April 2010: This Month's Highlights

Focus on U.S. Nursing Homes

Two articles in this month's issue focus on nursing homes. Legislation enacted in 1987 mandated provision of necessary mental health services to residents, although research in the 1990s found poor compliance. In this month's lead article, Yue Li, Ph.D., presents findings of an analysis of data from four National Nursing Home Surveys—1995, 1997, 1999, and 2004 (the most recent survey)—that identified which of three models of on-site service delivery was used by the surveyed facilities: provision on a regular basis, on an on-call basis, and on both a regular and an on-call basis. About 80% of facilities provided on-site mental health services each survey year. In 2004 services were provided regularly in 25%, on an on-call basis in 24%, and on both a regular and an on-call basis in 28%. The remaining 22% of nursing homes provided no on-site mental health services ( Original article: page 349 ). The second study, by Sonne P. Lemke, Ph.D., and Jeanne A. Schaefer, Ph.D., R.N., looked at changes in the prevalence of psychiatric disorders from the 1990s to 2006 among residents of the approximately 130 facilities operated by the Department of Veterans Affairs. First, the authors used data from admission and census samples to document overall changes. However, more detailed analyses by birth cohort and age group revealed interesting trends that might have been overlooked ottherwise. The authors encourage use of their approach to provide policy makers and planners with a better understanding of the complexity of changing prevalence patterns ( Original article: page 356 ). In Taking Issue, Martha Sajatovic, M.D., cites several reasons for inadequate mental health service provision in nursing homes and calls for collaboration among policy makers, insurers, and health care professionals to head off a major problem ( Original article: page 335 ).

Disparities and Stigma

Although racial and ethnic disparities in pharmacotherapy have been documented, possible disparities in psychotherapy use have not been investigated. In an analysis of Medical Expenditure Panel Survey data from 1996 to 2006 for more than 7,000 patients with depressive or anxiety disorders, Jie Chen, Ph.D., and John Rizzo, Ph.D., found little evidence of disparities in psychotherapy use. However, because large proportions of African Americans and Latinos were covered by Medicaid, Caucasians paid a significantly higher out-of-pocket share for treatment. The authors caution that any health care reforms affecting mental health coverage under Medicaid would have a significant impact on use of psychotherapy by persons from minority groups ( Original article: page 364 ). Some disparities may result from stigmatizing attitudes of a particular culture, and stigma measures that help elucidate these attitudes are needed. Alejandro Interian, Ph.D., and colleagues report on the psychometric properties of four measures of various aspects of stigma in a sample of 200 Latinos ( Original article: page 373 ).

Utility of Psychiatric Advance Directives

The primary purpose of psychiatric advance directives is to document preferences for future treatment in case of loss of decisional capacity. Clinicians also recognize their utility in promoting shared decision making. Two studies reported in this issue found evidence of their usefulness in achieving other objectives. In a 12-month study of 123 participants with serious mental illness who completed an advance directive at baseline, Christine M. Wilder, M.D., and colleagues showed that expressing a preference for a specific medication in a directive led not only to an increased likelihood of being prescribed that medication but also to improved adherence ( Original article: page 380 ). Psychiatric advance directives often include a record of what treatments have been effective and a limited waiver of confidentiality—two features that could make them useful in jail settings. Jails face many barriers to providing treatment to people with serious mental illness, including lack of knowledge of treatment history and inability to communicate with providers because of confidentiality restrictions. In a survey of administrators at 80 North Carolina jails, Anna M. Scheyett, Ph.D., M.S.W., and colleagues found that only 10% had any knowledge of advance directives. However, when they understood what these documents include, three-fourths of administrators supported their use in jail settings ( Original article: page 409 ).

Briefly Noted …

• An intensive initiative in New York State has been successful in promoting physical health screening at public mental health clinics ( Original article: page 346 ).

• Although several drugs have been approved for treating alcohol use disorders, a Department of Veterans Affairs study found that only 3% of patients with these disorders received them ( Original article: page 392 ).

• The Law & Psychiatry column examines the impact of the Genetic Information Nondiscrimination Act ( Original article: page 338 ).