with SPD.

Measuring the Patient Experience of Mental Health Care: A Systematic and Critical Review of Patient-Reported Experience Measures

BACKGROUND

There is growing concern about measuring patient experience with mental health care. There are currently numerous patient-reported experience measures (PREMs) available for mental health care, but there is little guidance for selecting the most suitable instruments. The objective of this systematic review was to provide an overview of the psychometric properties and the content of available PREMs.

METHODS

A comprehensive review following the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines was conducted using the MEDLINE database with no date restrictions. The content of PREMs was analyzed using an inductive qualitative approach, and the methodological quality was assessed according to Pesudovs quality criteria.

RESULTS

A total of 86 articles examining 75 PREMs and totaling 1932 items were included. Only four PREMs used statistical methods from item response theory (IRT). The 1932 items covered seven key mental health care domains: interpersonal relationships (22.6%), followed by respect and dignity (19.3%), access and care coordination (14.9%), drug therapy (14.1%), information (9.6%), psychological care (6.8%) and care environment (6.1%). Additionally, a few items focused on patient satisfaction (6.7%) rather than patient experience. No instrument covered the latent trait continuum of patient experience, as defined by the inductive qualitative approach, and the psychometric properties of the instruments were heterogeneous.

CONCLUSION

This work is a critical step in the creation of an item library to measure mental health care patient-reported experience that will be used in France to develop, validate, and standardize item banks and computerized adaptive testing (CAT) based on IRT. It will also provide internationally replicable measures that will allow direct comparisons of mental health care systems.

TRIAL REGISTRATION

NCT02491866.

National Trends in Outpatient Mental Health Service Use Among Adults Between 2008 and 2015

OBJECTIVE

This study sought to characterize recent trends in mental health visits of adult outpatients to primary care physicians (PCPs), specialty mental health providers (SMHPs), and other providers (non-primary care physicians, specialists other than SMHPs, nurse practitioners, and physician assistants). Trends determined by degree of patients' psychological distress and in the types of treatments received within different settings were also examined.

METHODS

Data were from the household component of the nationally representative Medical Expenditure Panel Survey for the 2008-2011 and 2012-2015 periods for adults ages ≥18 years (N=13,111) who had a mental health outpatient visit. Bivariate logistic regression was used to compare means between the two periods.

RESULTS

The percentage of adults having mental health outpatient visits increased between the two periods, largely driven by an increase in visits with providers other than SMHPs and PCPs, which rose from 11.9% (N=667) to 15.5% (N=1,048). Outpatient mental health visits with PCPs decreased from 29.0% (N=1,802) to 26.8% (N=1,945). The proportion of respondents with mental health outpatient visits increased both among those with high psychological distress and among those with low or no psychological distress (from 30.7% [N=1,332] to 36.2% [N=1,491] and from 6.0% [N=4,516] to 6.9% [N=5,772], respectively). The percentage of respondents receiving only psychotropic medication decreased over the two periods.

CONCLUSIONS

Mental health outpatient visits for adults increased between 2008 and 2015, and visits with SMHPs remained relatively stable during that time. A greater understanding of recent trends in types of outpatient mental health services may help identify targets for future mental health workforce studies.

Implementing a transdiagnostic sleep and circadian intervention in a community mental health setting: A qualitative process evaluation with community stakeholders

The implementation of evidence-based psychological treatments (EBPTs) may be particularly challenging to accomplish in community mental health settings for individuals with severe mental illness (SMI). Transdiagnostic treatments, or treatments that target a mechanism that underpins multiple mental health problems, may be particularly well-suited to community mental health settings. This study examines community stakeholder perspectives (N = 22) of the Transdiagnostic Sleep and Circadian Intervention (TranS-C) implemented in a community mental health setting in the context of a randomized controlled trial of TranS-C for SMI. The present study aimed to identify barriers and facilitators to the implementation of TranS-C for SMI in a community mental health setting using (1) a deductive theory-based process based on the Framework for Dissemination in Health Services Intervention Research and (2) an inductive thematic analysis process. All deductive themes were identified as both barriers and facilitators to the implementation of EBPTs and TranS-C in this community mental health setting. Seven additional themes were identified through the inductive thematic analysis. A discussion of how the findings are related to prior research, other EBPT implementation, and future TranS-C implementation are included.

Unmet mental health needs in the general population: perspectives of Belgian health and social care professionals

Background

An unmet mental health need exists when someone has a mental health problem but doesn’t receive formal care, or when the care received is insufficient or inadequate. Epidemiological research has identified both structural and attitudinal barriers to care which lead to unmet mental health needs, but reviewed literature has shown gaps in qualitative research on unmet mental health needs. This study aimed to explore unmet mental health needs in the general population from the perspective of professionals working with vulnerable groups.

Methods

Four focus group discussions and two interviews with 34 participants were conducted from October 2019 to January 2020. Participants’ professional backgrounds encompassed social work, mental health care and primary care in one rural and one urban primary care zone in Antwerp, Belgium. A topic guide was used to prompt discussions about which groups have high unmet mental health needs and why. Transcripts were coded using thematic analysis.

Results

Five themes emerged, which are subdivided in several subthemes: (1) socio-demographic determinants and disorder characteristics associated with unmet mental health needs; (2) demand-side barriers; (3) supply-side barriers; (4) consequences of unmet mental health needs; and (5) suggested improvements for meeting unmet mental health needs.

Conclusions

Findings of epidemiological research were largely corroborated. Some additional groups with high unmet needs were identified. Professionals argued that they are often confronted with cases which are too complex for regular psychiatric care and highlighted the problem of care avoidance. Important system-level factors include waiting times of subsidized services and cost of non-subsidized services. Feelings of burden and powerlessness are common among professionals who are often confronted with unmet needs. Professionals discussed future directions for an equitable mental health care provision, which should be accessible and targeted at those in the greatest need. Further research is needed to include the patients’ perspective of unmet mental health needs.

Development of the Motivation and Skills Support (MASS) social goal attainment smartphone app for (and with) people with schizophrenia

People with schizophrenia and schizoaffective disorder (SZ) often struggle with social impairment, including small social networks and loneliness. Limitations in social skills and reduced social motivation-effort to engage in social connection-are key contributors to social impairment. While evidence-based approaches to improving social outcomes are available, including social skills training and cognitive behavioral therapy for psychosis, ongoing access to these interventions is often limited. Mobile technologies, including smartphone applications (apps), may address some of this need. In this paper, we describe the development of a smartphone app designed to address social skill and motivation deficits in SZ: the Motivation and Skills Support (MASS) app. We discuss the incorporation of stakeholder input into intervention design as well as results from usability pilot testing of the app in a sample of people with SZ. Finally, we describe next steps in the development and testing process of the MASS app.

Comparison of Mental Health Treatment Adequacy and Costs in Public Hospitals in Boston and Madrid

Analyses of healthcare expenditures and adequacy are needed to identify cost-effective policies and practices that improve mental healthcare quality. Data are from 2010 to 2012 electronic health records from three hospital psychiatry departments in Madrid (n = 29,944 person-years) and three in Boston (n = 14,109 person-years). Two-part multivariate generalized linear regression and logistic regression models were estimated to identify site differences in mental healthcare expenditures and quality of care. Annual total average treatment expenditures were $4442.14 in Boston and $2277.48 in Madrid. Boston patients used inpatient services more frequently and had higher 30-day re-admission rates (23.7 vs. 8.7%) despite higher rates of minimally adequate care (49.5 vs. 34.8%). Patients in Madrid were more likely to receive psychotropic medication, had fewer inpatient stays and readmissions, and had lower expenditures, but had lower rates of minimally adequate care. Differences in insurance and healthcare system policies and mental health professional roles may explain these dissimilarities.

Health Implications of Incarceration and Reentry on Returning Citizens: A Qualitative Examination of Black Men's Experiences in a Northeastern City

While a great deal of research captures the lived experiences of Black men as they navigate through the criminal legal system and onto reentry, very little research is grounded in how those processes are directly connected to their health. Although some research argues that mass incarceration is a determinant of poor health, there is a lack of qualitative analyses from the perspective of Black men. Black men face distinct pathways that lead them into the criminal legal system, and these same pathways await them upon reentry. This study aims to examine the health implications associated with incarceration and reentry of Black men. While adopting a phenomenological approach alongside interviews, our findings show both race- and gender-specific outcomes for the men in our sample. For example, health and wellness appears to be a significant theme that governs their (in)ability to matriculate society. Moreover, their contact with the criminal legal system appears to exacerbate health concerns and hindrances toward reentry. Other themes include mental health and the role of masculinity. We conclude with implications on policy and future research.

A Community Mental Health Needs Assessment of a Racially and Ethnically Diverse Population in New England: Narratives from Community Stakeholders

Despite the existence of numerous efficacious treatments for mental disorders, many individuals in need do not receive adequate treatment particularly racial and ethnic minorities. Community stakeholders can provide: (1) a more nuanced understanding of community mental health needs, and in (2) informing the planning and provision of mental health services. Qualitative data for this mental health needs assessment come from 61 individuals who represent local residents and/or consumers of mental health services, Executive Directors, providers of mental health and non-mental health community based services. We identified systems-related and psychosocial barriers to seeking mental health services: difficulty navigating the mental health system, language barriers, dearth of culturally competent providers; and mental health stigma and mental health literacy and non-Western notions of mental health. Collaborative efforts across stakeholders are called for to address the mental health needs of racial and ethnic minorities in a local community.

Optimizing Smartphone-Delivered Cognitive Behavioral Therapy for Body Dysmorphic Disorder Using Passive Smartphone Data: Initial Insights From an Open Pilot Trial

Background

Smartphone-delivered cognitive behavioral therapy (CBT) is becoming more common, but research on the topic remains in its infancy. Little is known about how people typically engage with smartphone CBT or which engagement and mobility patterns may optimize treatment. Passive smartphone data offer a unique opportunity to gain insight into these knowledge gaps.

Objective

This study aimed to examine passive smartphone data across a pilot course of smartphone CBT for body dysmorphic disorder (BDD), a psychiatric illness characterized by a preoccupation with a perceived defect in physical appearance, to inform hypothesis generation and the design of subsequent, larger trials.

Methods

A total of 10 adults with primary diagnoses of BDD were recruited nationally and completed telehealth clinician assessments with a reliable evaluator. In a 12-week open pilot trial of smartphone CBT, we initially characterized natural patterns of engagement with the treatment and tested how engagement and mobility patterns across treatment corresponded with treatment response.

Results

Most participants interacted briefly and frequently with smartphone-delivered treatment. More frequent app usage (r=–0.57), as opposed to greater usage duration (r=–0.084), correlated strongly with response. GPS-detected time at home, a potential digital marker of avoidance, decreased across treatment and correlated moderately with BDD severity (r=0.49).

Conclusions

The sample was small in this pilot study; thus, results should be used to inform the hypotheses and design of subsequent trials. The results provide initial evidence that frequent (even if brief) practice of CBT skills may optimize response to smartphone CBT and that mobility patterns may serve as useful passive markers of symptom severity. This is one of the first studies to examine the value that passively collected sensor data may contribute to understanding and optimizing users’ response to smartphone CBT. With further validation, the results can inform how to enhance smartphone CBT design.

Mental Health Services and Personal Recovery in California: A Population-Based Analysis

OBJECTIVE

Personal recovery measures have been examined among treatment-seeking individuals enrolled in high-quality care. The authors examined whether utilization of mental health services as typically delivered is associated with personal recovery among adults with clinically significant psychological distress.

METHODS

The Kessler Psychological Distress Scale (K-6) measured respondents' (N=1,954) psychological distress level. The authors also assessed five dimensions of personal recovery-hope, life satisfaction, empowerment, connectedness, and internalized stigma. Multivariable linear regression analyses were used to examine relationships between personal recovery and treatment, self-reported treatment completion, provider type, and adequacy of care, adjusting for covariates including K-6 score.

RESULTS

Participants who received care >12 months prior to the survey reported lower levels of hope (95% confidence interval [CI]=-0.36, -0.06, p<0.01), empowerment (95% CI=-0.26, -0.02, p<0.05), and connectedness (95% CI=-0.37, -0.06, p<0.01) than those who had not received treatment. Those who received care in the past 12 months reported lower levels of hope (95% CI=-0.47, -0.14, p<0.001) and life satisfaction (95% CI=-0.42, -0.05, p<0.01). However, treatment completion was associated with higher levels of empowerment (95% CI=0.02, 0.56, p<0.05) and hope (95% CI=0.04, 0.62, p<0.05) and lower levels of stigma (95% CI=-1.21, -0.21, p<0.01) compared with noncompletion. Differences according to provider type and adequacy of care were nonsignificant.

CONCLUSIONS

Utilization of mental health services was associated with lower levels of personal recovery, which may indicate that care-as typically utilized and received-does not promote personal recovery. Longitudinal research is needed to determine causal relationships underlying these associations.

Applying a Transdiagnostic Cognitive-Behavioral Treatment to Adolescents at High Risk for Serious Mental Illness: Rationale and Preliminary Findings

Given the chronic and deleterious course of serious mental illness (SMI; schizophrenia and bipolar disorder), significant efforts have been undertaken to improve prediction of SMI and provide treatment for adolescents in the early, putatively prodromal stage of these illnesses. While risk assessments and disorder-specific treatments for adolescents at risk for SMI have shown some efficacy, significant issues remain around disorder-specific treatments for these youth. There is substantial heterogeneity of psychopathology within adolescents at high risk for SMI that leads to many false-positives and varying diagnostic outcomes. As a result, initial treatment focusing on broad symptoms and skills has been proposed in place of disorder-specific treatments. We discuss the rationale for providing an already-developed and empirically supported transdiagnostic treatment for emotional disorders (termed the Unified Protocol) as a first-line staging of treatment for adolescents experiencing early SMI symptoms. Additionally, we outline the open trial we are piloting using this transdiagnostic treatment in adolescents between the ages of 13 - 17 who have begun experiencing distressing yet subsyndromal psychosis or bipolar mood symptoms. Preliminary findings suggest feasibility and acceptability as well as initial efficacy in improving psychiatric symptoms, quality of life, and difficulties regulating emotions. We also present case studies from our open trial. A unified, cognitive-behavioral treatment for early presentations of SMI has important clinical and public health benefits, including streamlining treatment and providing broad skills that are applicable to a wide range of psychopathology.

Double-edged sword of federalism: variation in essential health benefits for mental health and substance use disorder coverage in states

The Affordable Care Act requires all insurance plans sold on health insurance marketplaces and individual and small-group plans to cover 10 Essential Health Benefits (EHB), including behavioral health services. Instead of applying a uniform EHB plan design, the Department of Health and Human Services let states define their own EHB plan. This approach was seen as the best balance between flexibility and comprehensiveness, and assumed there would be little state-to-state variation. Limited federal oversight runs the risk of variation in EHB coverage definitions and requirements, as well as potential divergence from standardized medical guidelines. We analyzed 112 EHB documents from all states for behavioral health coverage in effect from 2012 to 2017. We find wide variation among states in their EHB plan required-coverage, and divergence between medical-practice guidelines and EHB plans. These results emphasize consideration of federated regulation over health insurance coverage standards. Federal flexibility in states benefit design nods to state-specific policymaking-processes and population needs. However, flexibility becomes problematic if it leads to inadequate coverage that reduces access to critical health care services. The EHBs demonstrate an incomplete effort to establish appropriate minimum standards of coverage for behavioral health services.

Psychiatry Trainees' Attitudes, Knowledge, and Training in Addiction Psychiatry-A European Survey

Background: Although psychoactive substance use disorders (PSUDs) are a domain of mental health, addiction psychiatry is only formally recognized as a subspecialty in a few European countries, and there is no standardized training curriculum. Methods: A 76-item questionnaire was developed and disseminated through an online anonymous data-collecting system and hand-to-hand amongst psychiatric trainees from the 47 European countries of the Council of Europe plus Israel and Belarus. Results: 1,049/1,118 psychiatric trainees from 30 European countries completed the questionnaire. Fifty-nine-point nine percent of trainees stated to have training in addictions. Amongst the trainees who described having training in addictions, 43% documented a not well-structured training and 37% an unsatisfactory training, mainly due to poor acquired knowledge. Overall, 97% of trainees stated that addiction represents a core curriculum for their training. Overall, general adult psychiatric trainees reported a better knowledge in addictions, compared to trainees in child and adolescent psychiatry. Conclusion: Despite a growing spread of PSUDs in European countries, addiction psychiatry is a relatively poorly trained field within psychiatry training programs. Further research should investigate reasons for poor training and timings of the educational activities to optimize experiential education training in addiction psychiatry.

The psychosis treatment gap and its consequences in rural Ethiopia

BACKGROUND

The "treatment gap" (TG) for mental disorders, widely advocated by the WHO in low-and middle-income countries, is an important indicator of the extent to which a health system fails to meet the care needs of people with mental disorder at the population level. While there is limited research on the TG in these countries, there is even a greater paucity of studies looking at TG beyond a unidimensional understanding. This study explores several dimensions of the TG construct for people with psychosis in Sodo, a rural district in Ethiopia, and its implications for building a more holistic capacity for mental health services.

METHOD

The study was a cross-sectional survey of 300 adult participants with psychosis identified through community-based case detection and confirmed through subsequent structured clinical evaluations. The Butajira Treatment Gap Questionnaire (TGQ), a new customised tool with 83 items developed by the Ethiopia research team, was administered to evaluate several TG dimensions (access, adequacy and effectiveness of treatment, and impact/consequence of the treatment gap) across a range of provider types corresponding with the WHO pyramid service framework.

RESULTS

Lifetime and current access gap for biomedical care were 41.8 and 59.9% respectively while the corresponding figures for faith and traditional healing (FTH) were 15.1 and 45.2%. Of those who had received biomedical care for their current episode, 71.7% did not receive minimally adequate care. Support from the community and non-governmental organisations (NGOs) were negligible. Those with education (Adj. OR: 2.1; 95% CI: 1.2, 3.8) and history of use of FTH (Adj. OR: 3.2; 95% CI: 1.9-5.4) were more likely to use biomedical care. Inadequate biomedical care was associated with increased lifetime risk of adverse experiences, such as history of restraint, homelessness, accidents and assaults.

CONCLUSION

This is the first study of its kind. Viewing TG not as a unidimensional, but as a complex, multi-dimensional construct, offers a more realistic and holistic understanding of health beliefs, help-seeking behaviors, and need for care. The reconceptualized multidimensional TG construct could assist mental health services capacity building advocacy and policy efforts and allow community and NGOs play a larger role in supporting mental healthcare.

Assessing the quality of care for paediatric depression and anxiety in Australia: A population-based sample survey

OBJECTIVE

We examine the prevalence of quality care (as measured by adherence to recommendations in clinical practice guidelines) for Australian paediatric patients (⩽15 years) with depression and/or anxiety, using data from the CareTrack Kids study; a population-based study of the quality of healthcare practice in inpatient and ambulatory healthcare settings.

METHODS

A multistage stratified sample identified records of 6689 children. Of these, 156 records were identified for depression and 356 for anxiety. These were assessed for adherence to 15 depression and 13 anxiety indicators, respectively, using a review of medical records.

RESULTS

Adherence to assessment and management guidelines was low for both conditions: assessment bundle (depression = 33%, 95% confidence interval = [20, 48]; anxiety = 54%, 95% confidence interval = [43, 64] and depression management bundle = 35%, 95% confidence interval = [15, 60]). Across both conditions, the highest adherence was recorded for indicators that addressed prescription of medications (e.g. venlafaxine, 100%; benzodiazepines, 100%; selective serotonin reuptake inhibitor, 94% and antidepressants, 91%), while compliance was the lowest for ensuring children with depression had an emergency safety plan (44%), informing parents of the risks and benefits of prescribed anxiety medication (51%) and assessment for other causes (59% for depression; 68% for anxiety).

CONCLUSION

These findings suggest that strategies are needed to improve guideline adherence for mental health disorders in children and adolescents, particularly among general practitioners. Learning from these indicators could inform clinical prompts in electronic medical records, as well as links to additional information, to assist in decision-making and streamline work practices.

Maternal Eating Disorders and Eating Disorder Treatment Among Girls in the Growing Up Today Study

PURPOSE

The aim of the study was to assess whether girls with mothers who have had an eating disorder (ED) have greater odds of developing ED symptoms and whether girls with ED symptoms have greater odds of receiving ED treatment if their mothers have an ED history.

METHODS

Data came from 3,649 females in the Growing Up Today Study. Data were collected via questionnaires that were mailed every 12-24 months from 1996 to 2013. Girls who reported on ED treatment in 2013 and whose mothers completed a questionnaire in 2004 about maternal and child EDs were included in main analyses. Generalized estimating equations were used.

RESULTS

Among complete cases, 28.3% of girls reported symptoms meeting criteria for an ED in at least 1 year and, of these, 12.4% reported receiving treatment. Girls with mothers with ED histories had nearly twice the odds of reporting symptoms of any ED (adjusted odds ratio: 1.89; 95% confidence interval: 1.38-2.60). Girls who reported symptoms meeting criteria for any ED had more than twice the odds of reporting treatment if their mother had an ED history (adjusted odds ratio: 2.23; 95% confidence interval: 1.25-3.99).

CONCLUSIONS

Girls with mothers with an ED history had greater odds of both reporting ED symptoms and receiving ED treatment. Screening both girls and their mothers for current or previous disordered eating may be important for the prevention and detection of ED symptoms. More research is needed to examine reasons for the association between maternal ED history and ED treatment in girls.

Twelve-month mental health service use in six countries of the Americas: A regional report from the World Mental Health Surveys

AIMS

To provide cross-national data for selected countries of the Americas on service utilization for psychiatric and substance use disorders, the distribution of these services among treatment sectors, treatment adequacy and factors associated with mental health treatment and adequacy of treatment.

METHODS

Data come from data collected from 6710 adults with 12 month mental disorder surveys across seven surveys in six countries in North (USA), Central (Mexico) and South (Argentina, Brazil, Colombia, Peru) America who were interviewed 2001-2015 as part of the World Health Organization (WHO) World Mental Health (WMH) Surveys. DSM-IV diagnoses were made with the WHO Composite International Diagnostic Interview (CIDI). Interviews also assessed service utilization by the treatment sector, adequacy of treatment received and socio-demographic correlates of treatment.

RESULTS

Little over one in four of respondents with any 12 month DSM-IV/CIDI disorder received any treatment. Although the vast majority (87.1%) of this treatment was minimally adequate, only 35.3% of cases received treatment that met acceptable quality guidelines. Indicators of social-advantage (high education and income) were associated with higher rates of service use and adequacy, but a number of other correlates varied across survey sites.

CONCLUSIONS

These results shed light on an enormous public health problem involving under-treatment of common mental disorders, although the problem is most extreme among people with social disadvantage. Promoting services that are more accessible, especially for those with few resources, is urgently needed.

Potential for Integrating Mental Health Specialist Video Consultations in Office-Based Routine Primary Care: Cross-Sectional Qualitative Study Among Family Physicians

BACKGROUND

Although real-time mental health specialist video consultations have been proposed as an effective care model for treating patients with mental health conditions in primary care, little is known about their integration into routine practice from the perspective of family physicians.

OBJECTIVE

This study aimed to determine the degree to which family physicians advocate that mental health specialist video consultations can be integrated into routine primary care, where most patients with mental health conditions receive treatment.

METHODS

In a cross-sectional qualitative study, we conducted 4 semistructured focus groups and 3 telephonic interviews in a sample of 19 family physicians from urban and rural districts. We conducted a qualitative content analysis applying the Tailored Implementation in Chronic Diseases framework in a combined bottom-up (data-driven) and top-down strategy for deriving key domains.

RESULTS

Family physicians indicated that mental health specialist video consultations are a promising and practical way to address the most pressing challenges in current practice, that is, to increase the accessibility and co-ordination of specialized care. Individual health professional factors were the most frequently discussed topics. Specifically, family physicians valued the anticipated clinical outcomes for patients and the anticipated resources set for the primary care practice as major facilitators (16/19, 84%). However, family physicians raised a concern regarding a lack of facial expressions and physical interaction (19/19, 100%), especially in emergency situations. Therefore, most family physicians considered a viable emergency plan for mental health specialist video consultations that clearly delineates the responsibilities and tasks of both family physicians and mental health specialists to be essential (11/19, 58%). Social, political, and legal factors, as well as guideline factors, were hardly discussed as prerequisites for individual family physicians to integrate mental health specialist video consultations into routine care. To facilitate the implementation of future mental health specialist video consultation models, we compiled a checklist of recommendations that covers (1) buy-in from practices (eg, emphasizing logistical and psychological relief for the practice), (2) the engagement of patients (eg, establishing a trusted patient-provider relationship), (3) the setup and conduct of consultations (eg, reliable emergency plans), and (4) the fostering of collaboration between family physicians and mental health specialists (eg, kick-off meetings to build trust).

CONCLUSIONS

By leveraging the primary care practice as a familiar environment for patients, mental health specialist video consultations provide timely specialist support and potentially lead to benefits for patients and more efficient processes of care. Integration should account for the determinants of practice as described by the family physicians.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00012487; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00012487.

Impact of integrated district level mental health care on clinical and social outcomes of people with severe mental illness in rural Ethiopia: an intervention cohort study

AIM

There is limited evidence of the safety and impact of task-shared care for people with severe mental illnesses (SMI; psychotic disorders and bipolar disorder) in low-income countries. The aim of this study was to evaluate the safety and impact of a district-level plan for task-shared mental health care on 6 and 12-month clinical and social outcomes of people with SMI in rural southern Ethiopia.

METHODS

In the Programme for Improving Mental health carE, we conducted an intervention cohort study. Trained primary healthcare (PHC) workers assessed community referrals, diagnosed SMI and initiated treatment, with independent research diagnostic assessments by psychiatric nurses. Primary outcomes were symptom severity and disability. Secondary outcomes included discrimination and restraint.

RESULTS

Almost all (94.5%) PHC worker diagnoses of SMI were verified by psychiatric nurses. All prescribing was within recommended dose limits. A total of 245 (81.7%) people with SMI were re-assessed at 12 months. Minimally adequate treatment was received by 29.8%. All clinical and social outcomes improved significantly. The impact on disability (standardised mean difference 0.50; 95% confidence interval (CI) 0.35-0.65) was greater than impact on symptom severity (standardised mean difference 0.28; 95% CI 0.13-0.44). Being restrained in the previous 12 months reduced from 25.3 to 10.6%, and discrimination scores reduced significantly.

CONCLUSIONS

An integrated district level mental health care plan employing task-sharing safely addressed the large treatment gap for people with SMI in a rural, low-income country setting. Randomised controlled trials of differing models of task-shared care for people with SMI are warranted.

Prevalence of Depression Among Women of Reproductive Age in the United States

OBJECTIVE

To describe the prevalence, use of antidepressants, and predictors of major and minor depression among nonpregnant women of childbearing age.

METHODS

Using data from the National Health and Nutrition Examination Surveys 2007-2014, we performed a cross-sectional study of 3,705 nonpregnant women of childbearing age. The primary outcome is the prevalence of major depression, and secondary outcomes are the prevalence of minor depression, rates of antidepressant use, and predictors of major and minor depression. Major and minor depression were classified using the Patient Health Questionnaire 9. Univariate and multivariate associations between major depression and minor depression with potential predictors were estimated using multinomial logistic regression.

RESULTS

The overall prevalences of major and minor depression were 4.8% (95% CI 4.0-5.7%) and 4.3% (95% CI 3.5-5.2%), respectively. The prevalences of antidepressant use among women with major depression and minor depression were 32.4% (95% CI 25.3-40.4%) and 20.0% (95% CI 12.9-29.7%), respectively. Factors most strongly associated with major depression were government insurance (adjusted relative risk [RR] ratio 2.49, 95% CI 1.56-3.96) and hypertension (adjusted RR 2.09, 95% CI 1.25-3.50); for minor depression, these were education less than high school (adjusted RR 4.34, 95% CI 2.09-9.01) or high school education (adjusted RR 2.92, 95% CI 1.35-6.31).

CONCLUSION

Our analysis indicates that 1 in 20 nonpregnant women of childbearing age experience major depression. Antidepressants are used by one third of those with major depression and one fifth of those with minor depression.

Do timely mental health services reduce re-incarceration among prison releasees with severe mental illness?

OBJECTIVE

To examine whether the receipt of timely mental health services is associated with changes in criminal justice interactions.

DATA SOURCES

We used linked administrative data from Medicaid, mental health, and criminal justice settings in Washington State for persons with severe mental illness released from prison (n = 3086).

STUDY DESIGN

We estimate local and average treatment effects to examine measures of criminal justice use in the year following release as a function of timely mental health services.

DATA EXTRACTION METHODS

Measures of timely service and criminal justice use within 12 months postrelease were created from administrative data.

PRINCIPAL FINDINGS

Individuals receiving timely mental health services are more likely to experience prison re-incarceration overall and specifically for technical violations 12 months postrelease. The effect of service receipt on incarceration for new charges was negative but not significant.

CONCLUSIONS

The finding that mental health services receipt is associated with increased risk of re-incarceration due to technical violations speaks to the complexity of the relationship between mental health and criminal justice services for justice-involved persons with severe mental illness. Further research should examine strategies at the interface of criminal justice and mental health that can improve mental health and criminal justice outcomes for this vulnerable population.

Substituting specialist care for patients with severe mental illness with primary healthcare. Experiences in a mixed methods study

WHAT IS KNOWN ON THE SUBJECT?: Care planning and coordination are currently insufficiently based on scientific insights due to a lack of knowledge on this topic. Most patients with severe mental illness receive long-term treatment from specialized mental health services. This long-term, highly intensive treatment is not always the best option for two reasons. Firstly, because as long as a patient receives intensive treatment aimed at safety, it is hard for that patient to take full responsibility for their own life. Secondly, because care is not available unlimitedly, some patients are waiting to receive specialist mental healthcare while others who do not need it anymore still receive it. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Most stable patients with severe mental illness can be treated outside of specialized mental health services. Some patients are too dependent on a specific mental healthcare professional to be referred to primary healthcare. In such instances, a referral will most likely lead to destabilization and the referral will therefore be unsuccessful. Patients preferred primary healthcare to specialized mental health services, mainly because of the absence of stigma associated with the latter. There should be more attention for personal recovery (especially the social support system) of patients with severe mental illness who are referred to primary healthcare services. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Most stable patients with severe mental illness can be treated in primary healthcare. Professionals in primary healthcare should keep personal recovery in mind when treating patients, focusing on problem solving skills and also making use of social support systems. ABSTRACT: Aim/question Care planning and coordination are currently insufficiently based on scientific insights due to a lack of knowledge on this topic. In the United Kingdom and the Netherlands, most patients with severe mental illness receive long-term specialized mental healthcare, even when they are stable. This study aims to explore the outcome of these stable patients when they are referred to primary healthcare. Methods Patients (N = 32) receiving specialized mental healthcare that were referred to primary healthcare were interviewed in focus groups, as were the involved professionals (N = 6). Results 84% of the participants still received primary healthcare after 12 months. Despite the successful referral, the patient's personal recovery did not always profit. The participants of the focus groups agreed that some patients were too dependent on a specific mental healthcare professional to be referred to primary healthcare. Discussion Most stable patients with severe mental illness can be referred to primary healthcare. Personal recovery and dependency on a specific healthcare provider should be considered when referring a patient to primary healthcare. Implications for practice Professionals in community mental healthcare teams should consider a referral to primary mental healthcare in stable patients. Professionals in primary healthcare should keep the patient's personal recovery in mind.

Mental Health Disparities, Treatment Engagement, and Attrition Among Racial/Ethnic Minorities with Severe Mental Illness: A Review

Mounting evidence indicates that there are mental health disparities in the United States that disadvantage racial/ethnic minorities in medical and mental health settings. Less is known, however, about how these findings apply to a particularly vulnerable population, individuals with severe mental illness (SMI). The aim of this paper is to (1) provide a critical review of the literature on racial/ethnic disparities in mental health care among individuals with SMI; (2) identify factors which may contribute to the observed disparities; and (3) generate recommendations on how best to address these disparities. Specifically, this article provides an in-depth review of sociocultural factors that may contribute to differences in treatment engagement and rates of attrition from treatment among racial/ethnic minorities with SMI who present at medical and mental health facilities. This review is followed by a discussion of specific strategies that may promote engagement in mental health services and therefore reduce racial/ethnic disparities in SMI.

Supervisor practice when guiding therapists working with depression: the impact of supervisor and patient characteristics

Currently recommended psychotherapies for depression are not always delivered in a consistent manner. There is an assumption that the use of clinical supervision will ensure reliable treatment and patient recovery. However, there is limited research supporting this assumption. This study explored the role of supervision in the treatment of depression. In particular, it examined how supervisors’ own characteristics and those of patients can influence the focus of supervision sessions. Clinical supervisors who worked with cognitive behavioural therapy (CBT) therapists treating depression cases were asked to indicate their supervision focus for three different patient vignettes. These vignettes varied in clinical complexity. Participants’ intolerance to uncertainty and their self-esteem were also assessed. Supervisors tended to focus their supervisees on the use of evidence-based therapeutic techniques for both straightforward and complex cases. However, their approach was less evidence-based for diffuse cases. Three supervisory types emerged: an ‘Alliance- and Technique-Focused’ group, a ‘Case Management-Focused’ group, and an ‘Unfocused’ group. Personal characteristics of the supervisors varied across the groups. The content of supervision sessions is influenced by factors from outside the therapy process. These factors might cause supervisors to avoid focusing on evidence-based aspects of therapy, thus feeding therapist drift. Suggestions are made for new supervision protocols that consider the supervisor's personal characteristics.

Utilization of psychiatric rehabilitation services and influencing factors among people with psychotic disorders in rural communities of Guangxi, China

Objectives

To identify the rate and predictors of utilization of rehabilitation services among people with psychotic disorders in rural communities of Guangxi.

Study design

A cross-sectional survey was conducted among individuals with schizophrenia or other psychoses (severe mental disorder, ICD10: F20–F29), aged over 15 years, and their care-givers in Guangxi, China. Trained village doctors located individuals known to them and suspected as having schizophrenia or other psychoses within the target areas and recruited them into the study. Data on demographic characteristics, clinical symptoms and functions, treatment history, and reasons, if any, for non-utilization of mental health service were collected. Logistic regression was used to determine associated factors for utilization of mental health services.

Results

A total of 424 individuals experiencing psychosis (mean age 41.4 ± 13.0 years, 60.6% male) and 319 caregivers (mean age 55.3 ± 14.2 years) were interviewed. The median duration of disease was 13.4 years. 83.0% of patients had never used rehabilitation services. Greater use of rehabilitation was associated with having a non-organic disorder (OR = 11.6, 95% CI = 1.6–86.0) and living with a caregivers (OR = 3.2, 95% CI = 1.2–8.3). The top three reasons for not using rehabilitation services were lack of awareness (57.1%), lack of money (14.2%) and lack of belief in the service (12.8%).

Conclusions

These findings indicate a high unmet need for psychiatric rehabilitation services among people with psychotic disorders in rural areas of Guangxi. Strategies such as outreach programme and collaborative and partnership network with the local community are needed to encourage people with psychotic disorders in rural communities to increase their utilization of rehabilitation services.

Communicating about Mental Illness and Violence: Balancing Stigma and Increased Support for Services

In the ongoing national policy debate about how to best address serious mental illness (SMI), a major controversy among mental health advocates is whether drawing public attention to an apparent link between SMI and violence, shown to elevate stigma, is the optimal strategy for increasing public support for investing in mental health services or whether nonstigmatizing messages can be equally effective. We conducted a randomized experiment to examine this question. Participants in a nationally representative online panel (N = 1,326) were randomized to a control arm or to read one of three brief narratives about SMI emphasizing violence, systemic barriers to treatment, or successful treatment and recovery. Narratives, or stories about individuals, are a common communication strategy used by policy makers, advocates, and the news media. Study results showed that narratives emphasizing violence or barriers to treatment were equally effective in increasing the public's willingness to pay additional taxes to improve the mental health system (55 percent and 52 percent, vs. 42 percent in the control arm). Only the narrative emphasizing the link between SMI and violence increased stigma. For mental health advocates dedicated to improving the public mental health system, these findings offer an alternative to stigmatizing messages linking mental illness and violence.

Psychiatric Treatment and Management of Psychiatric Comorbidities of Movement Disorders

Pediatric movement disorders may present with psychiatric symptoms at many points during the course of the disease. For the relatively common pediatric movement disorder, Tourette syndrome, psychiatric comorbidities are well-described and treatment is well-studied. Managing these comorbidities may be more effective than improving the movements themselves. For more uncommon movement disorders, such as juvenile-onset Huntington disease, treatment of psychiatric comorbidities is not well-characterized, and best-practice recommendations are not available. For the least common movement disorders, such as childhood neurodegeneration with brain iron accumulation, psychiatric features may be nonspecific so that underlying diagnosis may be apparent only after recognition of other symptoms. However, psychiatric medication, psychotherapy, and psychosocial support for these disorders may prove helpful to many children and adolescents.

Trends In News Media Coverage Of Mental Illness In The United States: 1995-2014

The United States is engaged in ongoing dialogue around mental illness. To assess trends in this national discourse, we studied the volume and content of a random sample of 400 news stories about mental illness from the period 1995-2014. Compared to news stories in the first decade of the study period, those in the second decade were more likely to mention mass shootings by people with mental illnesses. The most frequently mentioned topic across the study period was violence (55 percent overall) divided into categories of interpersonal violence or self-directed (suicide) violence, followed by stories about any type of treatment for mental illness (47 percent). Fewer news stories, only 14 percent, described successful treatment for or recovery from mental illness. The news media's continued emphasis on interpersonal violence is highly disproportionate to actual rates of violence among those with mental illnesses. Research suggests that this focus may exacerbate social stigma and decrease support for public policies that benefit people with mental illnesses.

Legislative and Policy Developments and Imperatives for Advancing the Primary Care Behavioral Health (PCBH) Model

The Primary Care Behavioral Health (PCBH) practice model continues to gain converts among primary care and behavioral health professionals as the evidence supporting its effectiveness continues to accumulate. Despite a growing number of practices and organizations using the model effectively, widespread implementation has been hampered by outmoded policies and regulatory barriers. As policymakers and legislators begin to recognize the contributions that PCBH model services make to the care of complex patients and the expansion of access to those in need of behavioral health interventions, some encouraging policy initiatives are emerging and the policy environment is becoming more favorable to implementation of the PCBH model. This article outlines the necessity for policy change, exposing the policy issues and barriers that serve to limit the practice of the PCBH model; highlights innovative approaches some states are taking to foster integrated practice; and discusses the compatibility of the PCBH model with the nation's health care reform agenda. Psychologists have emerged as leaders in the design and implementation of PCBH model integration and are encouraged to continue to advance the model through the demonstration of efficient and effective clinical practice, participation in the expansion of an appropriately trained workforce, and advocacy for the inclusion of this practice model in emerging healthcare systems and value-based payment methodologies.

An innovative model to coordinate healthcare and social services for people with serious mental illness: A mixed-methods case study of Maryland's Medicaid health home program

OBJECTIVE

We conducted a case study examining implementation of Maryland's Medicaid health home program, a unique model for integration of behavioral, somatic, and social services for people with serious mental illness (SMI) in the psychiatric rehabilitation program setting.

METHOD

We conducted interviews and surveys with health home leaders (N=72) and front-line staff (N=627) representing 46 of the 48 total health home programs active during the November 2015-December 2016 study period. We measured the structural and service characteristics of the 46 health home programs and leaders' and staff members' perceptions of program implementation.

RESULTS

Health home program structure varied across sites: for example, 15% of programs had co-located primary care providers and 76% had onsite supported employment providers. Most leaders and staff viewed the health home program as having strong organizational fit with psychiatric rehabilitation programs' organizational structures and missions, but noted implementation challenges around health IT, population health management, and coordination with external providers.

CONCLUSION

Maryland's psychiatric rehabilitation-based health home is a promising model for integration of behavioral, somatic, and social services for people with SMI but may be strengthened by additional policy and implementation supports, including incentives for external providers to engage in care coordination with health home providers.

Measuring and improving the quality of mental health care: a global perspective

Mental disorders are common worldwide, yet the quality of care for these disorders has not increased to the same extent as that for physical conditions. In this paper, we present a framework for promoting quality measurement as a tool for improving quality of mental health care. We identify key barriers to this effort, including lack of standardized information technology-based data sources, limited scientific evidence for mental health quality measures, lack of provider training and support, and cultural barriers to integrating mental health care within general health environments. We describe several innovations that are underway worldwide which can mitigate these barriers. Based on these experiences, we offer several recommendations for improving quality of mental health care. Health care payers and providers will need a portfolio of validated measures of patient-centered outcomes across a spectrum of conditions. Common data elements will have to be developed and embedded within existing electronic health records and other information technology tools. Mental health outcomes will need to be assessed more routinely, and measurement-based care should become part of the overall culture of the mental health care system. Health care systems will need a valid way to stratify quality measures, in order to address potential gaps among subpopulations and identify groups in most need of quality improvement. Much more attention should be devoted to workforce training in and capacity for quality improvement. The field of mental health quality improvement is a team sport, requiring coordination across different providers, involvement of consumer advocates, and leveraging of resources and incentives from health care payers and systems.

Patient Preferences of a Low-Income Hispanic Population for Mental Health Services in Primary Care

We used a discrete-choice conjoint experiment to model the mental health services preferences of patients of a federally-qualified health center serving a primarily low-income, Hispanic farmworker population in southwestern Arizona. The two attributes that had the largest influence on patient choices (i.e., received the highest importance scores) were where patients receive these services and the language and cultural awareness of the provider who prescribed their treatment. Simulations indicated that the clinic could substantially improve its patients' welfare with even a single change. The single most effective change in terms of patient preferences would be to offer behavioral health services onsite.

Retrospective analysis of risk factors in patients with treatment-emergent diabetes during clinical trials of antipsychotic medications

Aims

In this retrospective analysis, we assessed the short-term risk of treatment-emergent diabetes (TED) among patients with schizophrenia during clinical trials of antipsychotic medications.

Method

From a non-diabetic cohort of patients with schizophrenia (n=5013), the relationship between baseline non-fasting glucose measurement, presence at baseline of risk factors for diabetes, weight gain and therapy assignment on the risk of treatment-emergent diabetes were assessed.

Results

At the baseline assessment, about a third of patients identified with TED during treatment had non-fasting glucose levels over 7.8 mmol/l and two-thirds had multiple diabetes risk factors. Both baseline non-fasting glucose level and the presence of multiple pre-existing diabetes risk factors appeared to have a major impact on the risk of developing diabetes.

Conclusions

Overall, risk factors for diabetes in patients with schizophrenia overlap those in the general population. The results also suggest that many patients identified with TED might have had pre-existing glycaemic abnormalities or a high baseline burden of diabetes risk factors.

Long-term effects of mental disorders on marital outcomes in the National Comorbidity Survey ten-year follow-up

PURPOSE

Epidemiological research has consistently shown an association between mental disorders and marital dissolution. However, this research mostly examined the association of divorce as a risk factor for mental illness. This study prospectively examined the associations of mood, anxiety, and substance use disorders with future marital dissolution and new marriages in a representative population sample.

METHODS

The study used data from the National Comorbidity Survey panel study-a two-wave community epidemiological survey of 5001 participants interviewed in 1990-1992 and re-interviewed in 2001-2003. Mental disorders were ascertained with the Composite International Diagnostic Interview, a fully structured instrument. Associations of baseline lifetime disorders and disorders with onset after the baseline with subsequent divorce and marriage/remarriage were examined using discrete-time survival analysis models.

RESULTS

Mental disorders at baseline or with onset after baseline were associated with significantly greater odds of subsequent divorce among respondents who either were married at baseline or got married after baseline. Mental disorders with onset after baseline were associated with smaller odds of marriage or remarriage. Projections assuming causal effects of mental illness on marital outcomes suggest that preventing the effects of common mood, anxiety, and substance use disorders would be associated with 6.7 million fewer divorces and 3.5 million more marriages in the US population over an 11-year period.

CONCLUSIONS

Individuals with common mental disorders are at greater risk of marital dissolution and are less likely to enter new marriages. These factors contribute to the diminished social engagement and social support for individuals with these disorders. Interventions aimed at improving marital and family relationships could potentially ameliorate the effect of mental disorders on these vital social ties.

Geographic variation in mental health care disparities among racially/ethnically diverse adults with psychiatric disorders

PURPOSE

The main purpose of this paper is to examine geographic variation in unmet need for mental health care among racially/ethnically diverse adults with psychiatric disorders in the US.

METHODS

Drawn from the Collaborative Psychiatric Epidemiology Surveys (CPES; 2001-2003), adults with any past year psychiatric disorder diagnosis (n = 3211) from diverse racial/ethnic backgrounds were selected for analyses. Using weighted data, descriptive analyses and logistic regression analyses were conducted.

RESULTS

Two-thirds of the total sample had unmet mental health care need, which differed significantly by race/ethnicity (p < .001). Logistic regression analyses show regional variation of the effect of race/ethnicity in unmet need: after adjusting for covariates, Latinos in the South, Blacks and Latinos in the Midwest, and Latinos and Asians in the West had higher unmet need than non-Hispanic Whites, whereas no significant racial/ethnic effects were found in the Northeast.

CONCLUSIONS

Findings suggest that geographic region plays an important role in the sufficient use of mental health services among racial/ethnic minorities. Further research should elucidate reasons for geographic disparities in mental health care among racial/ethnic minority adults to reduce disparities.

Depression care among adults with co-occurring major depressive episodes and substance use disorders in the United States

OBJECTIVE

We examined 12-month prevalence and correlates of receiving depression care and perceiving helpfulness of depression care among U.S. adults with major depressive episodes (MDE) and substance use disorders (SUD).

METHOD

Data were from 325,800 adults who participated in the 2008-2014 National Surveys on Drug Use and Health (NSDUH). Descriptive analyses and bivariable and multivariable logistic regression models were applied.

RESULTS

In the U.S., 3.3 million adults (1.4% of the adult population) had co-occurring MDE and SUD in the past year. Among adults with both disorders, 55.4% reported receiving past-year depression care. Among those with past-year depression care, 36.1% perceived it as helpful. Compared with adults who did not receive substance use treatment in the past year, those who received substance use treatment were significantly more likely to receive depression care, and those who received treatment of both disorders were more likely to perceive their depression care as helpful (adjusted risk ratios (ARRs) = 1.5-1.6). Compared with adults who received depression care only from general medical providers, those who received depression care from specialty mental health providers were more likely to report that their care was helpful (ARRs = 1.4-1.6). Receipt of prescription medication for MDE was associated with perceived helpfulness of depression care (ARR = 1.3, 95% CI = 1.05-1.73).

CONCLUSIONS

Almost half of adults with co-occurring MDE and SUD did not receive past-year depression care. Among those who received depression care, most did not perceive it as helpful. Substance use treatment, specialty mental health treatment, and antidepressant medications were perceived as helpful aspects of depression care.

Predictors of Mental Health Treatment Seeking and Engagement in a Community Mental Health Center

Disparities in behavioral health treatment outcomes are multifactorial, but treatment engagement and dropout from treatment often contribute to unequal mental health outcomes in individuals with serious mental illnesses. Alcohol and other substance use disorders have been associated with poor treatment adherence and premature discontinuation of treatment, but few studies have examined these factors in a predominantly African American sample of individuals with serious mental illnesses. This study examined predictors of mental health treatment engagement and dropout in a sample of 90 African American individuals presenting for treatment at a community mental health treatment facility in Atlanta, Georgia. Having an alcohol use disorder was associated with being less likely to attend mental health follow up (OR 0.32, 95% CI 0.12-0.88). Among African American individuals with alcohol use disorders, specific, targeted interventions may be necessary to help reach individuals that are at extremely high risk of poor health and poor adherence to treatment.

Depression care among depressed adults with and without comorbid substance use disorders in the United States

OBJECTIVE

We compared the prevalence of receiving depression care between adults with past-year major depressive episodes (depressed) and substance use disorders (SUD) in the United States and their depressed counterparts without SUD.

METHOD

Data were from 25,500 adults who participated in the 2008-2014 National Surveys on Drug Use and Health. Descriptive analyses and logistic regression models were applied.

RESULTS

During 2008-2014, approximately 55.4% of depressed U.S. adults with SUD received past-year depression care, while 60.1% of depressed adults without SUD received such care. Overall, co-occurring SUD was associated with an 8% decreased likelihood of receiving past-year depression care (risk ratio (RR) = 0.92, 95% CI = 0.89-0.96). For depressed adults with severe functional impairment, co-occurring SUD was associated with a 9% decreased likelihood of receiving past-year depression care (RR = 0.91, 95% CI = 0.87-0.95). For depressed men, co-occurring SUD was associated with a 13% decreased likelihood of receiving past-year depression care (RR = 0.87, 95% CI = 0.81-0.94). The following depressed adults were at increased risk of not receiving depression care: those without functional impairment, without suicidal ideation, and without physical comorbidities, aged 18-29, male, racial/ethnic minorities, having less than high school education, uninsured, and never married.

CONCLUSIONS

Among depressed adults in the United States, comorbid SUD modestly but significantly decreases the likelihood of receiving past-year depression care. Depressed young adults, men, racial/ethnic minorities, less educated individuals, uninsured adults, and never married adults are also at increased risk for not receiving depression care. Outreach efforts are needed to broaden access to depression care for these underserved adults.