Psychiatric Services Articles

County-Level Estimates of Need for Mental Health Professionals in the United States [Articles]

Konrad, T. R., Ellis, A. R., Thomas, K. C., Holzer, C. E., Morrissey, J. P. — Thu, 01 Oct 2009 05:01:57 PDT

OBJECTIVE: The goal of this study was to develop the best current estimates of need for mental health professionals in the United States for workforce planning and to highlight major data gaps. METHODS: Need was estimated indirectly, on the basis of several steps. The 2001 National Comorbidity Survey Replication (NCS-R) (N=9,282) was used to model the probability of having serious mental illness, given demographic predictors. Synthetic estimation was then used to construct national and county-level prevalence estimates for adults in households. Provider time needed by these adults was estimated from NCS-R respondents with serious mental illness who used mental health services (N=356); provider time needed by adults without serious mental illness was estimated from respondents to the 2000 Medical Expenditure Panel Survey (MEPS) (N=16,418). National mental health professional workforce practice patterns were used to convert need estimates to full-time equivalents (FTEs). RESULTS: Adult service users with serious mental illness typically spend 10.5 hours per year with nonprescriber mental health professionals and 4.4 hours per year with prescriber mental health professionals or primary care physicians in mental health visits; adults without serious mental illness spend about 7.8 minutes with nonprescriber mental health professionals and 12.6 minutes with prescriber mental health professionals or primary care physicians in mental health visits per year. With adjustment for mental health services provided by primary care practitioners, the estimated 218,244,402 members of the U.S. adult civilian household population in 2006 required 56,462 FTE prescribing and 68,581 FTE nonprescribing mental health professionals. CONCLUSIONS: Available data indicate that need across the United States varies by demography and geography. These estimates are limited by several issues; in particular, they are based on current provider treatment patterns and do not address how much care ideally should be provided and by whom. Improved estimates will require refined standards of care and more extensive epidemiological data.

County-Level Estimates of Mental Health Professional Supply in the United States [Articles]

Ellis, A. R., Konrad, T. R., Thomas, K. C., Morrissey, J. P. — Thu, 01 Oct 2009 05:01:57 PDT

OBJECTIVE: This study compiled national county-level data and examined the geographic distribution of providers in six mental health professions and the correlates of county-level provider supply. METHODS: Data for six groups—advanced practice psychiatric nurses, licensed professional counselors, marriage and family therapists, psychiatrists, psychologists, and social workers—were compiled from licensing counts from state boards, certification counts from national credentialing organizations, and membership counts from professional associations. The geographic distribution of professionals was examined with descriptive statistics and a national choropleth map. Correlations were examined among county-level totals and between provider-to-population ratios and county characteristics. RESULTS: There were 353,398 clinically active providers in the six professions. Provider-to-population ratios varied greatly across counties, both within professions and overall. Social workers and licensed professional counselors were the largest groups; psychiatrists and advanced practice psychiatric nurses were the smallest. Professionals tended to be in urban, high-population, high-income counties. Marriage and family therapists were concentrated in California, and other mental health professionals were concentrated in the Northeast. CONCLUSIONS: Rural, low-income counties are likely candidates for interventions such as the training of local clinicians or the provision of incentives and infrastructure to facilitate clinical practice. Workforce planning and policy analysis should consider the unique combination of professions in each area. National workforce planning efforts and state licensing boards would benefit from the central collection of standardized practice information from clinically active providers in all mental health professions.

County-Level Estimates of Mental Health Professional Shortage in the United States [Articles]

Thomas, K. C., Ellis, A. R., Konrad, T. R., Holzer, C. E., Morrissey, J. P. — Thu, 01 Oct 2009 05:01:57 PDT

OBJECTIVE: This study examined shortages of mental health professionals at the county level across the United States. A goal was to motivate discussion of the data improvements and practice standards required to develop an adequate mental health professional workforce. METHODS: Shortage of mental health professionals was conceptualized as the percentage of need for mental health visits that is unmet within a county. County-level need was measured by estimating the prevalence of serious mental illness, then combining separate estimates of provider time needed by individuals with and without serious mental illness derived from National Comorbidity Survey Replication, U.S. Census, and Medical Panel Expenditure Survey data. County-level supply data were compiled from professional associations, state licensure boards, and national certification boards. Shortage was measured for prescribers, nonprescribers, and a combination of both groups in the nation's 3,140 counties. Ordinary least-squares regression identified county characteristics associated with shortage. RESULTS: Nearly one in five counties (18%) in the nation had unmet need for nonprescribers. Nearly every county (96%) had unmet need for prescribers and therefore some level of unmet need overall. Rural counties and those with low per capita income had higher levels of unmet need. CONCLUSIONS: These findings identified widespread prescriber shortage and poor distribution of nonprescribers. A caveat is that these estimates of need were extrapolated from current provider treatment patterns rather than from a normative standard of how much care should be provided and by whom. Better data would improve these estimates, but future work needs to move beyond simply describing shortages to resolving them.

Mental Health Policy Development in the States: The Piecemeal Nature of Transformational Change [Articles]

Garfield, R. L. — Thu, 01 Oct 2009 05:01:57 PDT

OBJECTIVE: Transformation—systemic, sweeping changes to promote recovery and consumerism—is a pervasive theme in discussions of U.S. mental health policy. State systems are a fundamental component of national transformation plans. However, it is not clear how the vision of transformation will be balanced against the idiosyncratic political forces that traditionally characterize state policy making. This article examines the development of state mental health policy to assess whether and how it reflects the broader context of transformation versus political forces. METHODS: Analysis used qualitative evidence collected from semistructured interviews in four states (California, Massachusetts, New Jersey, and New Mexico), which were chosen to capture variation in geography and population, health systems, and political environment. Interviewees included 35 key mental health officials, directors of principal mental health consumer and family advocacy groups, and executives of major mental health provider groups. Interviews were conducted between May 2007 and March 2008. RESULTS: Many recent state policy priorities in mental health are consistent with the overall goals of transformation, but some are particular to a state's circumstance. The case studies showed that these priorities are largely shaped by executive control, stakeholder interests, and crises. There is mixed evidence on whether these drivers of state priorities reflect an underlying transformative process. CONCLUSIONS: States' mental health policies are largely guided by the problems and resources of the states: sometimes these forces dovetail with nationwide transformation goals and processes, and sometimes they are idiosyncratic to a particular state. Thus, although states can play an integral role in forwarding transformation, their own mental health policy agendas are not eclipsed by this nationwide movement.

Race-Ethnicity as a Predictor of Attitudes Toward Mental Health Treatment Seeking [Articles]

Shim, R. S., Compton, M. T., Rust, G., Druss, B. G., Kaslow, N. J. — Thu, 01 Oct 2009 05:01:57 PDT

OBJECTIVE: Previous research on mental health disparities shows that persons from racial-ethnic minority groups have less access to mental health care, engage in less treatment, and receive poorer-quality treatment than non-Hispanic whites. Attitudes and beliefs about mental health treatment were examined to determine whether they contribute to these disparities. METHODS: Data from the National Comorbidity Survey Replication (NCS-R) were analyzed to determine attitudes toward treatment-seeking behavior among people of non-Hispanic white, African-American, and Hispanic or Latino race-ethnicity. Additional sociodemographic variables were examined in relation to attitudes and beliefs toward treatment. RESULTS: African-American race-ethnicity was a significant independent predictor of greater reported willingness to seek treatment and lesser reported embarrassment if others found out about being in treatment. These findings persisted when analyses adjusted for socioeconomic variables. Hispanic or Latino race-ethnicity also was associated with an increased likelihood of willingness to seek professional help and lesser embarrassment if others found out, but these differences did not persist after adjustment for the effects of socioeconomic variables. CONCLUSIONS: Contrary to the initial hypothesis, African Americans and Hispanics or Latinos may have more positive attitudes toward mental health treatment seeking than non-Hispanic whites. To improve access to mental health services among racial-ethnic minority groups, it is crucial to better understand a broader array of individual-, provider-, and system-level factors that may create barriers to care.

Complementary and Alternative Medicine for Mental Disorders Among African Americans, Black Caribbeans, and Whites [Articles]

Thu, 01 Oct 2009 05:01:57 PDT

OBJECTIVES: This study examined racial and ethnic differences in the use of complementary and alternative medicine (CAM) for the treatment of mental and substance use disorders. METHODS: Data were from the National Survey of American Life (NSAL) and the National Comorbidity Survey-Replication (NCS-R). The analytic sample included 631 African Americans and 245 black Caribbeans from the NSAL and 1,393 non-Hispanic whites from the NCS-R who met criteria for a mood, anxiety, or substance use disorder in the past 12 months. Logistic regression was used to examine racial and ethnic differences in the use of any CAM and in the use of CAM only versus the use of CAM plus services in another treatment sector. RESULTS: Thirty-four percent of respondents used some form of CAM. Whites were more likely than blacks to use any CAM, although there was no racial or ethnic difference in CAM use only versus CAM use plus traditional services. A higher proportion of blacks than whites used prayer and other spiritual practices. Among those with a mood disorder, black Caribbeans were less likely than African Americans to use any CAM. CONCLUSIONS: Findings of this study were similar to those of previous studies that examined physical illness in relation to CAM use in terms of its overall prevalence, the predominant use of CAM in conjunction with traditional service providers, and racial and ethnic differences in the use of CAM. The use of prayer was a major factor in differences between blacks and whites in CAM use; however, there were also differences among black Americans that warrant further research.

Racial and Ethnic Differences in Substance Abuse Service Needs, Utilization, and Outcomes in California [Articles]

Niv, N., Pham, R., Hser, Y.-I. — Thu, 01 Oct 2009 05:01:57 PDT

OBJECTIVE: This study examined differences in service needs and treatment utilization, retention, and outcomes between African-American, Hispanic, and white substance abusers in community-based treatment programs. METHODS: Data were collected from 2,401 African Americans, 3,222 Hispanics, and 7,980 whites who were admitted to 43 drug treatment programs across California from 2000 to 2001. The Addiction Severity Index (ASI) was administered at intake to assess clients' problem severity in a number of domains (alcohol use, drug use, employment, family and social relationships, legal, medical, and psychological), and treatment retention and arrest data were obtained from administrative records. A subsample was followed up at three months to assess service utilization (N=2,145) and again at nine months to readminister the ASI (N=2,566). RESULTS: All three groups had similar severity levels of drug and legal problems upon treatment entry. Upon entry to treatment, white clients had the highest severity levels of alcohol, family, and psychiatric problems and African Americans had the highest severity levels of employment problems compared with the other two groups. Treatment retention did not differ between the three groups, but whites received a greater number of alcohol treatment services than did African Americans or Hispanics, and African Americans received a greater number of employment services than did Hispanic and white clients. All three groups showed significant improvement in all outcome domains except for medical outcomes. At the nine-month follow-up, whites had worse outcomes in the alcohol domain compared with the other two groups, and whites had worse outcomes in the legal domain compared with Hispanics. Compared with whites, African Americans were significantly less likely to be charged with driving under the influence in the year after treatment admission. CONCLUSIONS: All three groups improved after treatment, although benefits from treatment can be further enhanced if services underscore different facets of the psychosocial problems of each racial and ethnic group.

Outcomes for Youths From Racial-Ethnic Minority Groups in a Quality Improvement Intervention for Depression Treatment [Articles]

Thu, 01 Oct 2009 05:01:57 PDT

OBJECTIVE: This study examined racial-ethnic differences in the impact of the Youth Partners in Care quality improvement intervention. The intervention was designed to improve access to evidence-based depression care, primarily cognitive-behavioral therapy and medication, through primary care. Previous analyses have shown that the quality improvement intervention was associated with improved depression and quality-of-life outcomes at the end of the six-month intervention period. METHODS: A randomized controlled trial comparing quality improvement and usual care for youths from diverse racial-ethnic groups from five health care organizations, including managed care, the public sector, and academic center clinics, was conducted. Depressed youths (N=325), who self-identified as black (N=59), Latino (N=224), and white (N=42), aged 13–21 years, were included in these analyses. To evaluate intervention effects within racial-ethnic groups, regression models were constructed, which adjusted for baseline and study site variation in depression symptoms, mental health status, satisfaction with mental health care, and mental health service utilization. RESULTS: Differential intervention effects were found across racial-ethnic groups. Black youths in the intervention group experienced significant reductions in depression symptoms and had higher rates of use of specialty mental health care at the six-month follow-up. Among Latino youths, the intervention was associated with significantly greater satisfaction with care. Intervention effects were weak among white youths. CONCLUSIONS: Quality improvement interventions may help to reduce disparities in mental health care for youths from racial-ethnic minority groups. (

Disparities in Adequate Mental Health Care for Past-Year Major Depressive Episodes Among Caucasian and Hispanic Youths [Articles]

Alexandre, P. K., Martins, S. S., Richard, P. — Thu, 01 Oct 2009 05:01:57 PDT

OBJECTIVE: Following efforts made in recent years to provide effective mental health treatments based on evidence-based guidelines, a working definition was developed in the literature detailing a minimum level of "adequate mental health care" for serious mental illness. However, little is known about racial or ethnic disparities in receipt of adequate mental health care for individuals affected with serious mental illness. The objective of this study was to examine disparities among Caucasian and Hispanic youths in receipt of adequate mental health care for past-year major depressive episodes. METHODS: Data for this study were drawn from the 2005 National Survey on Drug Use and Health. The study sample was composed of 1,169 Caucasian youths and 316 Hispanic youths aged 12 to 17 with past-year major depressive episodes. The percentages of youths in the sample who received adequate mental health care for past-year major depressive episodes were estimated, and the correlates of receipt of adequate mental health care were examined. RESULTS: Thirty-four percent of the full sample received adequate mental health care for past-year major depressive episodes, but separate analyses indicated that adequate mental health care was received by a significantly higher proportion of Caucasian youths (36%) than Hispanic youths (27%). The odds of receiving adequate mental health care for past-year major depressive episodes for Caucasians were 1.55 times that of Hispanics (p=.01). Having Medicaid or coverage via the State Children's Health Insurance Program significantly increased the odds of receiving adequate mental care for past-year major depressive episodes for both Hispanics and Caucasians. CONCLUSIONS: As mental health problems of adolescents from diverse racial or ethnic backgrounds become more easily identified and a larger proportion of these groups is referred to mental health treatment services, it is important to examine the degree to which treatment should be tailored to engage and retain specific racial or ethnic groups so that they will receive the minimum of adequate mental health care.

Part D and Dually Eligible Patients With Mental Illness: Medication Access Problems and Use of Intensive Services [Articles]

Tue, 01 Sep 2009 05:01:25 PDT

OBJECTIVE: This study examined the occurrence of medication access problems and use of intensive mental health services after the transition in January 2006 from Medicaid drug coverage to Medicare Part D for persons dually eligible for Medicaid and Medicare benefits. METHODS: Psychiatrists randomly selected from the American Medical Association's Physicians Masterfile reported on experiences of one systematically selected dually eligible patient (N=908) in the nine to 12 months after Part D implementation. Propensity score matching was used to compare use of psychiatric emergency department care and inpatient care between individuals who experienced a problem accessing a psychiatric medication after Part D and those who did not. RESULTS: Approximately 44% of dually eligible patients were reported to have experienced a problem accessing medications. The likelihood of visiting an emergency department was significantly higher for those who experienced an access problem than for those who did not (mean odds ratio=1.75, mean p=.003). There was no difference in number of emergency department visits or hospitalizations for those who had at least one. CONCLUSIONS: Many dually eligible patients had difficulty accessing psychiatric medications after implementation of Part D. These patients were significantly more likely to visit psychiatric emergency departments than patients who did not experience difficulties. These findings raise concerns about possible negative effects on quality of care. Additional study is needed to understand the full effects of Part D on outcomes and functioning as well as treatment costs for this population.

Off-Label Use of Antipsychotic Medications in the Department of Veterans Affairs Health Care System [Articles]

Leslie, D. L., Mohamed, S., Rosenheck, R. A. — Tue, 01 Sep 2009 05:01:25 PDT

OBJECTIVE: This study aimed to determine the prevalence of prescribing antipsychotics to adults without schizophrenia or bipolar disorder and to identify factors associated with such off-label use. METHODS: Patients with at least one prescription for an antipsychotic medication from the Department of Veterans Affairs (VA) during fiscal year (FY) 2007 were identified in national VA administrative databases. Rates of off-label antipsychotic use were determined along with average doses. Multivariate logistic regression models identified sociodemographic and clinical characteristics associated with off-label use. RESULTS: Of the 279,778 individuals in FY 2007 who received an antipsychotic medication, 168,442 (60.2%) had no record of a diagnosis for which these drugs are approved. The most common mental illness diagnoses among patients given prescriptions for antipsychotics off label were posttraumatic stress disorder (PTSD, 41.8%), minor depression (39.5%), major depression (23.4%), and anxiety disorder (20.0%). Among VA patients with mental illness other than schizophrenia or bipolar disorder, the proportion who received prescriptions for antipsychotic medications ranged from a low of 9.1% among patients with adjustment reaction; to about 20% for those with depression, dementia, or PTSD; and to a high of 40.7% among patients with other psychoses. Doses were low, with over half of patients who received off-label quetiapine, risperidone, or first-generation antipsychotics receiving doses below those recommended for schizophrenia. In logistic regression models, patients diagnosed as having other psychosis or dementia had the highest odds of receiving an antipsychotic medication off label. CONCLUSIONS: Off-label use of antipsychotic medications was common. Given that these drugs are expensive, have potentially severe side effects, and have limited evidence supporting their effectiveness for off-label usage, they should be used with greater caution.

A Comparison of the Life Goals Program and Treatment as Usual for Individuals With Bipolar Disorder [Articles]

Tue, 01 Sep 2009 05:01:25 PDT

OBJECTIVE: This randomized controlled study of 164 outpatients with bipolar disorder in a community mental health center who received standardized psychoeducation (Life Goals Program [LGP]) or treatment as usual sought to determine whether there were differences between the groups in medication adherence attitudes and behaviors. METHODS: Patients were randomly assigned to treatment as usual (N=80) or treatment as usual plus LGP (N=84) and were assessed at baseline and at the three-, six-, and 12-month follow-up. Primary outcomes were change in score from baseline on the Drug Attitude Inventory (DAI) and on self-reported treatment adherence behaviors (SRTAB). RESULTS: At baseline, there were no significant differences between the two groups. Slightly less than half (N=41, 49%) of the LGP group participated in most or all (four to six) LGP sessions, 14% (N=12) participated in one to three sessions, and 37% (N=31) did not participate in any sessions. At the 12-month follow-up there was improvement among all patients, with no significant differences between the two groups, in DAI scores, SRTAB, symptoms, psychopathology, and functional status. Greater depressive severity at baseline was associated with more negative attitudes toward treatment over time, although this finding was not significant (p=.056). Secondary analysis of persons in the LGP group found that compared with those who did not go to any LGP sessions, those with partial or full participation in LGP sessions had improved attitudes toward medication at the three- and six-month follow-up, but no difference was found between the three LGP subgroups by the 12-month follow-up. CONCLUSIONS: There were no differences between two groups in treatment attitudes at the 12-month follow-up. Low attendance rates mitigated effects on primary outcomes. Effects of LGP may become lost over time without ongoing intervention, and individuals with depression may have reduced response to LGP.

Low Socioeconomic Status and Mental Health Care Use Among Respondents With Anxiety and Depression in the NCS-R [Articles]

Roy-Byrne, P. P., Joesch, J. M., Wang, P. S., Kessler, R. C. — Tue, 01 Sep 2009 05:01:25 PDT

OBJECTIVE: This study sought to determine whether previously reported poor outcomes among patients of low socioeconomic status who have depression and anxiety could result from not receiving mental health treatment or from receiving minimally adequate treatment. METHODS: The study sample consisted of 1,772 participants in the National Comorbidity Survey Replication (NCS-R) who met criteria for a mood or anxiety disorder. Bivariate and multivariate logistic regression analyses were used to examine associations between education, income, and assets and receipt of treatment and quality of treatment (minimally adequate treatment) for mood and anxiety disorders in sectors with the capacity to deliver evidence-based treatments (the general medical and mental health specialty sectors). Multivariate analyses controlled for age, gender, race-ethnicity, marital status, health insurance, and urbanicity. RESULTS: Age, gender, marital status, and race-ethnicity were strong and fairly consistent predictors of mental health services use, with some modest variations by sector. In contrast, in bivariate and multivariate analyses, education, income, and assets were minimally related to use of mental health care and to receipt of minimally adequate care in both general medical and mental health specialty sectors. CONCLUSIONS: Socioeconomic status does not appear to play a major role in determining aspects of treatment for depression and anxiety disorders. Poor outcomes of depressed and anxious patients with low socioeconomic status may be due to differences in quality of care beyond the minimally adequate level assessed in this study or to factors unrelated to quality of care that could counteract effective treatments, such as the presence of ongoing chronic stress.

Four-Year Follow-Up of Long-Stay Patients Settled in the Community After Closure of Italy's Psychiatric Hospitals [Articles]

Tue, 01 Sep 2009 05:01:25 PDT

OBJECTIVE: This study reports on the final phase (1996–1999) of closure of Italy's psychiatric hospitals. In this phase the last group of patients was resettled in community-based care. These patients were particularly difficult to resettle, and many hospital staff considered their discharge impossible or inappropriate. Shorter-stay inpatients who were previously resettled in community facilities showed improvement in quality of life and socialization and apparent stability of psychotic symptoms. Compulsory resettlement, implemented by community-based practitioners, provided an opportunity to determine whether it could be considered positive for all patients. METHODS: A total of 176 patients were discharged in 1998 from two psychiatric hospitals in Northern Italy until 2002. All patients had been hospitalized for more than 20 years (median stay of 37 years). Patients were resettled in sheltered communities with 24-hour staff (N=101), in apartments with daily support (N=24), in residential health care facilities (N=49), and to their previous homes (N=2). Follow-up evaluations were at three and six months and then yearly (total of six). Psychological condition was evaluated with the 18-item Brief Psychiatric Rating Scale. Autonomy and relational skills were assessed with scales developed for the closure project. Analyses of variance were used to assess data. RESULTS: Clinical condition steadily improved and substantial improvements were noted in autonomy, socialization, and expression of volition. No worsening occurred in any category. CONCLUSIONS: Even among patients with very long hospital stays, resettlement in community-based care and changes in the social framework can have positive results in psychological and social functioning and quality of life.

Public Awareness Campaigns About Depression and Suicide: A Review [Articles]

Dumesnil, H., Verger, P. — Tue, 01 Sep 2009 05:01:25 PDT

OBJECTIVE: Numerous institutions, including the World Health Organization, recommend education campaigns targeted at the general public to improve awareness of suicidal crises and, more broadly, of depression; to improve access to care; and to combat the stigma associated with these illnesses and discrimination against people who have them. The purpose of this literature review was to gather information on campaigns about depression or suicide awareness and summarize data on the impact and effectiveness of these campaigns. METHODS: A search was conducted of MEDLINE, the Cochrane Library, PsycINFO, HDA (Health Development Agency) Evidence Base, DARE (Database of Abstracts of Reviews of Effects), and the ISI Web of Science to identify articles written in English and published between 1987 and 2007 that described depression or suicide awareness programs that targeted the public. RESULTS: Among the 200 publications for which references were found, 43 publications that described 15 programs in eight countries met inclusion criteria. Comparing the programs was difficult because of the diversity of their objectives and the methods used to deliver the programs and to evaluate them. Results suggest that these programs contributed to a modest improvement in public knowledge of and attitudes toward depression or suicide, but most program evaluations did not assess the durability of the attitude changes. No study has clearly demonstrated that such campaigns help to increase care seeking or to decrease suicidal behavior. CONCLUSIONS: Developing guidelines for assessment of public education campaigns to improve knowledge about suicide and depression is essential for the sharing of knowledge among scientists and stakeholders.

Coping With Thoughts of Suicide: Techniques Used by Consumers of Mental Health Services [Articles]

Alexander, M. J., Haugland, G., Ashenden, P., Knight, E., Brown, I. — Tue, 01 Sep 2009 05:01:25 PDT

OBJECTIVE: Suicide is a devastating public health problem, and research indicates that people with prior attempts are at the greatest risk of completing suicide, followed by persons with depression and other major mental and substance use conditions. Because there has been little direct input from individuals with serious mental illness and a history of suicidal behavior concerning suicide prevention efforts, this study examined how this population copes with suicidal thoughts. METHODS: Participants in 14 regional consumer-run Hope Dialogues in New York State (N=198) wrote up to five strategies they use to deal with suicidal thoughts. Strategies were classified according to grounded theory. RESULTS: First responses included spirituality, talking to someone, positive thinking, using the mental health system, considering consequences of suicide to family and friends, using peer supports, and doing something pleasurable. Although a majority reported that more formal therapeutic supports were available, only 12% indicated that they considered the mental health system a frontline strategy. Instead, respondents more frequently relied on family, friends, peers, and faith as sources of hope and support. CONCLUSIONS: Consumers' reliance on formal therapeutic supports and support from peers and family suggests that education and support for dealing with individuals in despair and crisis should be targeted to the social networks of this high-risk population. The disparity between availability of formal mental health services and reliance on them when consumers are suicidal suggests that suicide prevention efforts should evaluate whether they are effectively engaging high-risk populations as they struggle to cope with despair.

The Role of Social Network and Support in Mental Health Service Use: Findings From the Baltimore ECA Study [Articles]

Maulik, P. K., Eaton, W. W., Bradshaw, C. P. — Tue, 01 Sep 2009 05:01:25 PDT

OBJECTIVE: A significant number of people with mental illness do not use mental health services to receive treatment for their symptoms. This study examined the hypothesis that social network and social support affect mental health service use. METHODS: Data were from the Baltimore cohort of the Epidemiologic Catchment Area study, a prospective cohort study that gathered data over four time points. This study examined data gathered in 1993–1996 (N=1,920) and 2004–2005 (N=1,071). The study examined indicators of social network and social support in relation to four types of service use (general medical, mental health within general medical, specialty psychiatric, and other human services) with multivariate logistic regression. Examples of other human services include a self-help group or crisis center for help with any psychological problem. Weighted generalized estimating equations were used for the analyses. RESULTS: Among persons with major depressive disorder, generalized anxiety disorder, panic disorder, or alcohol use disorder in the past year or psychological distress in the past few weeks, general medical service use was reduced when the frequency of contact with relatives or friends occurred less than daily, but it was increased by about 40% when there was a higher than median level of spousal support. In contrast, receiving general medical services for mental health problems was reduced by about 50% when there was a higher than median level of social support from relatives. Specialty psychiatric service use was reduced when there was regular contact with six or more relatives and there was a higher than median level of social support from friends and relatives. None of the social network or social support measures were significantly (p≤.01) associated with use of other human services. CONCLUSIONS: Increased contact with the social network and higher levels of social support were associated with greater use of general medical services. However, more social support was associated with use of fewer services within the specialty psychiatric sector.

Preference-Weighted Health Status of PTSD Among Veterans: An Outcome for Cost-Effectiveness Analysis Using Clinical Data [Articles]

Freed, M. C., Yeager, D. E., Liu, X., Gore, K. L., Engel, C. C., Magruder, K. M. — Tue, 01 Sep 2009 05:01:25 PDT

OBJECTIVE: Posttraumatic stress disorder (PTSD) is a highly prevalent, chronic, disabling but treatable condition. Preference-based measures (for example, health utilities) are recommended for and useful in cost-effectiveness analyses and for policy decisions because they reflect a population's valuation of the desirability of disease states. However, no such measures exist for PTSD. This study aimed to estimate preference-weighted health status associated with PTSD and common co-occurring mental disorders in a sample of veterans by transforming health-related quality-of-life data into preference-weighted health status scores (PWHS scores), develop a usable regression model to predict PWHS scores from other data sets, and compare preference-weighted health status of PTSD with that of another chronic disorder, chronic obstructive pulmonary disease (COPD). METHODS: A secondary analysis was performed on data from a random sample of 808 veterans (79% male; 12% met criteria for PTSD) in four primary care clinics. Veterans responded to the PTSD Checklist (PCL), Clinician-Administered PTSD Scale, Mini-International Neuropsychiatric Interview, and Medical Outcomes Survey Short Form-36. RESULTS:PWHS scores were .029 lower among veterans with PTSD compared with veterans without PTSD, all else being equal. However, scores depended on PTSD severity, when the analysis controlled for other model variables. Specifically, PWHS scores dropped by .004 with a 1-unit increase in PCL scores among veterans without PTSD. Among veterans with PTSD, the reduction was .002. PTSD was associated with lower preference-weighted health status than COPD. CONCLUSIONS: This is the first study to estimate preference-weighted health status of persons with PTSD. These PWHS scores can be helpful in cost-effectiveness studies of PTSD treatments.

A Randomized Study Comparing the Treatment Environment in Alternative and Hospital-Based Acute Psychiatric Care [Articles]

Hawthorne, W. B., Green, E. E., Folsom, D., Lohr, J. B. — Tue, 01 Sep 2009 05:01:25 PDT

OBJECTIVE: Programs that offer alternatives to hospital-based acute psychiatric care have reported promising results of lower costs, equivalent or superior outcomes, and greater patient satisfaction. This study supplements previous research that compared the outcomes, satisfaction, and cost of hospital-based care and one such alternative program, short-term acute residential treatment (START), with an analysis of patient and staff perceptions of the treatment environments. METHODS: Patients who participated were all veterans and were randomly assigned to receive treatment in a hospital psychiatric unit (N=45) or in START (N=48). Both groups completed the Ward Atmosphere Scale (WAS), a standardized measure of treatment environment, at the time of discharge. During the study, staff members from both types of programs also completed the WAS (15 hospital staff and 75 START staff). RESULTS: Both patients and staff rated the START environment more favorably than the hospital environment on five of ten WAS subscales. No differences were found in congruence between staff and participants' scores at START or the hospital. WAS profiles for patients and staff from the hospital closely matched published national norms for hospitals, whereas WAS profiles for patients and staff from START more closely resembled treatment environments recommended for the most disturbed patients (lower levels of anger and aggression and higher levels of support, problem orientation, and order and organization). CONCLUSIONS: The more favorable ratings of the treatment environment at START in this study are consistent with previously published findings demonstrating the viability of the START model as an alternative to hospital-based acute psychiatric care.

Predicting Falls Among Psychiatric Inpatients: A Case-Control Study at a State Psychiatric Facility [Articles]

Estrin, I., Goetz, R., Hellerstein, D. J., Bennett-Staub, A., Seirmarco, G. — Tue, 01 Sep 2009 05:01:25 PDT

OBJECTIVE: The purpose of the study was to add to the research on risk of falling in an understudied population of psychiatric inpatients in an acute setting. METHODS: Five years of fall data in an inpatient psychiatric facility, where falls were frequent but benign, were examined for patient and treatment characteristics that might be associated with falls. This was a retrospective analysis, which matched 1:1 the medical records of fallers and nonfallers on primary psychiatric diagnoses. The total sample consisted of 148 patients. Statistical analysis was conducted on patient demographic characteristics, summed medical history items reported, summed physical complaints on the day of the fall, the number and types of medications taken within a 24-hour period of the fall, and the patient's vital signs. Multivariate logistic regression was used to identify the most salient associations with faller status. RESULTS: Univariate analyses revealed that fallers were prescribed significantly more medications and complained of more physical symptoms on the day of their fall. Fallers were more likely to have a current acute medical condition and to be currently prescribed clonazepam or antihypertensive medication. Multivariate logistic regression analysis revealed that current physical complaints and current clonazepam treatment had significant associations with faller status. CONCLUSIONS: Risk factors identified in this study should be assessed in replication studies. Psychiatric clinicians can use such risk factors to create evidence-based fall prevention programs.

Americans' Attitudes Toward Psychiatric Medications: 1998-2006 [Articles]

Mojtabai, R. — Fri, 31 Jul 2009 05:01:19 PDT

OBJECTIVES: This study examined recent changes in attitudes toward psychiatric medications in the U.S. general population. METHODS: Samples of adult participants in the U.S. General Social Surveys of 1998 (N=1,387) and 2006 (N=1,437) were compared for opinions on the benefits and risks of psychiatric medications as well as willingness to take them in hypothetical situations, including experiencing symptoms of panic attacks or major depression and difficulty in coping with stress or having trouble in personal life. RESULTS: Public opinions regarding benefits of psychiatric medications became more favorable between 1998 and 2006. More participants in 2006 than in 1998 thought that medications help people to deal with day-to-day stresses (83.4% versus 77.8%), make things easier in relation with family and friends (75.9% versus 68.4%), and help people feel better about themselves (68.0% versus 60.1%). The public expressed a greater willingness to take medications in 2006 compared with 1998 for trouble in personal life (29.1% versus 23.3%), to cope with stresses of life (46.6% versus 35.5%), for depression (49.1% versus 41.2%), and for panic attacks (63.7% versus 55.6%). Opinions regarding the risks of medications did not change between 1998 and 2006. CONCLUSIONS: Americans' opinions toward psychiatric medications became more favorable over the past decade, and people became more willing to take these medications. These changes have likely contributed to the increased use of psychiatric medications in recent years and will continue to do so in the coming years.

The Long-Term Impact of Employment on Mental Health Service Use and Costs for Persons With Severe Mental Illness [Articles]

Bush, P. W., Drake, R. E., Xie, H., McHugo, G. J., Haslett, W. R. — Fri, 31 Jul 2009 05:01:19 PDT

OBJECTIVE: Stable employment promotes recovery for persons with severe mental illness by enhancing income and quality of life, but its impact on mental health costs has been unclear. This study examined service cost over ten years among participants in a co-occurring disorders study. METHODS: Latent-class growth analysis of competitive employment identified trajectory groups. The authors calculated annual costs of outpatient services and institutional stays for 187 participants and examined group differences in ten-year utilization and cost. RESULTS: A steady-work group (N=51) included individuals whose work hours increased rapidly and then stabilized to average 5,060 hours per person over ten years. A late-work group (N=57) and a no-work group (N=79) did not differ significantly in utilization or cost outcomes, so they were combined into a minimum-work group (N=136). More education, a bipolar disorder diagnosis (versus schizophrenia or schizoaffective disorder), work in the past year, and lower scores on the expanded Brief Psychiatric Rating Scale predicted membership in the steady-work group. These variables were controlled for in the outcomes analysis. Use of outpatient services for the steady-work group declined at a significantly greater rate than it did for the minimum-work group, while institutional (hospital, jail, or prison) stays declined for both groups without a significant difference. The average cost per participant for outpatient services and institutional stays for the minimum-work group exceeded that of the steady-work group by $166,350 over ten years. CONCLUSIONS: Highly significant reductions in service use were associated with steady employment. Given supported employment's well-established contributions to recovery, evidence of long-term reductions in the cost of mental health services should lead policy makers and insurers to promote wider implementation.

Investigation of Racial and Ethnic Disparities in Service Utilization Among Homeless Adults With Severe Mental Illnesses [Articles]

Fri, 31 Jul 2009 05:01:19 PDT

OBJECTIVE: This study examined whether there are service disparities among homeless adults with severe mental illnesses, a vulnerable population with a high level of unmet need. METHODS: Data were collected at baseline for 6,829 black, Latino, and non-Latino white participants in the Access to Community Care and Effective Services and Support study. Outcome variables were measures of utilization of psychiatric outpatient, housing, and case management services in the previous 60 days. The sample was divided into white-black and white-Latino cohorts. Within each cohort, participants were stratified into comparable groups by propensity scores that estimated log-odds of being black or Latino as a function of several confounding variables. White-black and white-Latino differences in mean number of visits (a measure of intensity) and in the mean probability of at least one visit (a measure of access) were subsequently estimated for each of the three services. RESULTS: The composition of the sample was 50% black, 6% Latino, and 44% white. Service utilization was low for the three services regardless of race-ethnicity. On multivariate analyses of service utilization in the previous 60 days, blacks made fewer psychiatric outpatient visits than whites (mean difference=.46, 95% confidence interval [CI]=.10 to .81]), yet Latinos had more case management visits than whites (mean difference=-.51, CI=-1.03 to -.05]). Analyses of access did not reveal racial-ethnic disparities. CONCLUSIONS: Whereas blacks used psychiatric outpatient services less frequently than whites, hence experiencing a service disparity, Latinos used case management services more than whites did. Possible contributors and clinical and methodological implications of these results are discussed.

Racial and Ethnic Disparities in Caregiver Strain and the Use of Child Mental Health Services: A Structural Equation Model [Articles]

Shin, S. H., Brown, T. A. — Fri, 31 Jul 2009 05:01:19 PDT

OBJECTIVE: Although racial and ethnic disparities in the use of child mental health services have been well documented, the causes of and solutions to these disparities are not clearly understood. This study examined the role of caregiver strain in the disproportionately low rates of services use among youths from racial or ethnic minority groups who had already had contact with public service systems. METHODS: This cross-sectional study used secondary analysis of a stratified random sample of 1,370 youths from the Patterns of Youth Mental Health Care in Public Service Systems Study, who were involved with at least one of five public sectors of care. Caregiver strain and use of child mental health services in the past 12 months were assessed by the Caregiver Strain Questionnaire and the Service Assessment for Children and Adolescents, respectively. A structural equation model that examined the mediating role of caregiver strain for use of child services among three racial and ethnic groups was evaluated for goodness of fit. RESULTS: African-American caregivers reported lower levels of caregiver strain than did non-Hispanic white caregivers; Hispanic caregivers did not differ significantly from non-Hispanic white caregivers on reporting caregiver strain. Among African Americans, the effects of race on use of services were indirect, mediated through caregiver strain. CONCLUSIONS: Findings emphasize the importance of culturally influenced perceptions of caregiving practices and burden among caregivers of a child with emotional or behavioral problems. Intervention efforts to reduce disparities in use of services across racial or ethnic groups need to be informed by a better understanding of the causes of group differences in reporting caregiver strain and the relationship between reported caregiver strain and use of child mental health services.

Cultural Competence: A Literature Review and Conceptual Model for Mental Health Services [Articles]

Fri, 31 Jul 2009 05:01:19 PDT

This article presents a conceptual model of organizational cultural competence for use in mental health services that resulted from a comprehensive review of the research literature. The model identifies four factors associated with cultural competence in mental health services (community context, cultural characteristics of local populations, organizational infrastructure, and direct service support) and redefines cultural competence as the degree of compatibility among these factors. A strength of this model of organizational cultural competence is that it facilitates future research and practice in psychiatric services settings and links culturally competent practices to service parity.

Perceived Need for Mental Health Care and Service Use Among Adults in Western Europe: Results of the ESEMeD Project [Articles]

Fri, 31 Jul 2009 05:01:19 PDT

OBJECTIVE: This study assessed prevalence and correlates of perceived need for mental health care and its role in help seeking. METHODS: Data were from general population surveys conducted for the European Study of the Epidemiology of Mental Disorders. The sample consisted of adults who screened positive for specific mood and anxiety symptoms in surveys conducted in Belgium, France, Germany, Italy, the Netherlands, and Spain (N=8,796). These individuals were further assessed for mental disorders with the Composite International Diagnostic Interview 3.0. Respondents who reported voluntary use of health services to address concerns with their "emotions or mental health" or who reported a need for services for mental health reasons were considered to have perceived need. RESULTS: Nine percent of the total sample perceived some need for mental health care in the past 12 months. Among those who had a mental disorder in the past 12 months, 33% had perceived need. Psychiatric morbidity was the major determinant of perceived need. Among those with perceived need, older age, nonurban residence, and residence in Germany were positively associated with use of services. CONCLUSIONS: Only a third of those with a 12-month mental disorder perceived need for mental health care. Psychiatric morbidity was the main determinant of perceived need; however, other factors (being female and being older) were associated with use of health services among those with perceived need. Among those with perceived need, it is important to increase access to care for the youngest and those living in urban areas.

Psychiatric and General Medical Conditions Comorbid With Schizophrenia in the National Hospital Discharge Survey [Articles]

Weber, N. S., Cowan, D. N., Millikan, A. M., Niebuhr, D. W. — Fri, 31 Jul 2009 05:01:19 PDT

OBJECTIVE: Morbidity and mortality from general medical conditions are elevated among patients with schizophrenia compared with the general U.S. population. More than 50% of patients with schizophrenia have one or more comorbid psychiatric or general medical conditions. This study determined types of comorbid disorders and their prevalence among hospitalized patients with and without schizophrenia. METHODS: Data from the National Hospital Discharge Survey, a nationally representative sample, were analyzed for 1979–2003 (N=5,733,781 discharges). For discharges of patients aged 15 to 64 with at least one comorbid condition, the conditions of those with a primary diagnosis of schizophrenia (N=26,279) were compared with those with other primary diagnoses (N=1,936,876). Proportional morbidity ratios (PMRs) were calculated. RESULTS: The proportion of discharges listing schizophrenia, particularly schizoaffective disorder, increased significantly over time among both males and females. The proportion was higher among males, blacks, and discharges in the Northeast. Discharge records with a primary diagnosis of schizophrenia showed higher proportions of all comorbid psychiatric conditions examined and of some general medical conditions, including acquired hypothyroidism (PMR=2.9), contact dermatitis and other eczema (PMR=2.9), obesity (PMR=2.0), epilepsy (PMR=2.0), viral hepatitis (PMR=1.4), diabetes type II (PMR=1.2), essential hypertension (PMR=1.2), and various chronic obstructive pulmonary diseases (PMR range 1.2–1.5). CONCLUSIONS: Knowledge of the risks of comorbid psychiatric and general medical conditions is critical both for clinicians and for patients with schizophrenia. Closer attention to prevention, early diagnosis, and treatment of comorbid conditions may decrease associated morbidity and mortality and improve prognosis among patients with schizophrenia.

Perceptions of Need and Help Received for Substance Dependence in a National Probability Survey [Articles]

Grella, C. E., Karno, M. P., Warda, U. S., Moore, A. A., Niv, N. — Fri, 31 Jul 2009 05:01:19 PDT

OBJECTIVE: Most individuals with alcohol or other substance use disorders do not seek help for these problems. This study examined the factors associated with perceptions of need for help and receipt of help among individuals with alcohol or other substance dependence disorders in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). METHODS: The 2001–2002 NESARC surveyed a representative sample of the noninstitutionalized population in the United States. Individuals with a past-year substance dependence diagnosis (N=1,602) were classified into one of three groups: received help in the past year (14.7%), perceived a need for help but did not receive it (8.5%), or perceived no need and received no help (76.8%). Multinomial logistic regression with population weights was used to examine the influence of predisposing, enabling, and need-related factors on help seeking in the past year. RESULTS: Factors that increased the receipt of help included older age, drug dependence (versus alcohol dependence only), longer time since the onset of dependence, co-occurring mood disorder, and more problems associated with substance use. Nonwhites were about twice as likely as whites (odds ratio=2.2) to perceive a need for help but not receive it. Similarly, more problems associated with substance use increased the odds of both receiving help and perceiving a need for help but not receiving it. None of the enabling characteristics were associated with help seeking or perceived need, after analyses controlled for predisposing and need-related factors. CONCLUSIONS: Increasing the recognition of problems associated with substance dependence, particularly alcohol, may facilitate help seeking, although barriers persist in regard to age and race-ethnicity.

National Variation of ADHD Diagnostic Prevalence and Medication Use: Health Care Providers and Education Policies [Articles]

Fri, 31 Jul 2009 05:01:19 PDT

OBJECTIVES: Attention-deficit hyperactivity disorder (ADHD) diagnostic prevalence and medication use vary across U.S. census regions, but little is known about state-level variation. The purpose of this study was to estimate this variation across states and examine whether a state's health care provider characteristics and education policies are associated with this variation. METHODS: Logistic regression models were estimated with 69,505 children aged four to 17 from the state-stratified and nationally representative 2003 National Survey of Children's Health, conducted by the Centers for Disease Control and Prevention. RESULTS: Diagnostic prevalence was higher in the South (odds ratio [OR]=1.42, p<.001) than in the West; among children with ADHD diagnoses, medication use was higher in the South (OR=1.60, p<.01) and the Midwest (OR=1.53, p<.01) versus the West. On these measures, several states differed from the U.S. averages, including some states that, on the basis of the regional patterns found above, would not be expected to differ: Michigan had a high diagnostic prevalence; Vermont, South Dakota, and Nebraska had low diagnostic prevalences; and Connecticut, New Jersey, and Kentucky had low medication rates. Both diagnosis and medication status were associated with the number, age, and type of physicians within a state, particularly pediatricians. However, state education policies were not significantly associated with either diagnostic prevalence or medication rates. CONCLUSIONS: To better understand the association between a state's health care provider characteristics and both diagnostic prevalence and medication use, it may be fruitful to examine the content of provider continuing education programs, including the recommendations of major health professional organization guidelines to treat ADHD.

Mental Health Service Use During the Transition to Adulthood for Adolescents Reported to the Child Welfare System [Articles]

Ringeisen, H., Casanueva, C. E., Urato, M., Stambaugh, L. F. — Fri, 31 Jul 2009 05:01:19 PDT

OBJECTIVE: This study analyzed patterns of outpatient mental health service use from adolescence into early adulthood among young adults who were reported as victims of maltreatment in adolescence. METHODS: Data were from the National Survey of Child and Adolescent Well-Being, a national probability study of children for whom maltreatment was investigated by the child welfare system. The sample consisted of 616 young adults aged 12 to 15 at baseline. Analysis used descriptive statistics to determine need for and use of outpatient mental health services across time. Logistic regression was used to examine predictors of use of outpatient mental health services in young adulthood. RESULTS: Almost half of the young adults in this sample had one or more indicators of mental health problems. There was a significant decrease in use of specialty mental health services from adolescence to young adulthood, declining from 47.6% at baseline, to 14.3% at the five- to six- year follow-up. Among young adults with mental health problems, less than a quarter used outpatient mental health services. Logistic regression results indicated that having mental health problems, having Medicaid, and being white were positively associated with use of outpatient mental health services in young adulthood. CONCLUSIONS: Mental health problems were prevalent among young adults who were suspected of being maltreated when they were adolescents, but only about a quarter of those in need used outpatient mental health services. Interventions to improve access to outpatient mental health services for this vulnerable population should particularly support outreach and engagement of young adults who are uninsured and from racial or ethnic minority groups with a history of involvement with the child welfare system in order to meet their unique developmental needs.

Psychiatric Symptoms Among Juveniles Incarcerated in Adult Prison [Articles]

Murrie, D. C., Henderson, C. E., Vincent, G. M., Rockett, J. L., Mundt, C. — Fri, 31 Jul 2009 05:01:19 PDT

OBJECTIVE: Although studies reveal substantial mental health treatment needs among youths in the juvenile justice system, far less is known about young offenders transferred to adult criminal court. This statewide study examined the mental health needs of young offenders who committed serious crimes and were transferred to adult court and subsequently incarcerated in a prison for adults. METHODS: Sixty-four boys aged 16 and 17 years who were incarcerated in the Texas adult correctional system completed the Massachusetts Youth Screening Instrument-Version 2 (MAYSI-2), a mental health screening measure widely used in the juvenile justice system. Scores from the youths in adult prison were compared with those of a matched sample of youths in juvenile correctional facilities, drawn from the MAYSI-2 normative data. RESULTS: Youths in adult prison reported substantial symptoms of mental health problems. Most youths surveyed (51%) scored above the highest clinical cutoff (the "warning" range) on at least one MAYSI-2 subscale. For every clinical subscale except suicide ideation, the majority of youths (54% to 70%, depending on the subscale) scored above the "caution" range. Juveniles in adult prison reported higher rates of symptoms than did those in juvenile correctional facilities (effect sizes ranged from d=.18 to d=.65, depending on the subscale). CONCLUSIONS: Although the mental health needs of youths in the juvenile justice system are well documented, this study reveals that mental health treatment needs appear to be even more pronounced in the small subgroup of youths transferred to the adult criminal justice system and incarcerated in adult prison.

Mental Health Treatment Received by Youths in the Year Before and After a New Diagnosis of Bipolar Disorder [Articles]

Olfson, M., Crystal, S., Gerhard, T., Huang, C. S., Carlson, G. A. — Fri, 31 Jul 2009 05:01:19 PDT

OBJECTIVE: Despite a marked increase in treatment for bipolar disorder among youths, little is known about their pattern of service use. This article describes mental health service use in the year before and after a new clinical diagnosis of bipolar disorder. METHODS: Claims were reviewed between April 1, 2004, and March 31, 2005, for 1,274,726 privately insured youths (17 years and younger) who were eligible for services at least one year before and after a service claim; 2,907 youths had new diagnosis of bipolar disorder during this period. Diagnoses of other mental disorders and prescriptions filled for psychotropic drugs were assessed in the year before and after the initial diagnosis of bipolar disorder. RESULTS: The one-year rate of a new diagnosis of bipolar disorder was .23%. During the year before the new diagnosis of bipolar disorder, youths were commonly diagnosed as having depressive disorder (46.5%) or disruptive behavior disorder (36.7%) and had often filled a prescription for an antidepressant (48.5%), stimulant (33.0%), mood stabilizer (31.8%), or antipsychotic (29.1%). Most youths with a new diagnosis of bipolar disorder had only one (28.8%) or two to four (28.7%) insurance claims for bipolar disorder in the year starting with the index diagnosis. The proportion starting mood stabilizers after the index diagnosis was highest for youths with five or more insurance claims for bipolar disorder (42.1%), intermediate for those with two to four claims (24.2%), and lowest for those with one claim (13.8%). CONCLUSIONS: Most youths with a new diagnosis of bipolar disorder had recently received treatment for depressive or disruptive behavior disorders, and many had no claims listing a diagnosis of bipolar disorder after the initial diagnosis. The service pattern suggests that a diagnosis of bipolar disorder is often given tentatively to youths treated for mental disorders with overlapping symptom profiles and is subsequently reconsidered.

Psychiatrists' Use of Shared Decision Making in the Treatment of Schizophrenia: Patient Characteristics and Decision Topics [Articles]

Fri, 31 Jul 2009 05:01:19 PDT

OBJECTIVE: Shared decision making is advocated as a way of involving patients in medical decisions, but it can be achieved only when both patients and physicians commit to sharing decisions. This study explored psychiatrists' views of shared decision making in schizophrenia treatment. METHOD: A structured questionnaire was given to 352 psychiatrists at the 2007 congress of the German Society of Psychiatry, Psychotherapy, and Nervous Diseases to determine their self-reported decision-making styles. Approximately half of the psychiatrists (N=181) were then asked to rate how 19 patient characteristics would influence whether they would share in decision making, and the other half (N=171) were asked whether 19 decision topics would be suitable for shared decision making. RESULTS: Of the 352 participating psychiatrists, 51% reported regularly applying shared decision making, but decision-making styles were tailored to individual patients and decision topics. Shared decision making was seen as useful for well-informed and compliant patients and for those who currently dislike their antipsychotic, but it was not seen as useful in cases of potentially reduced decisional capacity. Psychosocial matters (for example, work therapy, future housing, and psychotherapy) were considered more suitable for shared decision making than were medical and legal decisions (for example, hospitalization, prescription of antipsychotics, and diagnostic procedures). CONCLUSIONS: It should be clarified whether and how patients with schizophrenia can be empowered and educated so they can share important treatment decisions.