Psychiatr Serv current issue

Weighing Scientific Evidence: Let's Keep the Blindfold Off [Taking Issue]

Zima, B. T. — Mon, 01 Feb 2010 05:01:20 PST

February 2010: This Month's Highlights [This Month's Highlights]

Mon, 01 Feb 2010 05:01:21 PST

Public-Academic Partnerships: Improving Depression Care for Disadvantaged Adults by Partnering With Non-Mental Health Agencies [Columns]

Mon, 01 Feb 2010 05:01:21 PST

Reaching disadvantaged adults who need mental health care is challenging, partly because of mistrust of institutions, cultural insensitivity, and stigma. Researchers from Western Psychiatric Institute and Clinic and leaders of 11 non-mental health community organizations formed a partnership to improve depression care, especially for elders and individuals from difficult-to-reach racial and ethnic minority groups. The overarching goal is to reduce disparities by providing and improving care. This column describes challenges overcome in working with a heterogeneous group of agencies to address issues of mental illness, stigma, inadequate staff training, and privacy—challenges that influenced the direction of research and ensuing projects.

Economic Grand Rounds: Did Medicare Part D Improve Access to Medications? [Columns]

Domino, M. E., Farley, J. F. — Mon, 01 Feb 2010 05:01:21 PST

This study examined medication use among Medicare beneficiaries and dually eligible beneficiaries before and after the implementation of Medicare Part D on January 1, 2006. Nationally representative 2004–2006 data from the Medical Expenditure Panel Survey were used. Two large classes of psychotropic medications (antidepressant and antipsychotic medications) and two large classes of nonpsychotropic medications (lipid-lowering and antihypertensive agents) were examined to determine whether changes in prescription patterns occurred as a result of the implementation of Part D. There was no strong evidence that Part D was associated with large changes in access to medications in the four classes of medications examined here.

Personal Accounts: A Simple Request for Sleep: An 11-Year Journey [Columns]

Morelli, E. — Mon, 01 Feb 2010 05:01:21 PST

Evidence-Based Use of Second-Generation Antipsychotics in a State Medicaid Pediatric Population, 2001-2005 [Articles]

Pathak, P., West, D., Martin, B. C., Helm, M. E., Henderson, C. — Mon, 01 Feb 2010 05:01:21 PST

OBJECTIVE: The purpose of this study was to identify children in a state Medicaid population who were newly treated with second-generation antipsychotics from 2001 through 2005, to classify each use of these agents as evidence based or not depending on the child's diagnoses, and to identify factors associated with the likelihood of evidence-based use of the medication. METHODS: A Medicaid claims database was used to retrospectively identify enrollees receiving initial outpatient treatment with a second-generation antipsychotic between 2001 and 2005. To capture all relevant treatments and diagnoses, claims were examined from January 2000 through December 2006. The final sample included 11,700 children under age 18. The primary measure of interest was the proportion for whom use of the antipsychotic was based on evidence. Evidence-based use (categorized as strong, plausible, or weak evidence) was defined as any use of the agent for a diagnosis supported by a clinical trial published before the end of 2005. Trend analysis and logistic regression were used. RESULTS: The number of children newly treated with second-generation antipsychotics increased from 1,482 in 2001 to 3,110 in 2005. Of the new users of these agents during the study period, 41.3% had no diagnosis for which such treatment was supported by a published study. The medication with the highest level of non-evidence-based use was aripiprazole (77.1%), and risperidone had the lowest (30.6%). CONCLUSIONS: The number of children receiving second-generation antipsychotics doubled in this Medicaid population between 2001 and 2005, and a large proportion of the treatments were not supported by evidence from clinical studies.

Off-Label Use of Second-Generation Antipsychotic Agents Among Elderly Nursing Home Residents [Articles]

Kamble, P., Sherer, J., Chen, H., Aparasu, R. — Mon, 01 Feb 2010 05:01:21 PST

OBJECTIVE: This study examined off-label and evidence-based use of second-generation antipsychotic agents among elderly nursing home residents and factors associated with off-label use. METHODS: This study involved a retrospective, cross-sectional analysis of data from the 2004 National Nursing Home Survey (NNHS). The sample included nursing home residents 65 years and older who received second-generation antipsychotic agents. This study used an indication-based definition of off-label use established by the U.S. Food and Drug Administration (FDA). Evidence-based use included FDA-approved indications and indications for which the Agency of Healthcare Research and Quality found at least moderate strength of evidence of effectiveness. Descriptive statistics were used to examine the prevalence of off-label and evidence-based use. Multiple logistic regression was used to examine the patient and facility factors associated with off-label use of second-generation antipsychotics. RESULTS: According to the 2004 NNHS, 308,990 (23.5%) elderly nursing home residents received at least one second-generation antipsychotic agent. Of those using second-generation antipsychotics, 86.3% received them for off-label indications and 56.9% received them for an evidence-based use. Multivariate analysis found that age (≥75 years), self-pay for nursing home care, diagnosis of dementia, and residing in a nonprofit nursing home were positively associated with off-label use, whereas receiving Medicaid benefits was negatively associated with such use. CONCLUSIONS: Although second-generation antipsychotics were frequently used for off-label indications, most of the usage was evidence based among elderly nursing home residents. However, the high level of non-evidence-based use combined with recent safety and efficacy data suggests an urgent need to address the evidence base for this vulnerable population.

Effectiveness and Outcomes of Assisted Outpatient Treatment in New York State [Articles]

Phelan, J. C., Sinkewicz, M., Castille, D. M., Huz, S., Link, B. G. — Mon, 01 Feb 2010 05:01:21 PST

OBJECTIVE: Outpatient commitment has been heralded as a necessary intervention that improves psychiatric outcomes and quality of life, and it has been criticized on the grounds that effective treatment must be voluntary and that outpatient commitment has negative unintended consequences. Because few methodologically strong data exist, this study evaluated New York State's outpatient commitment program with the objective of augmenting the existing literature. METHODS: A total of 76 individuals recently mandated to outpatient commitment and 108 individuals (comparison group) recently discharged from psychiatric hospitals in the Bronx and Queens who were attending the same outpatient facilities as the group mandated to outpatient commitment were followed for one year and compared in regard to psychotic symptoms, suicide risk, serious violence perpetration, quality of life, illness-related social functioning, and perceived coercion and stigma. Propensity score matching and generalized estimating equations were used to achieve the strongest causal inference possible without an experimental design. RESULTS: Serious violence perpetration and suicide risk were lower and illness-related social functioning was higher (p<.05 for all) in the outpatient commitment group than in the comparison group. Psychotic symptoms and quality of life did not differ significantly between the two groups. Potential unintended consequences were not evident: the outpatient commitment group reported marginally less (p<.10) stigma and coercion than the comparison group. CONCLUSIONS: Outpatient commitment in New York State affects many lives; therefore, it is reassuring that negative consequences were not observed. Rather, people's lives seem modestly improved by outpatient commitment. However, because outpatient commitment included treatment and other enhancements, these findings should be interpreted in terms of the overall impact of outpatient commitment, not of legal coercion per se. As such, the results do not support the expansion of coercion in psychiatric treatment.

Collaborative Care for Depressed Patients With Chronic Medical Conditions: A Randomized Trial in Puerto Rico [Articles]

Mon, 01 Feb 2010 05:01:21 PST

OBJECTIVE: This study examined whether a collaborative care model for depression would improve clinical and functional outcomes for depressed patients with chronic general medical conditions in primary care practices in Puerto Rico. METHODS: A total of 179 primary care patients with major depression and chronic general medical conditions were randomly assigned to receive collaborative care or usual care. The collaborative care intervention involved enhanced collaboration among physicians, mental health specialists, and care managers paired with depression-specific treatment guidelines, patient education, and follow-up. In usual care, study personnel informed the patient and provider of the diagnosis and encouraged patients to discuss treatment options with their provider. Depression severity was assessed with the Hopkins Symptom Checklist; social functioning was assessed with the 36-item Short Form. RESULTS: Compared with usual care, collaborative care significantly reduced depressive symptoms and improved social functioning in the six months after randomization. Integration of collaborative care in primary care practices considerably increased depressed patients' use of mental health services. CONCLUSIONS: Collaborative care significantly improved clinical symptoms and functional status of depressed patients with coexisting chronic general medical conditions receiving treatment for depression in primary care practices in Puerto Rico. These findings highlight the promise of the collaborative care model for strengthening the relationship between mental health and primary care services in Puerto Rico.

Positive Screens for Psychiatric Disorders in Primary Care: A Long-Term Follow-Up of Patients Who Were Not in Treatment [Articles]

Mon, 01 Feb 2010 05:01:21 PST

OBJECTIVE: Screening for psychiatric disorders has gained acceptance in some general medical settings, but critics argue about its value. The purpose of this study was to determine the clinical utility of screening by conducting a long-term follow-up of patients who screened positive for psychiatric disorders but who were initially not in treatment. METHODS: A cohort of 519 low-income, adult primary care patients were screened for major depression and bipolar, anxiety, and substance use disorders and reassessed with the Structured Clinical Interview for DSM-IV after a mean of 3.7 years by a clinician blind to the initial screen. Data on treatment utilization was obtained through hospital records. The sample consisted of 348 patients who had not received psychiatric care in the year before screening. RESULTS: Among 39 patients who screened positive for major depression, 62% (95% confidence interval=45.5%–77.6%) met criteria for current major depressive disorder at follow-up. Those who screened positive reported significantly poorer mental and social functioning and worse general health at follow-up than the screen-negative patients and were more likely to have visited the emergency department for psychiatric reasons (12.1% and 3.0%, odds ratio [OR]=6.4) and to have major depression (OR=7.6). Generally similar results were observed for patients who screened positive for other disorders. CONCLUSIONS: Commonly used screening methods identified patients with psychiatric disorders; about four years later, those not initially in treatment were likely to have enduring symptoms and to use emergency psychiatric services. Screening should be followed up by clinical diagnostic assessment in the context of available mental health treatment.

Advantages of Using Estimated Depression-Free Days for Evaluating Treatment Efficacy [Articles]

Vannoy, S. D., Arean, P., Unutzer, J. — Mon, 01 Feb 2010 05:01:21 PST

OBJECTIVE: Several common methods for measuring treatment response present a snapshot of depression symptoms. The construct of estimated depression-free days (DFDs) simultaneously captures treatment outcome and estimates the patient's experience of depression over time. The study compared this measure with traditional measures used in depression treatment research. METHODS: This secondary data analysis was based on data from the Improving Mood—Promoting Access to Collaborative Treatment trial, a multisite depression treatment study conducted in 18 primary care clinics in five states and representing eight health care systems. The sample of older adults (N=906) had been randomly assigned to receive collaborative care for depression. Participants were aged 60 or older and met criteria for major depressive disorder, dysthymia, or both. Exclusion criteria included severe cognitive impairment, active substance abuse, active suicidal behavior, severe mental illness, and active treatment from a psychiatrist. The Patient Health Questionnaire (PHQ-9) and the Hopkins Symptom Checklist (HSCL-20) were used as outcome measures at four assessment points (baseline, three months, six months, and 12 months). Outcomes were computed for relative change, standardized differences, the proportion of improvement in depression, and DFDs. RESULTS: Using four assessment points improved the agreement between DFDs and the course of symptom change between pre- and posttest measures. CONCLUSIONS: The DFD is a valid measure for estimating treatment outcomes that reflects the course of symptom change over time. When multiple assessments were conducted between the pre- and posttest periods, DFDs incorporated additional data yet remained easily interpreted. The DFD should be considered for reporting outcomes in depression research.

One-Year Treatment Outcomes of African-American and Hispanic Patients With Bipolar I or II Disorder in STEP-BD [Articles]

Mon, 01 Feb 2010 05:01:21 PST

OBJECTIVE: Few studies have compared treatment outcomes of African-American, Hispanic, and non-Hispanic white patients with bipolar disorder. The U.S. Systematic Treatment Enhancement Program for Bipolar Disorder compared one-year outcomes for bipolar I or II disorder from each of these racial-ethnic groups. METHODS: African Americans (N=155) were retrospectively compared with a matched group of non-Hispanic whites (N=729), and Hispanics (N=152) were compared with a separate matched group of non-Hispanic whites (N=822). Response and recovery outcomes were examined. Survival analysis was used to compare time to treatment response for depression (Montgomery-Asberg Depression Rating Scale) and mania (Young Mania Rating Scale) as well as global assessment of functioning (Global Assessment of Functioning). RESULTS: For manic and depressive symptoms, time to response and proportion of responders were similar across groups. Over the study year the proportion of days well was similar across groups. A smaller proportion of African Americans met criteria for improved global functioning. Depression response among African Americans with psychotic symptoms was slower than the response among African Americans without psychotic symptoms and among non-Hispanic whites with or without psychotic symptoms. No differences between Hispanics and non-Hispanic whites in response times and recovery were observed. CONCLUSIONS: Results are consistent with U.S. clinical trials for other psychiatric disorders, which have reported similar outcomes for ratings of primary symptoms. Baseline psychotic symptoms are likely a significant contributor when African Americans with bipolar disorder are slow to recover. These results may be less generalizable to uninsured patients.

Psychiatrists' Attitudes Toward and Awareness About Racial Disparities in Mental Health Care [Articles]

Mallinger, J. B., Lamberti, J. S. — Mon, 01 Feb 2010 05:01:21 PST

OBJECTIVE: Psychiatrists may perpetuate racial-ethnic disparities in health care through racially biased, albeit unconscious, behaviors. Changing these behaviors requires that physicians accept that racial-ethnic disparities exist and accept their own contributions to disparities. The purposes of this study were to assess psychiatrists' awareness of racial disparities in mental health care, to evaluate the extent to which psychiatrists believe they contribute to disparities, and to determine psychiatrists' interest in participating in disparities-reduction programs. METHODS: A random sample of psychiatrists, identified through the American Psychiatric Association's member directory, was invited to complete the online survey. The survey was also distributed to psychiatrists at a national professional conference. RESULTS: Of the 374 respondents, most said they were not familiar or only a little familiar with the literature on racial disparities. Respondents tended to believe that race has a moderate influence on quality of psychiatric care but that race is more influential in others' practices than in their own practices. One-fourth had participated in any type of disparities-reduction program within the past year, and approximately one-half were interested in participating in such a program. CONCLUSIONS: Psychiatrists may not recognize the pervasiveness of racial inequality in psychiatric care, and they may attribute racially biased thinking to others but not to themselves. Interventions to eliminate racial-ethnic disparities should focus on revealing and modifying unconscious biases. Lack of physician interest may be one barrier to such interventions.

Rational Protection of Subjects in Research and Quality Improvement Activities [Open Forum]

Mon, 01 Feb 2010 05:01:21 PST

This Open Forum illuminates shortcomings with the basis for determining degree of oversight of health services research and quality improvement activities. Using a federally regulated definition of research rather than a direct appraisal of risk to patients can misallocate effort from activities with higher risk for patients to those with lower risk. The case of the Johns Hopkins multicenter study of central line safety checklists in intensive care units is cited. Definitions of research promulgated by the Office of Human Research Protection are reviewed, and an alternative model based on patient risk is proposed. Suggestions for how quality improvement work fits into the larger paradigm of research are made.

The Dual Diagnosis Physician-infrastructure Assessment Tool: Examining Physician Attributes and Dual Diagnosis Capacity [Brief Reports]

Chambers, R. A., Connor, M. C., Boggs, C. J., Parker, G. F. — Mon, 01 Feb 2010 05:01:21 PST

OBJECTIVE: Inadequate physician training and involvement in addictions treatment are barriers to integrating mental health and addiction services in public behavioral health care. The authors designed and implemented the Dual Diagnosis Physician-infrastructure Assessment Tool (DDPAT) to quantify statewide dimensions of this workforce problem. METHODS: The DDPAT examined institutional dual diagnosis capability and physician workforce, training backgrounds, and clinical roles across Indiana's 30 community mental health centers (CMHCs), six psychiatric hospitals, and 13 addiction treatment centers. RESULTS: All treatment centers and 75% of physicians responded. Sixty-nine percent of all treatment centers and 97% of CMHCs reported dual diagnosis capability. However, 29% of physicians treated both mental illness and addictions, and only 8% had certification in an addiction specialty. Overall workforce shortages, particularly of younger psychiatrists, contextualized these findings. CONCLUSIONS: The DDPAT identified multiple deficiencies in the physician workforce with respect to dual diagnosis and addictions care in Indiana. The DDPAT may be useful for characterizing similar trends in other states.

Nonadherence to Medication Four Years After a First Episode of Psychosis and Associated Risk Factors [Brief Reports]

Mon, 01 Feb 2010 05:01:21 PST

OBJECTIVES: This study examined concurrent associations and predictors at first indication of nonadherence to antipsychotic medication four years after a first episode of psychosis. METHODS: A prospective cohort of 171 patients in urban Ireland with a first episode of psychosis was followed up four years after inception (follow-up primary analysis, N=84; secondary analysis, N=104). RESULTS: At the four-year follow-up 76% were adherent and 24% were not. Nonadherence was concurrently associated with substance misuse (p<.01), increased symptomatology (p<.01), less insight (p=.01), lower global functioning (p<.01), and negative attitudes toward medication (p<.01). Compared with other patients, those who were nonadherent had more readmissions (p=.01). Predictors of future nonadherence were substance misuse (p=.02) and duration of untreated psychosis (p=.04). CONCLUSIONS: This prospective investigation confirms previous cross-sectional studies. The association between longer duration of untreated psychosis and nonadherence warrants further research because it could be interpreted as further evidence of the importance of early intervention.

Weekend Prescribing Practices and Subsequent Seclusion and Restraint in a Psychiatric Inpatient Setting [Brief Reports]

Goldbloom, D. L., Mojtabai, R., Serby, M. J. — Mon, 01 Feb 2010 05:01:21 PST

OBJECTIVE:This case-control study examined the role of early medication management in preventing seclusion and restraint. METHODS: Data were extracted from the medical records, including whether standing medication was increased, decreased, or left unchanged during the first 48 hours of hospitalization. RESULTS: Compared with inpatients who did not experience seclusion or restraint (N=39), those who did (N=39) were younger (p=.01) and more likely to be male (p=.023) and to have a primary discharge diagnosis of bipolar disorder, mixed or manic episode, schizophrenia, or schizoaffective disorder (p<.001). Patients whose standing medication was not changed during the first 48 hours of hospitalization had 5.5 times as many restraints as patients whose dose was increased or who received new prescriptions (p=.027). CONCLUSIONS: Early use of medication can reduce the incidence of seclusion and restraint among high-risk patients early in their hospitalization.

Inpatient Psychiatric Treatment of Deaf Adults: Demographic and Diagnostic Comparisons With Hearing Inpatients [Brief Reports]

Landsberger, S. A., Diaz, D. R. — Mon, 01 Feb 2010 05:01:21 PST

OBJECTIVE: This study examined the diagnostic and clinical features of deaf psychiatric inpatients. METHODS: Archival clinical data for deaf and hard-of-hearing adults (N=30) were compared with data for a random sample of hearing adults (N=60) admitted to a state psychiatric hospital from 1998 to 2008. RESULTS: Significant differences were found between deaf and hearing inpatient groups in the frequency of impulse control disorders (23% versus 2%), pervasive developmental disorders (10% versus 0%), substance use disorders (20% versus 45%), mild mental retardation (33% versus 3%), and personality disorders (17% versus 43%). The deaf group had a larger proportion with diagnoses of psychotic disorder not otherwise specified (17% versus 2%). Deaf inpatients had longer hospitalizations than hearing inpatients (17 months versus ten months). CONCLUSIONS: Clinicians working with the underserved, understudied population of deaf and hard-of-hearing psychiatric inpatients should be aware of the cultural and linguistic differences in assessment and treatment and make efforts to modify their approach.

Predictors of Decertification From Involuntary Hospitalization for Patients With Bipolar Disorder [Brief Reports]

Xiong, G. L., Iosif, A.-M., Brook, M., Hilty, D. M. — Mon, 01 Feb 2010 05:01:21 PST

OBJECTIVE: This study examined predictors of decertification (release from involuntary hospitalization after legal hearing) among inpatients with bipolar disorder. METHODS: Records from 1992 to 1997 were examined retrospectively for 50 decertified and 48 certified patients with bipolar disorder. The relationship between demographic and clinical variables and decertification was examined using logistic regression analyses. RESULTS: In the overall multiple logistic regression model, participants were significantly more likely to be decertified if they used a mood stabilizer before the decertification hearing (odds ratio [OR]=6.73, 95% confidence interval [CI]=1.78–25.50) or if they had a comorbid substance use disorder (OR=3.45, CI=1.15–10.34). The odds of decertification increased with the number of prior hospitalizations (OR=3.92, CI=1.73–8.87) and decreased with the length of prior hospitalization (OR=.72 per week, CI=.49–1.04) and number of emergency room visits before admission (OR=.46, CI=.28–.74). CONCLUSIONS: Predictors of decertification in bipolar disorder require further research to guide future efforts to improve inpatient treatment outcomes.

Motivational Interviewing Training at a State Psychiatric Hospital [Frontline Reports]

Levy, M. D., Ricketts, S., Le Blanc, W. — Mon, 01 Feb 2010 05:01:21 PST

Personalized Intervention for Hoarders at Risk of Eviction [Frontline Reports]

Rodriguez, C., Panero, L., Tannen, A. — Mon, 01 Feb 2010 05:01:21 PST

DSM-IV-TR Casebook and Treatment Guide for Child Mental Health [Book Reviews]

Sitzer, L. M. — Mon, 01 Feb 2010 05:01:21 PST

The American Psychiatric Publishing Textbook of Alzheimer Disease and Other Dementias [Book Reviews]

Tonkonogy, J. — Mon, 01 Feb 2010 05:01:21 PST

Prescriptions for the Mind: A Critical View of Contemporary Psychiatry [Book Reviews]

Thompson, K. S. — Mon, 01 Feb 2010 05:01:21 PST

Guyland: The Perilous World Where Boys Become Men [Book Reviews]

Hoffman, C. — Mon, 01 Feb 2010 05:01:21 PST

Handbook of Human Services Management, 2nd edition [Book Reviews]

Kellogg, R. E. — Mon, 01 Feb 2010 05:01:21 PST

2010 Federal Budget Boosts Funding for Mental Health and Substance Abuse Programs [News & Notes]

Mon, 01 Feb 2010 05:01:21 PST

News Briefs [News & Notes]

Mon, 01 Feb 2010 05:01:21 PST