Adequacy of treatment for serious mental illness in the United States

Direct-to-consumer marketing of psychological treatments for anxiety disorders

Progress disseminating and implementing evidence-based psychological treatments (EBPTs) for the anxiety disorders has been gradual. To date, the dominant approach for promoting the uptake of EBPTs in clinical settings has been to target the education and training of mental health providers, with many consumers remaining unaware of the potential benefits of EBPTs for anxiety disorders. Direct-to-consumer (DTC) marketing may be a promising vehicle for increasing EBPT utilization rates in the treatment of anxiety disorders. This paper provides an overview of the rationale and important considerations for applying DTC efforts to promote evidence-based care in the treatment of anxiety disorders, and reviews current DTC efforts in this area, including resources on the Internet and other media and in-person events. We conclude with recommendations for future efforts in the DTC marketing of EBPTs for the anxiety disorders, including the need for increased funding and grassroots efforts to inform consumers about anxiety disorders and their most effective treatments.

Implementation of evidence-based employment services in specialty mental health

OBJECTIVE

Study a quality improvement approach for implementing evidence-based employment services at specialty mental health clinics.

DATA SOURCES/STUDY SETTING

Semistructured interviews with clinicians and administrators before, during, and after implementation. Qualitative field notes, structured baseline and follow-up interviews with patients, semistructured interviews with patients after implementation, and administrative data.

STUDY DESIGN

Site-level controlled trial at four implementation and four control sites. Hybrid implementation-effectiveness study with mixed methods intervention evaluation design.

DATA COLLECTION/EXTRACTION METHODS

Site visits, in-person and telephone interviews, patient surveys, patient self-assessment. A total of 801 patients completed baseline surveys and 53 clinicians and other clinical key stakeholders completed longitudinal qualitative interviews.

PRINCIPAL FINDINGS

At baseline, sites varied in the availability, utilization, and quality of supported employment. Each site needed quality improvement for this service, though for differing reasons, with some needing development of the service itself and others needing increased service capacity. Improvements in knowledge, attitudes, beliefs, and referral behaviors were evident in mid- and postimplementation interviews, though some barriers persisted. Half of patients expressed an interest in working at baseline. Patients at implementation sites were 2.3 times more likely to receive employment services during the study year. Those who had a service visit were more likely to be employed at follow-up than those who did not.

CONCLUSIONS

Studies of implementation and effectiveness require mixed methods to both enhance implementation in real time and provide context for interpretation of complex results. In this study, a quality improvement approach resulted in superior patient-level outcomes and improved clinician knowledge, attitudes, and behaviors, in the context of substantial variation among sites.

The role of mental and behavioral health in the application of the patient-centered medical home in the Department of Veterans Affairs

The patient-centered medical home, which is termed the Patient Aligned Care Team (PACT) in the Department of Veterans Affairs (VA), is a transformational initiative with mental and behavioral health as integral components. Funding has been provided to VA medical facilities to assist with the transformation and process redesign of primary care into interdisciplinary teams focused on increased access, Veteran-centered care, and active incorporation of collaborative expertise from specialists within primary care. Primary care clinics are not simple machines that change by merely replacing parts or colocating additional resources. Rather, they are complex systems with a relationship infrastructure among members of the team that is critically important to the change process. Mental health professionals are integral, mandated members of the PACTs providing needed mental and behavioral health care to Veterans as an integrated component of primary care. They also work to catalyze a quality improvement process that encourages collaboration, innovation, and adoption of best practices that promote transformation based on patient-centered principles of care. The purpose of this article is to describe the evolution of VA primary care settings toward interdisciplinary teams that provide patient-centered care in collaboration with Primary Care-Mental Health Integration providers and Health Promotion Disease Prevention team members.

Assessing functional impairment in siblings living with children with disability

OBJECTIVE

The purpose of this study was to empirically test if siblings of children with disability had higher levels of parent-reported behavioral and emotional functional impairment compared with a peer group of siblings residing with only typically developing children.

METHODS

This was a retrospective secondary analysis of data from the Medical Expenditure Panel Survey. We included only households with at least 2 children to ensure sibling relationships. Two groups of siblings were formed: 245 siblings resided in households with a child with disability and 6564 siblings resided in households with typically developing children. Parents responded to questions from the Columbia Impairment Scale to identify functional impairment in their children.

RESULTS

On the basis of parent reports and after adjusting for sibling demographic characteristics and household background, siblings of children with disability were more likely than siblings residing with typically developing children to have problems with interpersonal relationships, psychopathological functioning, functioning at school, and use of leisure time (P < .05). The percentage of siblings of children with disability classified with significant functional impairment was 16.0% at the first measurement period and 24.2% at the second (P < .001). For siblings of typically developing children there was a smaller percentage increase from 9.5% to 10.3% (P < .001).

CONCLUSIONS

Functional impairment is a key indicator for the need of mental health services and, as such, early assessment and interventions to limit increasing severity and short- to long-term consequences need to be addressed. Health care professionals need to consider a family-based health care approach for families raising children with disability.

Quality of life among patients with bipolar disorder in primary care versus community mental health settings

INTRODUCTION

Bipolar disorder is associated with functional impairment across a number of domains, including health-related quality of life (HRQOL). Many patients are treated exclusively in primary care (PC) settings, yet little is known how HRQOL outcomes compare between PC and community mental health (CMH) settings. This study aimed to explore the correlates of HRQOL across treatment settings using baseline data from a multisite, randomized controlled trial for adults with bipolar disorder.

METHODS

HRQOL was measured using the SF-12 physical (PCS) and mental (MCS) composite scale scores. Independent sample t-tests were calculated to compare differences in HRQOL between settings. Multivariate regression models then examined the effect of treatment setting on HRQOL, adjusting for covariate demographic factors, mood symptoms (Internal State Scale), hazardous drinking (AUDIT-C), and substance abuse.

RESULTS

A total of 384 enrolled participants completed baseline surveys. MCS and PCS scores reflected similar impairment in HRQOL across PC and CMH settings (p=0.98 and p=0.49, respectively). Depressive symptoms were associated with lower MCS scores (B=-0.68, p<0.001) while arthritis/chronic pain was strongly related to lower PCS scores (B=-5.23, p<0.001).

LIMITATIONS

This study lacked a formal diagnostic interview, relied on cross-sectional self-report, and sampled from a small number of sites in two states.

DISCUSSION

Participants reported similar impairments in both mental and physical HRQOL in PC and CMH treatment settings, emphasizing the need for integrated care for patients with bipolar disorder regardless of where they present for treatment.

Retention in mental health care of Portuguese-speaking patients

We compared service outcomes of dedicated language and cultural competency services in adequacy of care, ER, and inpatient care among Portuguese-speaking patients in ethnic- and non-ethnic-specific behavioral health clinics. We assessed adequacy of mental health care, and use of inpatient emergency department among Portuguese-speaking patients, comparing individuals receiving care from a culturally and linguistically competent mental health care setting (the Portuguese Mental Health Program [PMHP]) with usual mental health care in a community health care system in the USA. Propensity score matching was used to balance patients in treatment and control groups on gender, marital status, age, diagnosis of mental disorder, and insurance status. We used de-identified, longitudinal, administrative data of 854 Portuguese-speaking patients receiving care from the PMHP and 541 Portuguese-speaking patients receiving usual care from 2005-2008. Adequate treatment was defined as receipt of at least eight outpatient psychotherapy visits, or at least four outpatient visits of which one was a psychopharmacological visit. PMHP patients were more likely to receive adequate care. No differences were found in rates of ER use or inpatient mental health care. The present study suggests increased quality of care for patients that have contact with a clinic that dedicates resources specifically to a minority/immigrant group. Advantages of this setting include greater linguistic and cultural concordance among providers and patients. Further research is warranted to better understand the mechanisms by which culturally appropriate mental health care settings benefit minority/immigrant patients.

Religion and anxiety treatments in primary care patients

Earlier data suggested that religious physicians are less likely to refer to a psychiatrist or psychologist. This follow-up study measures how religious beliefs affect anxiety treatments in primary care. We surveyed US primary care physicians and psychiatrists using a vignette of a patient with anxiety symptoms. Physicians were asked how likely they were to recommend antianxiety medication, see the patient for counseling, refer to a psychiatrist, refer to a psychologist or licensed counselor, encourage meaningful relationships and activities, and encourage involvement in religious community. We experimentally varied symptom severity, whether the patient was Christian or Jewish, and whether she attended religious services. Physician attendance at religious services was assessed in the survey. The response rate was 896 out of 1427 primary care physicians and 312 out of 487 psychiatrists. Religious physicians were more likely to promote religious resources. There was no statistically significant difference between physicians' recommendations for religious and nonreligious patients. There was no statistically significant difference in religious and nonreligious physicians' referrals to a psychologist, licensed counselor, or psychiatrist. Ultimately, we did not find a difference in religious and nonreligious physicians' support for mental health referrals, however, religious physicians were more likely to encourage using religious resources.

The impact of mental health insurance laws on state suicide rates

In the 1990s and early 2000s, a number of states passed laws requiring mental health benefits to be included in health insurance coverage. The variation in the characteristics and enactment date of the laws provides an opportunity to measure the impact of increasing access to mental health care on mental health outcomes, as evidenced by state suicide rates. In contrast with previous research, results show that when states enact laws requiring insurance coverage to include mental health benefits at parity with physical health benefits, the suicide rate decreases significantly by 5%. The findings are robust to a number of specifications and falsification tests.

Disparities in mental health service use of racial and ethnic minority elderly adults

OBJECTIVES

To apply the Institute of Medicine definition of healthcare disparities, to measure disparities in different aspects of episodes of mental health care and to identify disparities in types of mental health services used.

DESIGN

Four 2-year longitudinal datasets from Panels 9 to 13 (2004-2009) of the Medical Expenditure Panel Surveys were combined.

SETTING

Large-scale surveys of families and individuals and their medical providers across the United States.

PARTICIPANTS

One thousand six hundred fifty-eight participants (981 white, 303 black, and 374 Latino) aged 60 and older with probable mental healthcare needs.

MEASUREMENTS

Mental healthcare need was defined as a Kessler-6 Scale score >12 and a Patient Health Questionnaire-2 score >2. Five aspects of mental healthcare episodes were analyzed: treatment initiation, adequacy of care, duration of care, number of visits, and expenditures. Whether episodes of care included only prescription drug fills, only outpatient visits, or both was assessed.

RESULTS

Treatment initiation and adequacy were lower for blacks and Latinos than whites. Latinos experienced episodes of longer duration, more visits, and higher expenditures. Blacks and Latinos had significantly lower rates of episodes that consisted of only medication refills. Blacks had significantly greater rates of episodes with only outpatient care visits. Latinos had significantly higher rates of medication plus outpatient visits.

CONCLUSION

Low mental health treatment initiation and poor adequacy suggest the need for culturally appropriate interventions to engage older blacks and Latinos in mental health care. The surprising findings in blacks (higher rates of outpatient care visits) and Latinos (higher rates of medication plus outpatient visits) highlight the complexities of the older adult population and suggest new avenues for disparities research.

US regional differences in death rates from depression

BACKGROUND

Studies in a few countries (including the US) have reported that mortality rates in the population from psychiatric disorders are much higher when they are based on all causes of death ("multiple causes" or "mentions") coded on death certificates versus only the underlying cause. Studies appear to be lacking on geographic variation within the US in mortality rates from psychiatric disorders based on multiple causes of death.

METHOD

The present study examined the US age-standardized rate (ASR) for death with depression using multiple causes versus underlying cause alone in each of the Census Bureau's four regions and nine divisions. ASRs for schizophrenia were also examined for comparison.

RESULTS

For the entire US, the ratio of the ASR based on multiple causes to the ASR based on underlying cause was 20.9 for depression and 9.2 for schizophrenia; in analyses by region and division, these ratios showed limited variation. The most consistent finding for both depression and schizophrenia was that ASRs, whether based on multiple causes or only on underlying cause, were highest in the Midwest region (especially the East North Central division) and lowest in the South (and in each of its three divisions). For ASRs (using multiple causes of death) from depression, these regional differences were evident within each of several levels of urbanization. For deaths with depression coded as other than the underlying cause, ASRs for each of the three most common underlying causes (cardiovascular diseases, intentional injuries, and neoplasms) were highest in the Midwest and lowest in the South.

CONCLUSION

Studies are needed to determine if these regional differences in mortality from depression are due to regional differences in: certifier practices (i.e., in assigning causes of death among persons with psychiatric conditions); the prevalence (among persons with psychiatric disorders) of lifestyle-related factors (e.g., tobacco use and obesity) that mediate mortality risks; and/or in unmet need for psychiatric treatment and medical care for other chronic diseases in persons with psychiatric conditions. Similar studies are needed of regional variation within other countries.

The effect of race-ethnicity and geography on adoption of innovations in the treatment of schizophrenia

OBJECTIVE

This study evaluated the effect of race-ethnicity and geography on the adoption of a pharmacological innovation (long-acting injectable risperidone [LAIR]) among Medicaid beneficiaries with schizophrenia as well as the contribution of geographic location to observed racial-ethnic disparities.

METHODS

The data source was a claims data set from the Florida Medicaid program for the 2.5-year period that followed the launch of LAIR in the U.S. market. Study participants were beneficiaries with schizophrenia who had filled at least one antipsychotic prescription during the study period. The outcome variable was any use of LAIR; model variables were need indicators and random effects for 11 Medicaid areas, which are multicounty units used by the Medicaid program to administer benefits. Adjusted probability of use of LAIR for blacks and Latinos versus whites was estimated with logistic regression models.

RESULTS

The study cohort included 13,992 Medicaid beneficiaries: 25% of the cohort was black, 37% Latino, and 38% white. Unadjusted probability of LAIR use was lower for Latinos than whites, and use varied across the state's geographic areas. Adjustment for need confirmed the unadjusted finding of a disparity between Latinos and whites (odds ratio=.58, 95% confidence interval=.49-.70). The inclusion of geographic location in the model eliminated the Latino-white disparity but confirmed the unadjusted finding of geographic variation in adoption.

CONCLUSIONS

Within a state Medicaid program, the initial finding of a disparity between Latinos and whites in adopting LAIR was driven by geographic disparities in adoption rates and the geographic concentration of Latinos in a low-adoption area. Possible contributors and implications of these results are discussed.

Comparative effectiveness of medication versus cognitive-behavioral therapy in a randomized controlled trial of low-income young minority women with depression

OBJECTIVE

To examine whether there are latent trajectory classes in response to treatment and whether they moderate the effects of medication versus psychotherapy.

METHOD

Data come from a 1-year randomized controlled trial of 267 low-income, young (M = 29 years), minority (44% Black, 50% Latina, 6% White) women with current major depression randomized to antidepressants, cognitive-behavioral therapy (CBT), or referral to community mental health services. Growth mixture modeling was used to determine whether there were differential effects of medication versus CBT. Depression was measured via the Hamilton Depression Rating Scale (Hamilton, 1960).

RESULTS

We identified 2 latent trajectory classes. The first was characterized by severe depression at baseline. At 6 months, mean depression scores for the medication and CBT groups in this class were 13.9 and 14.9, respectively (difference not significant). At 12 months, mean depression scores were 16.4 and 11.0, respectively (p for difference = .04). The second class was characterized by moderate depression and anxiety at baseline. At 6 months, mean depression scores for the medication and CBT groups were 4.4 and 6.8, respectively (p for difference = .03). At 12 months, the mean depression scores were 7.1 and 7.8, respectively, and the difference was no longer significant.

CONCLUSIONS

Among depressed women with moderate baseline depression and anxiety, medication was superior to CBT at 6 months, but the difference was not sustained at 1 year. Among women with severe depression, there was no significant treatment group difference at 6 months, but CBT was superior to medication at 1 year.

Twelve-month suicidal symptoms and use of services among adolescents: results from the National Comorbidity Survey

OBJECTIVE

The study assessed the prevalence of suicidal ideation, suicide plans, and suicide attempts as well as patterns of mental health service use among adolescents.

METHODS

Data came from the National Comorbidity Survey–Adolescent Supplement, a nationally representative sample of 10,123 adolescents aged 13 to 18 years who participated in computer-assisted, face-to-face interviews between February 2001 and January 2004. Prevalences of suicidal thoughts and behaviors in the past year were determined. Past-year use of any mental health treatment and receipt of four or more visits from one provider among youths with suicidal ideation, plans, or attempts were also assessed. Associations were evaluated by using logistic regression.

RESULTS

During the course of 12 months, 3.6% of adolescents reported suicidal ideation without a plan or attempt, .6% reported a suicide plan without an attempt, and 1.9% made a suicide attempt. Overall, two-thirds of adolescents with suicidal ideation (67.3%) and half of those with a plan (54.4%) or attempt (56.9%) did not have any contact with a mental health specialist in the past year. Different predictors of use of care were identified for each group.

CONCLUSIONS

Adolescent suicidality often is untreated in the United States. Increased outreach efforts to improve treatment access for youths with suicidal ideation and attempts are needed.

Use of the internet to assist in the treatment of depression and anxiety: a systematic review

OBJECTIVE

This systematic review aims to describe the Internet's potential role in assisting patients with depression and anxiety.

DATA SOURCES

A MEDLINE search was conducted of articles published between 1998 and 2008 using the terms depression and anxiety and Internet, computers and depression and anxiety, Internet and compliance and depression, and Internet and adherence and depression.

STUDY SELECTION

Publications cited include articles concerned with the Internet in screening, supporting, educating, and treating patients with depression and anxiety.

DATA EXTRACTION

The efficacy of Internet-based interventions for depression and anxiety was reviewed, alongside the quality of available online information regarding these disorders.

DATA SYNTHESIS

Little progress has been made in developing a universally accepted system for quality assurance of medical information Web sites. Furthermore, there is a lack of research describing the effect of self-diagnosis sites on meaningful outcomes, such as the proportion of patients who go on to receive successful treatment for their depression. Early studies of Internet-based cognitive-behavioral therapy for depression were promising; however, results of clinical trials for "e-therapy" have been variable due to methodological issues. A novel compliance support Web site for patients with depression and anxiety is being evaluated to establish whether providing such assistance can improve patient outcomes.

CONCLUSIONS

The use of the Internet to assist patients with depression and anxiety is currently in its infancy. However, it appears that the Internet has great potential to support patients with depression and may consequently also be of benefit to physicians.

Exploring exercise as an avenue for the treatment of anxiety disorders

Anxiety disorders constitute a significant public health problem. Current gold standard treatments are limited in their effectiveness, prompting the consideration of alternative approaches. In this review, we examine the evidence for exercise as an intervention for anxiety disorders. This evidence comes from population studies, studies of nonclinical anxiety reduction, as well as a limited number of studies of clinically anxious individuals. All of these studies provide converging evidence for consistent beneficial effects of exercise on anxiety, and are consistent with a variety of accounts of the mechanism of anxiety reduction with exercise. Further study of clinical populations is encouraged, as are studies of the mechanism of change of exercise interventions, which have the potential to help refine exercise intervention strategies. Likewise, studies that identify moderators of treatment efficacy will assist clinicians in deciding how and for whom to prescribe exercise.

The association of African Americans' perceptions of neighborhood crime and drugs with mental illness

BACKGROUND

Many African Americans are socioeconomically disadvantaged and live in neighborhoods containing chronic sources of stress. Although environmental stressors can contribute to the development of mental illness, there is a paucity of national studies examining the association of neighborhood crime and drug problems with psychiatric disorders. This study aims to determine if higher levels of perceived neighborhood problems are associated with greater prevalence of 12-month and lifetime psychiatric disorders among African Americans.

METHODS

To do so, we used cross-sectional data from the National Survey of American Life, which interviewed a nationally representative sample of 3,570 African Americans.

RESULTS

Of these African Americans, nearly 20 and 40% reported that crime and drug use are problems in their neighborhoods, respectively. Respondents reporting high levels of perceived neighborhood crime or drug problems are 1.5-2.9 times more likely to have a 12-month psychiatric disorder and 1.4-2.1 times more likely to have a lifetime psychiatric disorder compared to the other respondents. After accounting for sociodemographics and chronic disease, neighborhood crime remains associated with 12-month mood, 12-month substance use, and lifetime substance use disorders, whereas neighborhood drug problems remain significantly associated with 12-month and lifetime anxiety and substance use disorders.

CONCLUSIONS

Among African Americans perceived neighborhood problems are widespread and positively associated with psychiatric disorders. Consideration of neighborhood context is important to more comprehensively understand mental illness and its treatment in this population.

African American Men’s Beliefs About Mental Illness, Perceptions of Stigma, and Help-Seeking Barriers

Little is known about African American men’s beliefs about mental illness. A descriptive qualitative study, using the common sense model (CSM), examined African American men’s beliefs about mental illness, perceptions of stigma associated with mental illness, and barriers to help-seeking. A total of 17 community-dwelling African American men participated in individual interviews. Dimensional analysis guided by the CSM showed most of the men identified mental illness causal factors consistent with the biopsychosocial model of mental disorders. They believed mental illness is a chronic disorder having negative consequences and reported experiencing barriers to help seeking. In contrast with previous studies, most men in the present study did not perceive stigma associated with mental illness and did not identify stigma as a barrier to help seeking. They were open to help seeking, were optimistic about professional treatment, encouraged others to seek treatment, and expressed strong interest in mental health research. Implications for counseling psychology research and practice are discussed.

The impact of buprenorphine on treatment of opioid dependence in a Medicaid population: recent service utilization trends in the use of buprenorphine and methadone

BACKGROUND

Buprenorphine provides an important option for individuals with opioid dependence who are unwilling or unable to attend a licensed methadone opioid agonist treatment program to receive opioid agonist therapy (OAT). Little empirical information is available, however, about the extent to which buprenorphine has increased the percentage of opioid dependent individuals receiving OAT, nor to what extent buprenorphine is being used in office based settings.

METHODS

Using administrative data from the largest Medicaid managed behavioral health organization in a large mid-Atlantic state, we used multivariate regression to examine rates and predictors of opioid agonist use and treatment setting for 14,386 new opioid dependence treatment episodes during 2007-2009.

RESULTS

Despite an increase in the use of buprenorphine, the percentage of new treatment episodes involving OAT is unchanged due to a decrease in the percentage of episodes involving methadone. Use of buprenorphine was significantly more common in rural communities, and 64% of buprenorphine use was in office-based settings.

CONCLUSION

Buprenorphine use has increased in recent years, with the greatest use in rural communities and in office based settings. However, the percentage of new opioid dependence treatment episodes involving an opioid agonist is unchanged, suggesting the need for further efforts to increase buprenorphine use among urban populations.

The role of social structural factors in treatment of mental health disorder

BACKGROUND

Mental disorder implies a biopsychosocial condition, so adequate mental health treatment involves not just medical and pharmacological care but also psychotherapy or counseling.

AIMS

The present study determined how social structural factors might explain accessing of primary care providers and specialty care providers in response to mental disorder, hypothesizing that the two broad types of care differ as to the likelihood of offering minimally adequate treatment.

METHOD

We analyzed data from the cross-sectional study called "2000-2001 Healthcare for Communities", employing five imputed data sets to handle missing data and defining minimally adequate treatment of mental disorder as "at least four counseling sessions at any provider and prescribed medication". Results While mental disorder can be treated in primary care or specialty facilities, our results show that minimally adequate treatment (as defined) is most likely to be obtained via specialty care.

CONCLUSION

For individuals with mental disorder, accessing only primary care creates social inequity, because care from specialty facilities is comparatively more adequate.

Vitality predicts level of guideline-concordant care in routine treatment of mood, anxiety and somatoform disorders

OBJECTIVE

To examine the clinical and psychosocial correlates of adherence to treatment guidelines among outpatients with common mental disorders in a routine clinical setting.

METHODS

In this retrospective cohort study, we analysed 192 patients who were treated for a mood, anxiety or somatoform disorder with pharmacotherapy, psychotherapy or a combination of both treatment modalities. Guideline adherence was assessed with a disorder independent set of quality indicators during up to 3 years of follow-up. At baseline, a standardized diagnostic interview, the Brief Symptom Inventory (BSI), the Short Form 36 (SF-36) and demographic variables were assessed. Using multivariable regression analysis we identified independent predictors associated with guideline adherence.

RESULTS

Patients were aged 36.8 years (SD 11.6) on average. The majority of patients were treated with psychotherapy (47.4%), followed by pharmacotherapy (37.5%) and a combination of pharmacotherapy and psychotherapy (15.1%). Three adherence groups were defined: low (29.7%), intermediate (43.2%) and high (27.1%). Univariate predictors of low adherence were low scores on the subscales vitality and social functioning of the SF-36. In the multivariable model, low adherence was independently predicted by a score lower than 50 on the subscale vitality of the SF-36 (odds ratio per 10 units increase in vitality = 1.34, 95% confidence interval: 1.06-1.71). No significant differences were found within socio-demographic variables, co-morbidity and the scores on the BSI subscales between the adherence groups.

CONCLUSIONS

We found that patients with low scores on the vitality subscale of the SF-36 were at the highest risk to receive low guideline-concordant care. Understanding factors that affect treatment adherence may help to prevent non-adherence and increase the quality of care as well as cost-effectiveness.

Mental Health Disability

Mental health disability imposes an enormous cost to patients, families, and society. Across free market countries, the rate of mental health disability is growing and now constitutes about one third of all disability claimants. Living on disability benefits begets demoralization and passivity. This article reviews (a) the current status of mental health disability and mental health disability systems, (b) the encouraging findings related to research on evidence-based treatments and supported employment, and (c) policy changes that might ameliorate the problem of rising rates (and costs) of mental health disability. Mental health treatments, employment services, and disability policies powerfully shape the disability experience. Evidence-based mental health and employment services can ameliorate disability and could potentially prevent disability if applied as early interventions. Yet evidence-based mental health treatments and supported employment services are rarely available. Furthermore, current disability policies tend to trap people in a “disability benefits culture.” Policy changes should recognize that people with mental health disabilities usually want to work, that they are often able to work when provided with appropriate mental health and vocational services, and that employment is highly therapeutic. Disability policies need to strengthen work incentives for beneficiaries, providers, and employers.

Mobile mental health: review of the emerging field and proof of concept study

BACKGROUND

The ubiquitous nature of mobile phones and their increasing functionality make them an ideal medium for the delivery of large-scale public health information and interventions. While mobile phones have been used to this end in behavioural and physical health settings, their role in monitoring and managing mental health is in its infancy.

AIMS

The purpose of this paper is (1) to provide an overview of the field of mobile mental health and (2) by way of illustration, describe an initial proof of concept study carried out to assess the potential utility and effectiveness of a newly developed mobile phone and web-based program in the management of mild-to-moderate stress, anxiety and depression.

METHODS

Over 6 weeks, participants were given access to "myCompass": an interactive self-help program, which includes real-time self-monitoring with short message service prompts and brief online modules grounded in cognitive behavioural therapy.

RESULTS

Preliminary analyses found that participants' symptoms of stress, anxiety, depression and overall psychological distress were significantly reduced after using myCompass. Improvements were also found in functional impairment and self-efficacy.

CONCLUSIONS

These preliminary results support the feasibility of implementing mobile phone-based interventions with the potential of improving psychological wellbeing.

Anxiety, mood, and substance use disorders in United States African-American public housing residents

BACKGROUND

African-Americans experience considerable mental healthcare disparities in the United States, but little is known about sensitive subgroups within this population. To better understand healthcare disparities within African-Americans communities, we characterized anxiety, mood, and substance use disorder prevalence and associated service utilization among public and non-public housing residents.

METHODS

We used data from a nationally representative sample of African-Americans recruited as part of the National Survey of American Life.

RESULTS

In public housing residents, the 12-month prevalence of anxiety disorders was 1.8 times higher than in non-public housing residents (P = 0.002), mood disorders was 1.4 times higher (P = 0.189), and substance use disorders was 2.2 times higher (P = 0.031). Public housing remained associated with mental illness after controlling for sociodemographics and chronic illness. Public and non-public housing residents did not differ significantly in mental healthcare utilization, but utilization was low with 16-30% of public housing residents with a 12-month disorder receiving mental health assistance.

CONCLUSIONS

A relatively high proportion of African-American public housing residents suffered from psychiatric disorders, and few received mental healthcare assistance, indicating that further work is needed to enhance utilization.

Treatment disparities for major depressive disorder: Implications for pharmacists

OBJECTIVES

To determine whether differences exist in overall antidepressant use and specific antidepressant drug class (selective serotonin reuptake inhibitor [SSRI]/ serotonin norepinephrine reuptake inhibitor [SNRI] versus other) use among patients of different race/ethnicity groups (blacks and Hispanics compared with whites) with a diagnosis of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) 12-month major depressive disorder (MDD) and to discuss ways in which pharmacists can decrease the gap in treatment disparities.

DESIGN

Cross-sectional study.

SETTING

United States from February 2001 through April 2003.

PARTICIPANTS

Respondents of the National Comorbidity Survey-Replication with DSM-IV 12-month MDD.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Previous 12-month overall antidepressant use and previous 12-month specific antidepressant drug class (SSRI/SNRI versus other) use.

RESULTS

For respondents who screened positive for 12-month MDD (n = 362.3), only 34% reported antidepressant use in the previous 12-month period. Blacks (17.5%) and Hispanics (21.8%) reported significantly (P < 0.0001) lower overall use of antidepressants in the unadjusted analysis compared with whites (37.6%). Although not statistically significant, odds ratios (ORs) indicated that blacks and Hispanics were 61% and 47% less likely to report use of antidepressants (OR = 0.39 [95% CI 0.20-0.77], P = 0.10, and 0.53 [0.31-0.91], P = 0.61, respectively).

CONCLUSION

Among respondents with a diagnosis of MDD, race/ethnicity plays an important role in the use of antidepressants. The results of this study indicate a need for pharmacists to proactively interact and manage their patients' antidepressant therapy.

Mental health screening and follow-up care in public high schools

OBJECTIVE

Despite increased interest in screening adolescents for mental health problems and suicide risk, little is known regarding the extent to which youth are identified and connected with appropriate services.

METHOD

Between 2005 and 2009, a total of 4,509 ninth-grade students were offered screening. We reviewed the records of the 2,488 students who were screened. Students identified as being at risk were provided with a referral. Data were collected on screening results, mental health referrals, and completion of recommended treatment over approximately 90 days.

RESULTS

Among students screened, 19.6% were identified as being at risk, 73.6% of whom were not currently receiving any treatment. Students referred for school services tended to be less severely ill than those referred for community services, with lower rates of suicidal ideation, prior suicide attempts, and self-injury. Among at-risk students not currently in treatment, 76.3% of students referred received at least one mental health visit during the follow-up period. Overall, 74.0% of students were referred to school and 57.3% to community services. A great majority of school referrals (80.2%) successfully accessed services, although a smaller proportion of community services referrals successfully accessed treatment (41.9%).

CONCLUSIONS

Systematic voluntary school-based mental health screening and referral offers a feasible means of identifying and connecting high-risk adolescents to school- and community-based mental health services, although linkages to community-based services may require considerable coordination.

Mental health service use and treatment adequacy for anxiety disorders in Canada

BACKGROUND

This study examined mental health service use, minimal standards of treatment adequacy and correlates of service use and treatment adequacy for anxiety disorders in Canada.

METHOD

Data were drawn from the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2, 2002). Respondents (n = 1,803) met criteria for panic disorder, agoraphobia and/or social phobia in the past 12 months. Multiple logistic regression models were used to estimate patterns of associations between respondent characteristics, service use and treatment adequacy.

RESULTS

The prevalence of service use for mental health problems in the past 12 months was approximately 36.9% among respondents with anxiety disorders. The rates of minimal standards of treatment adequacy ranged from 36.8% among those consulting exclusively in primary care to 51.5% among those consulting exclusively in specialised mental health services, and reached 79.5% for respondents consulting healthcare professionals in both sectors of care. Correlates of treatment adequacy included age, education level, marital status, urbanicity medical insurance, acceptability of care, comorbid mental disorders and limitations of activities.

CONCLUSION

These findings emphasize the need to improve the access to mental health services and the quality of care for individuals with anxiety disorders in primary care.

Overcoming barriers to disseminating exposure therapies for anxiety disorders: a pilot randomized controlled trial of training methods

The present study evaluated methods for training mental health providers (N=46) in exposure therapies (ETs) for anxiety disorders. A pilot randomized controlled trial compared: (1) an interactive, multimedia online training (ET OLT), (2) the ET OLT plus a brief Motivational Interviewing-based intervention (ET OLT+MI), and (3) a placebo control OLT. Assessments were completed at baseline, post-training, and one-week following training. Both ET OLT and ET OLT+MI received high satisfaction ratings and were comparably effective at increasing knowledge of ETs as well as clinicians' overt efforts to learn and use the treatment. ET OLT+MI was the most effective method for improving clinicians' attitudes toward ETs. Results indicate that OLT is effective for disseminating knowledge about ETs to clinicians, and suggest that supplementing OLT with a brief MI-based intervention may be a promising direction to address potential attitudinal barriers to adopting these highly efficacious treatments.

Serious psychological distress and diabetes care among California adults

OBJECTIVE

To evaluate three aspects of diabetes care (foot checks, eye examinations, and hemoglobin A 1 C checks by a physician) among California adults with Type 2 diabetes and serious psychological distress (SPD).

METHOD

Data were from the population-based 2005 California Health Interview Survey. Estimates were that in 2005, 1,516,171 Californians (5.75% of all adults) had a physician-given diabetes diagnosis, and of those, 108,621 (7.16%) had co-morbid SPD.

RESULTS

Among Californians with Type 2 diabetes, SPD was associated with fewer physician foot checks (odds ratio = 0.56, 95% Confidence Interval = 0.32 to 0.97) but not with fewer eye examinations or hemoglobin A 1 C checks.

CONCLUSIONS

The findings highlight a specific area--foot complication evaluation and prevention--for improving the quality of diabetes care among adult Californians with Type 2 diabetes and SPD.

Cell phone-supported cognitive behavioural therapy for anxiety disorders: a protocol for effectiveness studies in frontline settings

Background

Reviews of randomized controlled trials (RCTs) of cognitive behavioural therapy (CBT) for anxiety disorders have reported large pre- to post-treatment within-group effect sizes on measures of anxiety when supplied in therapist consultations and in technology-supported settings. However, the stringent experimental control of RCTs results in a lack of external validity, which limits the generalizability of findings to real-world frontline clinical practice. We set out to examine the specification of a protocol for study of the effectiveness of cell phone-supported CBT for in situ management of anxiety disorders.

Methods and design

Nominal group methods were used for requirements analysis and protocol design. Making a distinction between different forms of technology-supported therapy, examination of therapists' role, and implementing trials in existing organizational and community contexts were found to be the central requirements in the protocol.

Discussion

The resulting protocol (NCT01205191 at clinicaltrials.gov) for use in frontline clinical practice in which effectiveness, adherence, and the role of the therapists are analyzed, provides evidence for what are truly valuable cell phone-supported CBT treatments and guidance for the broader introduction of CBT in health services.

The relationship between treatment settings and diagnostic attributions of depression among African Americans

OBJECTIVE

To explore the relationship between treatment setting characteristics and diagnostic attributions of depression among community-dwelling African Americans.

METHODS

Data come from the National Survey of American Life, a nationally representative sample of African Americans and Caribbean Blacks. Major Depression (MD) was assessed using the Composite International Diagnostic Inventory. Participants were categorized into four diagnostic groups: never MD, MD never attributed to physical health problems (i.e., affective depression), MD sometimes attributed to physical health problems (i.e., complicated depression), and MD always attributed to physical health problems (i.e., physical depression). Multinomial regression was used for assessment.

RESULTS

Among 441 participants, 66.4% were classified as affective depression, 17.8% as complicated depression and 15.8% as physical depression. Seeking treatment from a mental health professional was associated with increased likelihood of being in the complicated depression group [adjusted odds ratio (AOR): 5.52; 95% confidence interval (CI): 2.28-13.36]. Seeking treatment from a family doctor was associated with physical depression (AOR: 2.93; 95% CI: 1.18-7.26). Seeking care from three or more different health care providers was associated with complicated depression (AOR: 1.99; 95% CI: 1.17-3.40).

CONCLUSION

Results suggest that encounters with health care providers influence the diagnostic attribution of depression in a systematic manner.

Social determinants of mental health treatment among Haitian, African American, and White youth in community health centers

We examine adequate mental health treatment, emergency room (ER) use, and early treatment dropout for Haitian, African American and White youth with a psychiatric diagnosis treated in community health centers in the United States. We present associations with possible socioeconomic determinants of care. Adequate treatment was less likely among Haitian youth from areas with greater poverty and among all youth from areas with more female-headed households. Medicaid-insured youth had more ER visits, especially African Americans. The relative impact of poverty on adequate care was higher for Haitians than Whites, and the relative impact of Medicaid coverage on ER use was higher for African Americans than for Whites. Early dropout was more likely among youth who were uninsured or from areas with more female-headed households. Socioeconomic factors and insurance status were significant determinants of care. Haitians living in poverty in the U.S. may face barriers to mental health services relative to other racial/ethnic groups.

Exploring the Relationship between Access and Retention among Substance Abuse Treatment Admissions

To explore whether relationships exist among the timeliness of access to outpatient (OP) and intensive outpatient (IOP) substance abuse assessment and treatment and the participation, retention and completion of treatment, admission data from the State of Maine substance abuse treatment data system, reflecting episodes both admitted and discharged during state fiscal year 2008 (N=6,157) were examined using linear and logistic regression techniques. Shorter wait times for assessment were found to lead to lower rates of treatment completion for both OP and IOP and to fewer numbers of sessions attended and shorter lengths of stay for IOP. Shorter waits between assessment and treatment were found to lead to lower attendance at OP treatment sessions, shorter lengths of stay for OP and IOP, but higher rates of treatment completion for IOP. Policy implications are discussed.

Barriers to physical and mental condition integrated service delivery

OBJECTIVE

To assess pragmatic challenges faced when implementing, delivering, and sustaining models of integrated mental health intervention in primary care settings. Thirty percent of primary care patients with chronic medical conditions and up to 80% of those with health complexity have mental health comorbidity, yet primary care clinics rarely include onsite mental health professionals and only one in eight patients receive evidence-based mental health treatment. Integrating specialty mental health into primary care improves outcomes for patients with common disorders, such as depression.

METHODS

We used key informant interviews documenting barriers to implementation and components that inhibited or enhanced operational success at 11 nationally established integrated physical and mental condition primary care programs.

RESULTS

All but one key informant indicated that the greatest barrier to the creation and sustainability of integrated mental condition care in primary care settings was financial challenges introduced by segregated physical and mental health reimbursement practices. For integrated physical and mental health program initiation and outcome changing care to be successful, key components included a clinical and administrative champion-led culture shift, which valued an outcome orientation; cross-disciplinary training and accountability; use of care managers; consolidated clinical record systems; a multidisease, total population focus; and active, respectful coordination of colocated interdisciplinary clinical services.

CONCLUSIONS

Correction of disparate physical and mental health reimbursement practices is an important activity in the development of sustainable integrated physical and mental condition care in primary care settings, such as a medical home. Multiple clinical, administrative, and economic factors contribute to operational success.

The impact of hurricane Katrina on the mental and physical health of low-income parents in New Orleans

The purpose of this study was to document changes in mental and physical health among 392 low-income parents exposed to Hurricane Katrina and to explore how hurricane-related stressors and loss relate to post-Katrina well-being. The prevalence of probable serious mental illness doubled, and nearly half of the respondents exhibited probable posttraumatic stress disorder. Higher levels of hurricane-related loss and stressors were generally associated with worse health outcomes, controlling for baseline sociodemographic and health measures. Higher baseline resources predicted fewer hurricane-associated stressors, but the consequences of stressors and loss were similar regardless of baseline resources. Adverse health consequences of Hurricane Katrina persisted for a year or more and were most severe for those experiencing the most stressors and loss. Long-term health and mental health services are needed for low-income disaster survivors, especially those who experience disaster-related stressors and loss.

Barriers to evidence-based practice implementation: results of a qualitative study

This study reports on a qualitative study of barriers to EBP implementation in one state that sought to implement supported employment and integrated dual diagnosis treatment. The study found that the most significant obstacles emanated from the behavior of supervisors, front-line staff and other professionals in the agency. A lack of synergy profoundly impeded implementation.

Is major depression adequately diagnosed and treated by general practitioners? Results from an epidemiological study

OBJECTIVES

The aim of this study was to (1) to explore the validity of the depression diagnosis made by the general practitioner (GP) and factors associated with it, (2) to estimate rates of treatment adequacy for depression and factors associated with it and (3) to study how rates of treatment adequacy vary when using different assessment methods and criteria.

METHODS

Epidemiological survey carried out in 77 primary care centres representative of Catalonia. A total of 3815 patients were assessed.

RESULTS

GPs identified 69 out of the 339 individuals who were diagnosed with a major depressive episode according to the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) (sensitivity 0.22; kappa value: 0.16). The presence of emotional problems as the patients' primary complaint was associated with an increased probability of recognition. Rates of adequacy differed according to criteria: in the cases detected with the SCID-I interview, adequacy was 39.35% when using only patient self-reported data and 54.91% when taking into account data from the clinical chart. Rates of adequacy were higher when assessing adequacy among those considered depressed by the GP.

CONCLUSION

GPs adequately treat most of those whom they consider to be depressed. However, they fail to recognise depressed patients when compared to a psychiatric gold standard. Rates of treatment adequacy varied widely depending on the method used to assess them.

Racial and ethnic disparities in the treatment of a Medicaid population with schizophrenia

OBJECTIVE

To assess health care disparities among black and Latino adults with schizophrenia receiving services during the period July 1994-June 2006, and to evaluate trends in observed disparities.

DATA SOURCES

Administrative claims data from the Florida Medicaid program. Data sources included membership files (demographic information), medical claims (diagnostic, service, and expenditure information), and pharmacy claims (prescriptions used and expenditures).

STUDY DESIGN

We identified adults with at least two schizophrenia claims during a fiscal year. We used generalized estimating equation models to estimate disparities in spending on psychotropic drugs, psychiatric inpatient services, all mental health services, and all health services.

PRINCIPAL FINDINGS

Spending on psychotropic drugs, mental health, and all health was 0.9-70 percent lower for blacks and Latinos than for whites. With the exception of blacks with substance use disorder comorbidity, minorities were less likely than whites to use psychiatric inpatient services. Psychiatric inpatient spending among users did not differ by race/ethnicity. With the exception of psychiatric inpatient utilization/spending, trend analyses showed no change or modest reductions in disparities.

CONCLUSIONS

Black and Latino Medicaid recipients diagnosed with schizophrenia experience health care disparities. Some but not all disparities narrowed modestly over the study period.

An exploration of the factor structure and development of potentially useful subscales of etiological beliefs about schizophrenia in a general population sample

BACKGROUND

Given that accessing care, treatment engagement, and course and outcomes among people with schizophrenia may be influenced by beliefs about causes in the larger community, causal beliefs about schizophrenia have been studied in numerous communities around the world. In particular, the 30-item list of etiological attributions developed by Angermeyer and colleagues has been used to describe causal beliefs in patients, family members, and lay community members within such communities. The current study, the first examination of the latent or factorial structure of these 30 causal beliefs, seeks to provide informative subscales that may enhance reliability and validity of groupings of causes for future analyses involving community members.

METHOD

Data were gathered from six separate surveys involving three distinct groups of individuals from the same community within the southeastern United States: lay community members, relatives of individuals with schizophrenia-spectrum disorders, and police officers at the start of a 1-week mental health training program.

RESULTS

Exploratory factor analysis in the overall sample (n=577) revealed four factors that were used to define four subscales, termed: personal/family/social stressors (14 items), inconsistent with modern conceptions of risk (8 items), external/environmental insults to the brain (6 items), and consistent with modern biological conceptions (2 items). Cronbach's internal consistency reliability coefficients for these subscales were 0.91, 0.83, 0.71, and 0.65, respectively.

CONCLUSIONS

These findings suggest that subscales could be derived to provide continuous measures for assessing causal beliefs in order to study how this concept relates to attitudes toward schizophrenia, the people affected by the disorder, and treatments that are recommended by mental health professionals. Replication within similar and dissimilar groups is warranted.

Psychiatrists for medically complex patients: bringing value at the physical health and mental health/substance-use disorder interface

BACKGROUND

In their current configuration, traditional reactive consultation-liaison services see a small percentage of the general-hospital patients who could benefit from their care. These services are poorly reimbursed and bring limited value in terms of clinical improvement and reduction in health-service use.

METHOD

The authors examine models of cross-disciplinary, integrated health services that have been shown to promote health and lower cost in medically-complex patients, those with complicated admixtures of physical, mental, social, and health-system difficulties.

CONCLUSION

Psychiatrists who specialize in the treatment of medically-complex patients must now consider a transition from traditional consultation to proactive, value-added programs and bill for services from medical, rather than behavioral, insurance dollars, since the majority of health-enhancement and cost-savings from these programs occur in the medical sector. The authors provide the clinical and financial arguments for such program-creation and the steps that can be taken as psychiatrists for medically-complex patients move to the next generation of interdisciplinary service.

Substance abuse detoxification and residential treatment among Medicaid-enrolled adults: rates and duration of subsequent treatment

BACKGROUND

Substance use disorders are chronic disorders with substantial public health significance, yet the treatment provided is often episodic despite ongoing need. Among the more severely ill individuals requiring detoxification or residential treatment, little empirical information is available about rates and predictors of subsequent engagement in necessary subsequent treatment.

METHODS

Using administrative data from the largest Medicaid managed behavioral health organization in a large mid-Atlantic state, we used multivariate regression to examine rates and predictors of subsequent treatment engagement and retention following new episodes of detoxification or residential substance abuse treatment among 5670 Medicaid-enrolled adults during 2004-2006.

RESULTS

Slightly less than half (49%) of the sample received follow-up care within 30 days of discharge. Rates of follow-up were significantly higher in individuals with a serious mental illness, and significantly lower in African-American individuals, males, individuals with disabilities, and those who received detoxification without residential treatment. The mean duration of follow-up treatment was 84 days, and was longer among individuals with a serious mental illness and Caucasians. Even after controlling for individuals' sociodemographic and clinical characteristics, there was substantial variation in follow-up rates among discharging providers.

CONCLUSION

The relatively low rates of follow-up care and relatively brief duration of treatment for many of those who received such follow-up care are concerning in a population receiving substance abuse detoxification or residential treatment. The markedly lower rates among those receiving detoxification alone without subsequent residential treatment and among those without a comorbid serious mental illness suggest that efforts specifically targeting those individuals may be of particular benefit.

Implementing evidence-based practices for people with schizophrenia

Over the last decade, a consensus has emerged regarding a set of evidence-based practices for schizophrenia that address symptom management and psychosocial functioning. Yet, surveys suggest that the great majority of the population of individuals with schizophrenia do not receive evidence-based care. In this article, we review the empirical literature on implementation of evidence-based practices for schizophrenia patients. We first examine lessons learned from implementation studies in general medicine. We then summarize the implementation literature specific to schizophrenia, including medication practices, psychosocial interventions, information technology, and state- and federal-level interventions. We conclude with recommendations for future directions.

Disparities in use of mental health and substance abuse services by persons with co-occurring disorders

OBJECTIVES

Individuals with co-occurring mental and substance use disorders require psychiatric and substance abuse treatments. A critical question is whether these individuals are treated for both disorders.

METHODS

This study prospectively examined 24-month service utilization patterns of 224 persons with co-occurring disorders who were recruited from crisis residential programs in the mental health treatment system (N=106) and from crisis residential detoxification programs in the substance abuse treatment system (N=118) in San Francisco. Utilization data were collected from the billing-information systems of both treatment systems. Demographic and clinical data were obtained in interviews with participants. Data were analyzed for group differences with chi square tests and logistic, linear, and zero-truncated negative binomial regression.

RESULTS

After the analyses controlled for demographic and clinical factors, participants recruited from the substance abuse treatment system were less likely than those from the mental health treatment system to obtain any mental health services, mental health day treatment, transitional residential care, case management, and other outpatient services (p<.001 for all comparisons). They were more likely to obtain crisis residential detoxification (p=.003), had more days of drug residential treatment (p=.028), but received fewer hours of outpatient services (p=.012).

CONCLUSIONS

There were disparities in patterns of service utilization, although there were no significant diagnostic differences between the two groups. These findings should be valuable in considering systems development and modification. Furthermore, they can contribute to research about factors that underlie results. Study replications should be conducted to assess the robustness of these findings in other locales.