Patterns of psychotherapy utilization

Brief dynamic psychotherapy

The notion of brief dynamic psychotherapy (BDP) may seem at first sight to be a contradiction in terms. ‘Dynamic’ is a Freudian psychoanalytic term implying conflictual psychological forces — an opposition between the conscious and unconscious mind, and the use of defence mechanisms to arrive at a compromise between them. The rigidity of the obsessional person whose self-expression is traded for security, the self-reproaches of the depressive reflecting inhibited aggression, the clinging of the phobic individual who lacks an inner sense of a secure base — these would be examples of the relationship between dynamic conflict and psychiatric symptoms. But the image of psychoanalysis conjures up a picture of prolonged and intensive couch-based therapy. How can this be brief?

Mental health and substance abuse treatment utilization among individuals served by multiple public agencies in 3 states

Patterns of mental health (MH) and substance abuse (SA) treatment utilization among populations receiving services through multiple public programs are not well known. This study examines to what extent populations with MH and/or SA conditions utilize treatment services through Medicaid and State MH/SA Agencies. Data are from the Substance Abuse and Mental Health Services Administration Integrated Database, a multiyear file for 3 states combining Medicaid and State MH/SA Agency administrative data into a uniform database. Although populations with co-occurring conditions and those served by both Medicaid and State MH/SA Agencies have substantial contact with the public treatment system, a majority of the MH/SA populations examined here utilize few services over brief periods of time. Utilization is most limited among individuals with MH-only conditions and those served exclusively by Medicaid. While a lack of data on clinical outcomes prevents us from drawing conclusions about the effectiveness of MH/SA services, results of this analysis indicate that public programs in the states examined here do not provide services that are primarily utilized on a frequent or chronic basis.

Does psychopathology predict counseling duration?

Many university counseling centers have adopted case management policies in an effort to conserve limited resources. Fearing that students with more severe problems will consume too many clinical resources, many counseling centers have decided to refer such students to external agencies or providers for mental health services. However, this fear might be unwarranted because empirical research has not shown a substantial relationship between psychopathology and counseling duration. This investigation examined whether a new treatment-planning inventory, the Butcher Treatment Planning Inventory, might be useful for better understanding the relationships between various problem areas and counseling duration. Participants were new clients (students and staff members) at a university counseling center in the southeastern USA. Professional staff members and graduate students in counselor education, clinical psychology, and clinical social work provided counseling services to the participants. Lower scores on several scales predicted counseling duration. In other words, clients with lower scores on these scales (representing less psychopathology) attended more counseling sessions than clients with greater psychopathology. Therapists' background also predicted counseling duration; clients who worked with either a professional staff member or graduate student in counselor education attended more sessions than clients who worked with a graduate student in clinical psychology. The results of this study, combined with previous research, suggest that measures of psychopathology are not very useful for identifying which clients will complete long-term counseling. Until better information becomes available, actuarial tables remain the most efficient means for predicting counseling duration.

Estimates of use and costs of behavioural health care: a comparison of standard and finite mixture models

Estimates of health care demand are known to depend on the empirical specification used in the analysis. In this paper, an innovative specification, the finite mixture model (FMM), is employed to estimate the utilization of and expenditures on behavioural health care. Unlike standard specifications, the FMM has the ability to distinguish between distinct classes of users of behavioural health care (e.g. the 'worried well' and the severely mentally ill). This new model is tested against standard empirical specifications using data from the National Medical Expenditure Survey. Using common risk stratifiers, estimates of utilization and costs are generated with each specification. It is found that the FMM provides a much better fit of both expenditure and utilization data than standard specifications, particularly among high intensity users that standard models have been unable to represent adequately. Furthermore, the results provide preliminary evidence that there are (at least) two distinct groups of users of behavioural health care. The empirical advantages of the FMM translate into superior estimates of mean costs and utilization that have widespread application in rate-setting exercises.

Managed care: a critical review

Widely perceived and accepted as the simplest way to control escalating health care costs, managed care is the way health care is now, and will continue to be, delivered in the foreseeable future. Growing numbers of Medicaid beneficiaries are required to participate in managed health care and Medicare beneficiaries are strongly encouraged to do so. In essence, America's poor and elderly are serving as the vanguard for health care reform. This article describes the evolution of managed care in the United States, then examines the implications of the transfer of financial risk to health care providers; the impact of managed care on existing inequalities in access to health care and services; the quality of managed care compared with fee-for-service arrangements; and the delivery of mental health services under managed care. We suggest that the role of the social work profession in managed care should be to mitigate the costs borne by clients, and offer specific suggestions for advocates in this arena.

Local factors affecting the tendency to bypass local hospitals for inpatient mental health care: an exploratory analysis

Using the records of 2,171 rural residents of Illinois who received inpatient treatment for mental illness or substance abuse, this paper examines factors that influence the tendency to seek service from a distant rather than a local hospital. Results indicate that the age and insurance coverage of the individual, the per capita income of the community area, surrogates for the service orientation of the local hospital and the proximity of the patient's residence to an urban center are significant influences. With the exceptions of drug abuse requiring detoxification or other symptomatic treatment, drug abuse accompanied by comorbidity and psychosocial disorders, psychosis, and childhood disorders, the primary diagnosis of the individual failed to have a significant effect on the propensity to bypass local sources of inpatient treatment.

Considerations in predicting mental health care use: implications for managed care plans

Managed care plans and other health care providers face a difficult task in predicting outpatient mental health services use. Existing research offers some guidance, but our knowledge of which factors influence use is confounded by methodological problems and sampling constraints. Consequently, available findings are insufficient for developing accurate predictions, which managed care plans need in order to formulate fiscally responsible service delivery contracts. This article reviews the primary data sources and research on ambulatory mental health services. On the basis of this review, the probability and intensity of outpatient visits are estimated. The primary predictors of use are also examined because they may help managed care plans forecast use by a given population or group of enrollees. Gender, age, race, education, health status, and insurance coverage are several variables surfacing as statistically significant predictors of use. The implications for planning capitated mental health services are discussed.

An economic and clinical rationale for changing utilization review practices for outpatient psychotherapy

The growth of managed care has led to greater cost consciousness in the financing and delivery of mental health and substance abuse services. The authors examine whether pressures to reduce the costs associated with mental health and substance abuse treatment have led to the overapplication of a popular managed care strategy, utilization review (UR), to the management of outpatient psychotherapy benefits. Several arguments are presented highlighting why changing outpatient psychotherapy UR practices would be in the best economic and clinical interests of all involved parties, including payers, managed care organizations (MCOs), mental health consumers, and providers. A number of alternatives to the aggressive management of outpatient psychotherapy benefits are outlined and discussed.

Utilization patterns of community mental health services by newly referred patients

The present study compared the pattern of service utilization over a 1-year period, of 349 newly referred adult patients to the four community mental health clinics in Jerusalem. Treatment in these clinics is provided free of charge and there are no limits on length of treatment. Irrespective of patient diagnosis and clinic setting, the percentage of patients remaining in contact with the clinics declined sharply during the first 3 months, and after 6 months stabilized to around 25-40%. However, among patients with nonmajor psychiatric disorders, inter-clinic variation in compliance with treatment was observed. In clinics with a long-term psychotherapeutic orientation, a larger proportion of patients was referred to other services following intake, and a larger proportion of patients dropped out of treatment. In these clinics, more patients were placed on waiting lists before beginning treatment, and the drop-out rate among these patients was significantly higher than that of patients in treatment. The implications of these results for treatment policy in public services are discussed.

Drop-out rate as a performance indicator in psychotherapy

Many large studies of psychotherapy show that the median patient drops out by the 5th session and most before the 10th session. Data from an effective behavior therapy clinic for the anxiety disorders showed that only 17% of patients failed to complete a median of 60 h of therapy. Patient characteristics were not associated with attrition. We examined 5 meta-analytic treatment reviews and found the median drop-out rate was 8% after 20 h of therapy. We suggest that low attrition is associated with effective, standardized treatment and as such, drop-out rate may be a proxy variable that can indicate effective service delivery.