Psychiatr Serv recent issues

[Taking Issue] Lessons to Be Learned From CATIE and CUtLASS

Sutton, B. J. — 2008-05-01

[This Month's Highlights] May 2008: This Month's Highlights

2008-05-01

[Columns] Datapoints: Did CATIE Influence Antipsychotic Use?

Citrome, L., Jaffe, A., Martello, D., Allingham, B., Levine, J. — 2008-05-01

[Columns] Focus on Mental Health Care Reforms in Europe: Mental Health Services in Europe: An Overview

Muijen, M. — 2008-05-01

Psychiatric services in Europe are experiencing a period of change, driven by political commitment at national and intergovernmental levels in response to the public health challenges posed by mental health problems. However, diversity among European countries makes any generalization speculative. Resources such as funding, workforce, and infrastructure vary dramatically, and new investment is limited. Some European countries can take pride in sophisticated service systems, whereas others continue to rely almost exclusively on asylums. Reforms are hampered by a lack of comparable information and a lack of research, particularly in less developed countries. However, many exciting local initiatives are emerging, even in the poorest countries. The challenge will be to translate good local practice into national policies and practice, supported by adequate resources.

[Columns] Public-Academic Partnerships: The Continuous Improvement for Veterans in Care: Mood Disorders (CIVIC-MD) Study, a VA-Academic Partnership

2008-05-01

The Department of Veterans Affairs (VA) provides an ideal opportunity to conduct mental health services research among vulnerable populations, given its extensive data sources, disproportionate number of vulnerable patients (older, often with comorbidities), and quality improvement mission. Although VA facilities are often affiliated with universities, successful VA-academic research partnerships are sometimes elusive. The Continuous Improvement for Veterans in Care: Mood Disorders (CIVIC-MD) study was a partnership with a VA facility that had not been engaged in mood disorders research. This column describes how the partnership formed, key elements of its success, and challenges and opportunities to inform future research partnerships.

[Articles] Science and Recovery in Schizophrenia

2008-05-01

Mental health advocates and policy makers are increasingly attuned to the importance of the recovery concept, and psychiatrists and neuroscientists increasingly emphasize the medical model and neurobiological mechanisms in relation to schizophrenia. Studies have shown that people with schizophrenia are tremendously heterogeneous in each domain of recovery, and the various domains of recovery are themselves relatively independent from one another. Studies have also shown that current interventions are effective for specific dimensions of the illness and functions, are usually ameliorative rather than curative, and are effective only for a proportion of patients. Hence, the authors suggest defining recovery in terms of improvements in specific domains rather than globally—for example, "recovery of cognitive functioning" or "recovery of vocational functioning"—to signify improvements in specific areas. This definition realistically emphasizes states of relative and partial recovery that patients can achieve in response to treatment. The emphasis on a range of improvements in specific areas should allow clinicians to communicate more clearly regarding the current findings and goals of treatment. The article also examines current research on various aspects of recovery, including the effects of treatment on pathophysiology, symptoms, cognitive impairments, quality of life, and self-agency. An operational definition of recovery allows for bridging hope and recovery with important advances in the science of the brain. Future clinical and neuroscience research and service development should emphasize measures of recovery as outcomes for people with schizophrenia.

[Special Section on Implications of CATIE] Introduction to the CATIE Special Section

Swartz, M. S. — 2008-05-01

[Special Section on Implications of CATIE] What CATIE Found: Results From the Schizophrenia Trial

2008-05-01

The authors provide an overview of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) sponsored by the National Institute of Mental Health. CATIE was designed to compare a proxy first-generation antipsychotic, perphenazine, to several newer drugs. In phase 1 of the trial, consenting patients were randomly assigned to receive olanzapine, perphenazine, quetiapine, risperidone, or ziprasidone for up to 18 months on a double-blind basis. Patients with tardive dyskinesia were excluded from being randomly assigned to perphenazine and were assigned to one of the four second-generation antipsychotics in phase 1A. Clozapine was included in phase 2 of the study. Overall, olanzapine had the longest time to discontinuation in phase 1, but it was associated with significant weight and metabolic concerns. Perphenazine was not significantly different in overall effectiveness, compared with quetiapine, risperidone, and ziprasidone. Also, perphenazine was found to be the most cost-effective drug. Clozapine was confirmed as the most effective drug for individuals with a poor symptom response to previous antipsychotic drug trials, although clozapine was also associated with troublesome adverse effects. There were no differences in neurocognitive or psychosocial functioning in response to medications. Subsequent randomizations suggest that a poor response to an initial medication may mean that a different medication will be more effective or better tolerated. Although the CATIE results are controversial, they are broadly consistent with most previous antipsychotic drug trials and meta-analyses; however, the results may not generalize well to patients at high risk of tardive dyskinesia. Patient characteristics and clinical circumstances affected drug effectiveness; these patient factors are important in making treatment choices.

[Special Section on Implications of CATIE] Who Are the New Users of Antipsychotic Medications?

Domino, M. E., Swartz, M. S. — 2008-05-01

OBJECTIVE: This study examined changes in the prevalence of antipsychotic medication use and the characteristics of antipsychotic users in the U.S. population between 1996 and 2005. METHODS: Data from the Medical Expenditure Panel Survey from 1996–1997 and 2004–2005 were used to examine the rate of first- and second-generation antipsychotic medication use and changes in the characteristics of users of all ages. Trends were examined in the level of use by antipsychotic users, both in terms of defined daily dose units and number of prescriptions. RESULTS: The rate of antipsychotic use has increased substantially between 1996–1997 and 2004–2005, but the average dose measured both by defined daily dose units and number of prescriptions has remained constant. The rapid diffusion of antipsychotic medications did not occur among individuals with schizophrenia, but rather it included substantial growth among those with newer on-label conditions (such as bipolar disorder) and a high, constant rate of off-label use. Demographic, financial, and insurance characteristics of users have remained fairly constant, with few exceptions. The average age of antipsychotic users declined during the study period, because more children were using these medications in 2004–2005. However, the gender, racial, ethnic, and insurance composition of users has been fairly stable over time. CONCLUSIONS: The rapid diffusion of second-generation antipsychotic medications was achieved by large increases in the rate of use in certain subpopulations, most notably youths. Increasing understanding about the marginal efficacy and side-effect risks of newer and more expensive antipsychotic agents, even when prescribed as indicated, suggests that the dramatic increase in use warrants careful attention.

[Special Section on Implications of CATIE] Second-Generation Antipsychotics: Cost-Effectiveness, Policy Options, and Political Decision Making

Rosenheck, R. A., Leslie, D. L., Doshi, J. A. — 2008-05-01

The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) and other recent research suggest that second-generation antipsychotics other than clozapine may offer few, if any, advantages over first-generation antipsychotics, especially agents of intermediate potency. Thus the newer agents are not likely to generate sufficient benefit to justify their $11.5 billion annual cost. Policy approaches for containing drug costs are available and could improve cost-effectiveness by encouraging that second-generation antipsychotics be prescribed more selectively, such as only when clearly indicated. However, restrictions on either drug availability or physician choice are vigorously opposed by professional and consumer advocacy groups as well as by industry, and excessively restrictive approaches could unintentionally reduce access to beneficial treatments. Interventions that directly reduce second-generation antipsychotic prices would increase access for consumers but are inconsistent with broad opposition to government price regulation in the United States. High expenditures on these medications are thus likely to continue without concomitant gains for public health.

[Special Section on Implications of CATIE] Policy Toward Second-Generation Antipsychotic Drugs: A Cautionary Note

Frank, R. G. — 2008-05-01

[Special Section on Implications of CATIE] Lessons to Take Home From CATIE

Carpenter, W. T., Buchanan, R. W. — 2008-05-01

The publicly funded Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) did not support superiority hypotheses for second-generation antipsychotic drugs in schizophrenia. Instead, the study supported the view that first- and second-generation antipsychotics have similar therapeutic properties and diverse adverse effect profiles. This emphasizes the importance of designing pharmacotherapy for the individual in order to optimize the benefit-to-risk profile. First- and second-generation antipsychotic drugs are extensively similar in mechanism of action, efficacy for psychosis, and lack of efficacy for avolition and impaired cognition. However, adverse effect profiles vary between drugs. The authors review the clinical implications of these data, with an emphasis on individualizing pharmacotherapy in an effort to reduce risk. Rather than selecting drugs on the basis of unfounded expectations of superior efficacy, clinicians can focus on selecting drugs and optimizing dosages to minimize adverse effects without sacrificing efficacy. Tardive dyskinesia may be a good reason to avoid a high dosage of first-generation antipsychotics, although the evidence for differential risk is less compelling for a modest dosage of low-affinity first-generation antipsychotics. Similarly, the metabolic effects of some second-generation antipsychotics can be decisive in considering risks. In either case, the clinician should detect earliest signs and take action while dyskinetic or metabolic effects are most reversible. Bottom line: the dichotomy between first- and second-generation antipsychotics was not supported by efficacy data (and now, is not supported effectiveness data). Only clozapine has documented superiority in treatment-resistant cases.

[Special Section on Implications of CATIE] Implications of CATIE for Mental Health Services Researchers

Covell, N. H., Finnerty, M. T., Essock, S. M. — 2008-05-01

The authors discuss the implications of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) for mental health services researchers, in particular the need to monitor and change prescriber behavior to encourage informed medication selection. Given the complexity and variability of response to antipsychotic medications in CATIE, use of restricted formularies is not the answer. Rather, services researchers should collaborate with service systems to develop interventions to identify questionable prescriber practices and develop interventions to change them. The CATIE results also suggest that some quality measures for antipsychotic treatment, such as the proportion of a population taking second-generation antipsychotics, need to be revisited by researchers. Also, because the CATIE findings highlighted the prevalence of cardiac and metabolic disorders among treatment populations and the potential impact of antipsychotics on these conditions, services researchers should use secondary data to monitor whether prescribers are providing appropriate screening and treatment. Given the health risks of some antipsychotics, services researchers should develop ways to identify individuals at risk, encourage behavior change among prescribers, and support informed and shared decision making about medications. Mental health services researchers can build relationships with multiple stakeholders, including service system administrators, service providers, and consumers, to help translate results from trials such as CATIE into policy and practice.

[Special Section on Implications of CATIE] What CATIE Did: Some Thoughts on Implications Deep and Wide

Owens, D. C. — 2008-05-01

The author discusses five lessons that can be learned from the seminal results of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE). The lessons extend beyond practice implications to fundamental questions about how psychopharmacology studies are conducted and how results are interpreted and given relevance in regard to prescribing. The author recounts the history of the term "atypical" and how it came to be understood in the context of antipsychotics. The error of using high-dose haloperidol as a comparator in assessments of new antipsychotics—and of generalizing from the results of these studies—is also discussed. The CATIE results force uncomfortable questions about the extent of knowledge concerning the clinical pharmacology of a major treatment modality, which the author illustrates by examining possible reasons for the differential clinical actions of clozapine. The author concludes that CATIE benefited both patients and clinicians by opening up to patients the full gamut of antipsychotics for treatment planning and by reinstating to physicians their key skill in expert, individualized prescribing.

[Special Section on Implications of CATIE] Impact of the CATIE Findings on State Mental Health Policy

Parks, J. J., Radke, A. Q., Tandon, R. — 2008-05-01

The authors, who are medical directors of three state mental health agencies and members of the Medical Directors' Council of the National Association of State Mental Health Program Directors (NASMHPD), describe the impact on public mental health policy of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE). Before publication of the CATIE results, the preponderance of information indicated substantial and broad-ranging advantages of second-generation antipsychotics over first-generation agents. State mental health authorities focused on improving access to and increasing utilization of the newer agents. In many states, expenditures for these agents accounted for 10% of the total pharmacy budget of the Medicaid program. After CATIE, state policy makers have had to take a more critical look at the data and formulate more nuanced approaches. The authors summarize policy recommendations of the NASMHPD Medical Directors' Council, which reviewed efficacy studies of antipsychotics and formulated a position statement. The recommendations cover three broad areas of policy. First, neither complete open access for all patients at all times nor a uniform fail-first trial of a first-generation antipsychotic is an optimal approach. A more nuanced middle ground is necessary. Second, excessive emphasis on the cost of second-generation antipsychotics has led to a lack of focus on optimizing use of all antipsychotic medication in usual practice. More research and management attention must be focused on improving how these medications are prescribed for individual patients. Third, more resources should be invested in clinical trials that more clearly and accurately reflect current practice.

[Special Section on Implications of CATIE] NAMI Perspective on CATIE: Policy and Research Implications

Duckworth, K., Fitzpatrick, M. J. — 2008-05-01

The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) was designed to assess effectiveness of antipsychotic medication for people with schizophrenia. The authors, who are administrators of the National Alliance on Mental Illness (NAMI), discuss CATIE and related policy and research studies and their implications. CATIE has answered some important questions for consumers and their families and raises many more. The prevalence of medical risk factors in the population with schizophrenia is an important part of advancing prevention. Poor adherence to medications randomly prescribed by CATIE physicians in a blinded procedure is also a key finding and points to the need for individually tailoring medication regimens. Policy makers may be tempted to oversimplify the results of CATIE by restricting access to the costlier second-generation medications. However, doing so will hurt clinical care, and any savings to state and community mental health programs may be illusory. Policy can be constructed to focus on clinical outcomes and not merely restrict access to medications on the basis of cost. Research is urgently needed on a new generation of medications with benign side effects and greater efficacy than their predecessors for people with schizophrenia.

[Articles] Effect of Prior Authorization of Second-Generation Antipsychotic Agents on Pharmacy Utilization and Reimbursements

Law, M. R., Ross-Degnan, D., Soumerai, S. B. — 2008-05-01

OBJECTIVE: Medicaid expenditures for antipsychotic medications have risen rapidly, from under $1.0 billion in 1995 to over $5.5 billion in 2005. In response, at least ten states have implemented prior-authorization programs that restrict access to particular second-generation antipsychotic agents (aripiprazole and olanzapine). Twenty-two states restrict particular dosing forms (injections). This study examined the impact of such restrictions. METHODS: The authors used interrupted time-series analysis of quarterly state-level drug utilization data to examine the impact of prior authorization for particular agents in West Virginia and Texas. Changes in market share of nonpreferred medications and total pharmacy costs were compared with changes in states without similar prior-authorization requirements. RESULTS: The West Virginia policy led to an immediate 3.5% reduction in market share level (p<.01) and a 1.3% decrease in trend per quarter in market share (p<.001) for nonpreferred antipsychotics, leading to a 13.9% reduction after two years. In Texas, prior authorization reduced the market share level of nonpreferred agents by 2.6% (p=.055). However, prior authorization did not lead to a significant decrease in pharmacy reimbursements in either state. CONCLUSIONS: Current prior-authorization policies for second-generation antipsychotics do not appear to reduce pharmacy reimbursement, probably because alternative medications are costly. These findings suggest that any cost savings from prior-authorization policies would accrue largely through supplemental rebate agreements with manufacturers, which are likely reduced by the transfer of dually eligible Medicaid enrollees to Medicare Part D plans. Further evaluation of the clinical consequences resulting from such policies is urgently needed to determine whether the minimal cost savings outweigh the potential clinical risks.

[Articles] Utilization and Costs of Antipsychotic Agents: A Canadian Population-Based Study, 1996-2006

2008-05-01

OBJECTIVE: This study evaluated the prescribing patterns and costs for antipsychotic agents in the population of the Canadian province of Manitoba over the past decade. METHODS: A population-based study of antipsychotic utilization and costs was conducted on data collected from the administrative databases of the Manitoba Population Health Data Repository and the Statistics Canada census between index years 1996 and 2006 (April 1, 1995, through March 31, 2006). RESULTS: The total annual number of antipsychotic prescriptions dispensed in Manitoba increased by 227% between 1996 and 2006, and the prevalence of antipsychotic users increased by 62% over the same time interval. The fastest-growing segment of antipsychotic users in Manitoba appears to be young males, who increased from .16% in 1996 to .88% in 2006. The highest numbers of prescriptions were reported for schizophrenia, dementia, and conduct disorder. Annual expenditures for antipsychotics increased from $1.7 million in 1996 to $22.0 million in 2006 (expenditures are in Canadian dollars). The cost of second-generation agents reached 80% of total antipsychotic expenditures in 2006; risperidone was the most prescribed agent in all age groups of patients. The per-patient annual cost of antipsychotic pharmacotherapy increased by approximately 680% between 1996 and 2006 in Manitoba. CONCLUSIONS: The number of antipsychotic prescriptions and the prevalence of users of antipsychotic medications increased significantly in Manitoba over the study period, despite a steady-state population of approximately 1.2 million. Incremental costs relative to the use of antipsychotic medications can be explained by the market penetration of the second-generation agents and their expanded use in the treatment of various diagnoses.

[Articles] Use of Antipsychotic Drugs Among Dutch Youths Between 1997 and 2005

2008-05-01

OBJECTIVE: The authors examined prevalence, incidence, and duration of antipsychotic drug use in the northern and eastern regions of the Netherlands between 1997 and 2005 among youths in regard to age, gender, and class of drug. METHODS: Prescription drug dispensing data were collected from community pharmacies in the northern Netherlands (www.iadb.nl). Prevalence, incidence, and duration of use were studied among roughly 100,000 youths ranging in age from infancy to age 19 years, calculated by age group (zero to four years, five to nine years, ten to 14 years, and 15 to 19 years), for boys and girls, and for first- and second-generation antipsychotics. Duration of use was compared between youths who started antipsychotic treatment in 1998–1999 and those who started in 2001–2002. RESULTS: From 1997 to 2005, prevalence increased from 3.0 to 6.8 per thousand. Prevalence was highest among ten-year-olds to 14-year-olds (11 per thousand), especially among boys (17 per thousand). The increased prevalence was mainly attributable to an increased use of second-generation antipsychotics and to a longer duration of use. Median duration of use doubled from .8 year in 1998–1999 to 1.6 years in 2001–2002. CONCLUSIONS: Second-generation antipsychotic drugs were increasingly prescribed, and for longer periods of time, to younger children, probably because of new indications. This practice increases the exposure of a young population to (partly unknown) risks.

[Brief Reports] Brief Reports: Psychiatric Opinion and Antipsychotic Selection in the Management of Schizophrenia

2008-05-01

OBJECTIVES: This study examined psychiatrists' opinions regarding the use of second-generation antipsychotics for treatment-resistant schizophrenia. It then sought to identify factors associated with these opinions. METHODS: A national survey was conducted (September 2003–January 2004) of psychiatrists engaged in the management of patients with schizophrenia. RESULTS: Among survey respondents (N=431), most psychiatrists (88%) believed that one or more of the five currently available second-generation antipsychotics could improve treatment-resistant positive symptoms after a failed trial of optimal oral haloperidol treatment. Psychiatrists who reported familiarity with schizophrenia practice guidelines were more likely to have high levels of optimism that these medications improve positive symptoms (odds ratio [OR]=3.6, 95% confidence interval [CI]=1.4–9.3, p=.009). Psychiatrists who met with a pharmaceutical representative at least once a week were also more likely to have high levels of optimism toward second-generation antipsychotics (OR=2.3, CI=1.4–3.9, p=.001). CONCLUSIONS: Reported familiarity with treatment guidelines and frequent contact with pharmaceutical representatives appear to be associated with optimism toward second-generation antipsychotics.

[Brief Reports] Commentary: The Need to Guard Against Pharmaceutical Industry Influence

Howland, R. H. — 2008-05-01

[Brief Reports] Antipsychotic Use in the Treatment of Outpatients With Schizophrenia in the VA From Fiscal Years 1999 to 2006

Sernyak, M. J., Rosenheck, R. A. — 2008-05-01

OBJECTIVE: This study examined changes in prescribing patterns of antipsychotic medications to treat schizophrenia. METHODS: Pharmacy records for patients with schizophrenia were obtained from Department of Veterans Affairs databases. The proportion of patients prescribed specific second-generation antipsychotics or any first-generation antipsychotic was calculated per year. RESULTS: In fiscal year (FY) 2006, 78,849 veterans with schizophrenia were prescribed antipsychotic medication. For FY 1999 to FY 2006 the percentage of patients with schizophrenia who received first-generation antipsychotics decreased from 40.8% to 15.9%, but the percentage receiving olanzapine, after peaking at 32.0% in FY 2001, decreased to 19.0%. The percentage of patients given quetiapine increased from 2.5% to 18.8%; risperidone, from 25.5% to 29.7%. However, clozapine usage remained flat, at 2.0%–3.0%. Use of then-new ziprasidone and aripiprazole rose from 5.0% to 9.0%. CONCLUSIONS: Use of each antipsychotic newly marketed over eight years increased while use of risperidone was unchanged and use of olanzapine and the first-generation antipsychotics declined.

[Brief Reports] Mental Health Care Institutions in Nine European Countries, 2002 to 2006

2008-05-01

OBJECTIVE: Although mental health reforms in the 20th century were characterized by deinstitutionalization, previous research suggested a new era of reinstitutionalization in six European countries between 1990 and 2002. This study aimed to establish whether there has been a trend in Europe toward more institutionalized care since 2002. METHODS: Primary data sources were used to collect data on conventional inpatient beds, involuntary hospital admissions, forensic beds, places in residential care and supervised and supported housing, and the prison population in nine countries: Austria, Denmark, England, Germany, Republic of Ireland, Italy, the Netherlands, Spain, and Switzerland. RESULTS: Between 2002 and 2006 the number of conventional psychiatric inpatient beds tended to fall and changes in involuntary admissions were inconsistent. The number of forensic beds, places in supervised and supported housing, and the prison population increased in most, but not all, of the countries studied. CONCLUSIONS: The findings suggest an ongoing although not consistent trend toward increasing provision of institutionalized mental health care across Europe.

[Brief Reports] Commentary: Interpreting Data on "Institutionalization": Not Simply Counting Beds

Muijen, M. — 2008-05-01

[Letters] Violence and Commitment to Treatment

Large, M. M., James Ryan, C., Nielssen, O. — 2008-05-01

[Letters] Violence and Commitment to Treatment: Reply

Torrey, E. F. — 2008-05-01

[Letters] Smoking Bans in State Hospitals: Patients' Rights and Patients' Health

Chisholm, D. D. — 2008-05-01

[Letters] Smoking Bans in State Hospitals: Patients' Rights and Patients' Health: Reply

Marcus, K. — 2008-05-01

[Letters] Surprising Predictor of Rehospitalization

Sledge, W. H., Dunn, C. L., Schmutte, T. — 2008-05-01

[Book Reviews] Principles and Practice of Psychiatric Rehabilitation: An Empirical Approach

Webster, S. L. — 2008-05-01

[Book Reviews] Working With People at High Risk of Developing Psychosis: A Treatment Handbook

Munetz, M. R. — 2008-05-01

[Book Reviews] Evidence-Based Outcome Research: A Practical Guide to Conducting Randomized Controlled Trials for Psychosocial Interventions

Fisher, W. H. — 2008-05-01

[Book Reviews] Ethics in Mental Health Research: Principles, Guidance and Cases

Lidz, C. W. — 2008-05-01

[Book Reviews] On Our Own, Together: Peer Programs for People With Mental Illness

Einhaus, S. — 2008-05-01

[Book Reviews] Empathy in Mental Illness

Justice, L. R. — 2008-05-01

[Book Reviews] The Healthcare Fix: Universal Insurance for All Americans

Gise, L. H. — 2008-05-01

[Book Reviews] Resolving Difficult Clinical Situations: A Personalized Psychotherapy Approach

Guzofski, S. — 2008-05-01

[Book Reviews] Rationality and Compulsion: Applying Action Theory to Psychiatry

Trevino, J. J. — 2008-05-01

[News & Notes] IOM Warns of Shortfalls in the Workforce That Will Provide Care to the Aging Population

2008-05-01

[News & Notes] New Briefs

2008-05-01

[Taking Issue] Treatment: "Just What the Preacher Ordered"

Mattox, R., Sullivan, G. — 2008-03-31

[This Month's Highlights] April 2008: This Month's Highlights

2008-03-31

[Columns] Law & Psychiatry: Sex Offenders in the Community: Are Current Approaches Counterproductive?

Appelbaum, P. S. — 2008-03-31

This column examines laws aimed at preventing sex offenders from reoffending and court challenges to those laws. All states have enacted registration and community notification requirements. More than 20 states and hundreds of municipalities now restrict where sex offenders can live. In many states, public disclosure of registration information is not limited to predatory offenders, but instead includes everyone convicted of a sexually related offense. The author argues that draconian approaches will likely not achieve the goal of protecting the public and that they divert limited resources from other law enforcement needs.

[Columns] Best Practices: Integrating Behavioral Health and Primary Care: The Harris County Community Behavioral Health Program

2008-03-31

This column describes and evaluates the Harris County Community Behavioral Health Program, a new integrated care program operating in community health centers serving low-income uninsured residents in Houston, Texas. Patient service data, provider satisfaction, patient outcome data, and appointment waiting periods were obtained to evaluate the initial operation of the program. The integrated care program has been successfully implemented on a large scale at an annual cost of about $800,000, or $268 per patient served. About 3,000 patients were treated for behavioral problems by behavioral health staff during the first 11 months of the program. In addition, efforts were made to expand the scope of behavioral health interventions provided by primary care physicians. Providers were satisfied with the program, improvement was detected among patients treated, and there was an increase in the average number of community-based behavioral health services received per patient since the program was implemented.

[Columns] Personal Accounts: Reflections on Adherence to a Medications Regimen

Sanders, D. M. — 2008-03-31

[Articles] Using Computerized Adaptive Testing to Reduce the Burden of Mental Health Assessment

2008-03-31

OBJECTIVE: This study investigated the combination of item response theory and computerized adaptive testing (CAT) for psychiatric measurement as a means of reducing the burden of research and clinical assessments. METHODS: Data were from 800 participants in outpatient treatment for a mood or anxiety disorder; they completed 616 items of the 626-item Mood and Anxiety Spectrum Scales (MASS) at two times. The first administration was used to design and evaluate a CAT version of the MASS by using post hoc simulation. The second confirmed the functioning of CAT in live testing. RESULTS: Tests of competing models based on item response theory supported the scale's bifactor structure, consisting of a primary dimension and four group factors (mood, panic-agoraphobia, obsessive-compulsive, and social phobia). Both simulated and live CAT showed a 95% average reduction (585 items) in items administered (24 and 30 items, respectively) compared with administration of the full MASS. The correlation between scores on the full MASS and the CAT version was .93. For the mood disorder subscale, differences in scores between two groups of depressed patients—one with bipolar disorder and one without—on the full scale and on the CAT showed effect sizes of .63 (p<.003) and 1.19 (p<.001) standard deviation units, respectively, indicating better discriminant validity for CAT. CONCLUSIONS: Instead of using small fixed-length tests, clinicians can create item banks with a large item pool, and a small set of the items most relevant for a given individual can be administered with no loss of information, yielding a dramatic reduction in administration time and patient and clinician burden.

[Articles] Commentary: Are We Ready for Computerized Adaptive Testing?

Unick, G. J., Shumway, M., Hargreaves, W. — 2008-03-31

[Articles] Familiarity With and Use of Accommodations and Supports Among Postsecondary Students With Mental Illnesses

Salzer, M. S., Wick, L. C., Rogers, J. A. — 2008-03-31

OBJECTIVE: Many persons with serious mental illnesses are interested in pursuing postsecondary education and are doing so in increasing numbers. Accommodations can be essential, but limited research suggests that few formally seek accommodations, although increased efforts to heighten awareness may be changing this. The purpose of this study was to examine whether students with mental illnesses are increasingly aware of, and utilize, accommodations and academic supports and to identify the supports that are most used and perceived to be most helpful. METHODS: A national Internet survey was conducted from July 2005 to July 2006, resulting in responses from 190 current and 318 former students with mental illnesses. RESULTS: The study found modest but significant negative correlations between how long ago students left college and their familiarity with accommodations, their request for or receipt of accommodations, and their use of the Office for Students With Disabilities. These results were particularly noticeable when comparing current and former students. Moderate positive correlations that were significant were found between familiarity with accommodations, use of campus disability offices, and request for or receipt of accommodations. CONCLUSIONS: There is increased awareness and use of accommodations among students with mental illnesses, but it is also clear that most receive supports directly from instructors without going through the formal accommodations process. Encouraging students to utilize disability offices and greater attention to accommodation barriers may further increase support seeking. Supports that are most used and viewed as most helpful provide direction for service providers and campus personnel in their efforts to facilitate students' educational goals.

[Articles] Commentary: The Importance of Accommodations in Higher Education

Saks, E. R. — 2008-03-31

[Articles] The Impact of Cost Sharing on Antidepressant Use Among Older Adults in British Columbia

2008-03-31

OBJECTIVE: Antidepressant therapies are underused among older adults and could be further curtailed by patient cost-sharing requirements. The authors studied the effects of two sequential cost-sharing policies in a large, stable population of all British Columbia seniors: change from full prescription coverage to $10–$25 copayments (copay) in January 2002 and replacement with income-based deductibles and 25% coinsurance in May 2003. METHODS: PharmaNet data were used to calculate monthly dispensing of antidepressants (in imipramine-equivalent milligrams) among all British Columbia residents age 65 and older beginning January 1997 through December 2005. Monthly rates of starting and stopping antidepressants were calculated. Population-level patterns over time were plotted, and the effects of implementing cost-sharing policies on antidepressant use, initiation, and stopping were examined in segmented linear regression models. RESULTS: Implementation of the copay policy was not associated with significant changes in level of antidepressant dispensing or the rate of dispensing growth. Subsequent implementation of the income-based deductible policy also did not lead to a significant change in dispensing level but led to a significant (p=.02) decrease in the rate of growth of antidepressant dispensing. The copay policy was associated with a significant (p=.01) drop in the frequency of antidepressant initiation among persons with depression. Income-based deductibles reduced the rate of increase in antidepressant initiation over time. Implementation of the copay and income-based deductible policies did not have significant effects on stopping rates. CONCLUSIONS: Introducing new forms of medication cost sharing appears to have the potential to reduce some use and initiation of antidepressant therapy by seniors. The clinical consequences of such reduced use need to be clarified.

[Articles] Benzodiazepine Use and Expenditures for Medicare Beneficiaries and the Implications of Medicare Part D Exclusions

Yang, H.-w. K., Simoni-Wastila, L., Zuckerman, I. H., Stuart, B. — 2008-03-31

OBJECTIVES: Benzodiazepines are excluded from prescription drug coverage under Medicare Part D. The objectives of this study were twofold: to provide national estimates of benzodiazepine utilization and expenditure patterns and to examine the impact of drug coverage and other factors associated with utilization of benzodiazepines and potential benzodiazepine substitute classes. METHODS: The 2002 Medicare Current Beneficiary Survey provided national estimates of benzodiazepine use and expenditures among Medicare beneficiaries. Multivariate logistic regression was conducted to assess the relationships between independent variables and use of benzodiazepines and potential substitute classes. The independent variable of interest was drug coverage, assessed by payer source. Other covariates included in the models were chronic conditions associated with benzodiazepine use, age, sex, race, and income. RESULTS: In 2002, 13.7% of Medicare beneficiaries received at least one benzodiazepine fill, with an average of 5.8 benzodiazepine prescriptions filled at an annual cost of $190. Specific sources of prescription drug coverage were not significantly associated with benzodiazepine use. Female gender, chronic mental illness, age under 65, and lower income were significantly positively associated with benzodiazepine use in the Medicare population, whereas black and other races were significantly negatively associated with benzodiazepine use in this population. Compared with Medicare beneficiaries without supplemental drug coverage, beneficiaries with supplemental drug coverage were more likely to use potential benzodiazepine substitute classes than benzodiazepines. CONCLUSIONS: Benzodiazepines were widely used by Medicare beneficiaries. Drug coverage influences access to benzodiazepines and potential substitute classes. These findings have important implications for identifying beneficiaries potentially affected by the exclusion of benzodiazepine coverage under Medicare Part D.

[Articles] Perceived Stigma and Mental Health Care Seeking

Golberstein, E., Eisenberg, D., Gollust, S. E. — 2008-03-31

OBJECTIVE: There is limited empirical evidence on the extent to which perceived public stigma prevents individuals from using mental health services, despite substantial recent policy interest in this issue. This study investigated associations between perceived public stigma and mental health care seeking. METHODS: This study used cross-sectional survey data from a representative sample of undergraduate and graduate students (N=2,782) at one university. A five-item scale was used to assess perceived public stigma toward mental health service use. Perceived need for help in the past 12 months and current presence of depressive and anxiety disorders were also assessed. RESULTS: Perceived stigma was higher among males, older students, Asian and Pacific Islanders, international students, students with lower socioeconomic status backgrounds, and students with current mental health problems. Perceived stigma was also higher among those without any family members or friends who had used mental health services and among those who believed that therapy or medication is not very helpful. Perceived stigma was negatively associated with the likelihood of perceiving a need for mental health services, but only among younger students. Among those with probable depressive or anxiety disorders, there was no evidence that perceived stigma was associated with service use. CONCLUSIONS: These results suggest that, at least in this population, perceived stigma may not be as important a barrier to mental health care as the mental health policy discourse currently assumes.

[Articles] Medical Clinic Characteristics and Access to Behavioral Health Services for Persons With HIV

Ohl, M. E., Landon, B. E., Cleary, P. D., LeMaster, J. — 2008-03-31

OBJECTIVE: Many persons with HIV do not receive needed behavioral health services. This study examined the impact of medical clinic characteristics on access to mental health and substance abuse care for persons with HIV. METHODS: This was a longitudinal survey of patients and clinic directors participating in the HIV Cost and Services Utilization Study, a national probability sample of persons in care for HIV between 1996 and 1998 (N=2,031). Primary outcomes were receipt of outpatient mental health specialist care, outpatient substance abuse care, and abstinence from substance use in the past 30 days. RESULTS: After adjustment for patient characteristics, the likelihood of care by a mental health specialist was higher for patients in HIV specialty clinics (odds ratio [OR]=2.1, 95% confidence interval [CI]=1.2–3.5) and clinics with a combination of on-site case management and affiliated mental health care (OR=2.3, CI 1.3–4.4, for off-site affiliated care; OR=2.1, CI=1.2–3.7, for on-site care). Outpatient substance abuse care also was more likely for patients in clinics with on-site case management and affiliated substance abuse care (OR=4.3, CI=1.5–12.2, for off-site affiliated care; OR=3.2, CI=1.3–8.0, for on-site care). In a subgroup of persons reporting active substance use, care in clinics with on-site case management predicted 30-day abstinence from substances at follow-up (OR=1.7, CI=1.1–2.5). CONCLUSIONS: The organizational structure of medical clinics can have an important effect on use of mental health and substance abuse specialist care.

[Articles] Community Determinants of Latinos' Use of Mental Health Services

Aguilera, A., Lopez, S. R. — 2008-03-31

OBJECTIVE: This study examined the role of community in understanding Latino adults' (18–64 years of age) use of community mental health services. METHODS: Service utilization data from the Los Angeles County Department of Mental Health were analyzed from 2003 in two service provider areas. Demographic data, including foreign-born status, language, education, and income for the Latino population, were obtained from the 2000 U.S. Census. The study sample consisted of 4,133 consumers of mental health services in 413 census tracts from an established immigrant community and 4,156 consumers of mental health services in 204 census tracts from a recent immigrant community. Negative binomial regression analyses were conducted to examine associations between locales, community characteristics, and use of services. RESULTS: Community of residence and foreign-born status were significantly associated with Latinos' service use. Latinos from the established immigrant community were more likely to use services than Latinos from the recent immigrant community. Across both communities, census tracts with a higher percentage of foreign-born noncitizen residents showed lower service use. Within the established immigrant community, as income levels increased there was little change in utilization. In contrast, in the recent immigrant community, as income levels increased utilization rates increased as well (β=.001, p<.001). CONCLUSIONS: The findings point out the importance of locale and community determinants in understanding Latinos' use of public mental health services.

[Articles] Rates and Risk Factors by Ethnic Group for Suicides Within a Year of Contact With Mental Health Services in England and Wales

Bhui, K. S., McKenzie, K. — 2008-03-31

OBJECTIVE: This study compared suicide rates, clinical symptoms, and perceived preventability of suicide among persons in four ethnic groups who completed suicide within 12 months of contact with mental health services. METHODS: The rates and standardized mortality ratios (SMRs) of suicide following contact with mental health services were calculated by using national suicide data from 1996 to 2001 for the four largest ethnic groups in England and Wales: black Caribbean, black African, South Asian (Indian, Pakistani, and Bangladeshi), and white. The study also investigated whether clinical indices of risk show ethnic variations. RESULTS: A total of 8,029 suicides in the four ethnic groups were investigated. Overall, compared with the SMRs for their white counterparts, low SMRs were found for South-Asian men and women (SMR=.5, 95% confidence interval [CI]=.4–.6 for South-Asian men and SMR=.7, CI=.5–.9 for South-Asian women). High SMRs were found for black Caribbean and black African men aged 13–24 (SMR=2.9, CI=1.4–5.3 for black Caribbean men and SMR=2.5, CI=1.1–4.8 for black African men). High SMRs were found for young women aged 25–39 of South-Asian origin (SMR=2.8, CI=1.9–3.9), black Caribbean origin (SMR=2.7, CI=1.3–4.8), and black African origin (SMR=3.2, CI=1.6–5.7). Some widely accepted suicide risk indicators were less common in the ethnic minority groups than in the white group. There were more symptoms of active psychosis for people from ethnic minority groups who later committed suicide, and perceived preventability was highest among black Caribbean people. CONCLUSIONS: Rates and SMRs varied across ethnic groups. Specific preventive actions must take account of the ethnic variations of clinical indices of risk and include more effective treatment of psychosis.

[Articles] Meso-level Comparison of Mental Health Service Availability and Use in Chile and Spain

2008-03-31

OBJECTIVES: There is a demand for international comparisons of mental health care in Latin America. The purpose of this study was to describe mental health care in catchment health areas in Chile and Spain in order to complement information reported at the macro-level (countries or regions). METHODS: Availability and utilization of services for the adult population were assessed in two urban areas in Chile and in three urban areas in Spain by using the European Service Mapping Schedule (meso-level data). Indicators from a previous data envelopment analysis (DEA) model of basic community care were applied to this analysis. RESULTS: For the two countries, local data on beds and staff differed from data provided at the national level. In Chile meso-level data indicated more available beds and more psychologists per capita than did macro-level data. Quantitative indicators of community care were described, and the main gaps in Chile's urban areas were identified, particularly in day care and nonhospital residential care. There was nearly a tenfold difference in use of residential and day care between the benchmark area in Spain and the areas explored in Chile. In Chile's catchment areas there was no availability of nonacute hospital services, any work-related services for persons with mental disorders, or 24-hour mobile or nonmobile emergency psychiatric care. The meso-level data indicated that delivery and use of care in Chile was more similar to the pattern found in the poorer area in southern Spain than macro-level data would indicate. CONCLUSIONS: The European Service Mapping Schedule was useful for describing mental health care outside of Europe and allowed for an international comparison between Chile and Spain. The meso-level description gathered in this study adds to the macro-level information on the mental health care system that has been provided in other reports. The gap between mental health treatment needed and mental health treatment received in Chile may be lower than expected.

[Brief Reports] Barriers to Care for Antenatal Depression

Kopelman, R. C., Moel, J., Mertens, C., Stuart, S., Arndt, S., O'Hara, M. W. — 2008-03-31

OBJECTIVE: This study examined the individual-level factors impacting pregnant women's access to mental health treatment for depression. METHODS: A total of 1,416 pregnant women receiving prenatal care completed measures of depressive symptomatology, willingness to seek treatment for depression or anxiety, and perceived barriers to seeking such care. RESULTS: Women with Beck Depression Inventory scores ≥16 (indicating possible depression) (N=183) were more likely than women with lower scores (N=1,233) to identify the following barriers: cost, lack of insurance, lack of transportation, long waits for treatment, previous bad experience with mental health care, and not knowing where to go for treatment. Lower income was correlated with increased endorsement of cost and transportation as barriers. CONCLUSIONS: Results suggest that addressing financial and logistical barriers through changes in mental health services and policy will improve access to care for antenatal depression. However, attending to these issues alone will not address additional important barriers to care such as lack of trust.

[Brief Reports] A Disease Management Program for Families of Persons in Hong Kong With Dementia

Chien, W. T., Lee, Y. M. — 2008-03-31

OBJECTIVES: This study tested the effectiveness of a dementia care management program for Chinese families of relatives with dementia on caregivers' and patients' health outcomes over a 12-month follow-up period. METHODS: The dementia care management program is an educational and supportive group for caregivers that lasts six months. A controlled trial was conducted with 88 primary caregivers of persons with dementia in two dementia care centers in Hong Kong. Family members were assigned randomly to either the dementia care program or standard care. The two groups were compared for patients' symptoms and institutionalization rates and caregivers' quality of life, burden, and social support upon recruitment and six and 12 months after group assignment. RESULTS: Over the 12-month follow-up period, patients with family members in the dementia care program showed significantly greater improvements in symptoms and institutionalization rates and their caregivers reported significantly greater improvements in quality of life and burden compared with the control group. CONCLUSIONS: The findings provide evidence that the dementia care management program can improve the psychosocial functioning of Chinese persons with dementia and their caregivers.

[Brief Reports] Collaboration Between Psychiatrists and Clergy in Recognizing and Treating Serious Mental Illness

Farrell, J. L., Goebert, D. A. — 2008-03-31

OBJECTIVE: A surprisingly high number of Americans seek clergy support for treatment of mental illness. However, little is known about how the clergy prepare for fulfilling this need or their beliefs regarding mental illness. This study examined the ability to recognize and treat mental illness among Hawaii's Protestant clergy. METHODS: Ninety-eight clergy members responded to the survey. RESULTS: Most (71%) reported feeling inadequately trained to recognize mental illness. The most common cause of mental illness that clergy members cited was medical (37%), yet when asked to comment on two case vignettes, many reported that they would provide counseling instead of referral. When referrals were made, 41% considered shared religious beliefs between parishioner and provider important, and 15% considered shared beliefs essential. CONCLUSIONS: These findings highlight the need for collaboration between mental health professionals and the clergy. Knowledge of a patient's belief system may help improve crisis interventions and treatment planning for religious patients.

[Brief Reports] Computerized Screening for Alcohol and Drug Use Among Adults Seeking Outpatient Psychiatric Services

Satre, D., Wolfe, W., Eisendrath, S., Weisner, C. — 2008-03-31

OBJECTIVE: This study examined routine computerized screening for alcohol and drug use of men and women seeking outpatient psychiatric services (excluding chemical dependency treatment) and prevalence based on electronic medical records of consecutive admissions. METHODS: The sample of 422 patients, ages 18–91, completed a self-administered questionnaire. Measures included 30-day, one-year, and lifetime substance use and alcohol-related problems. RESULTS: Seventy-five percent of patients completed electronic intakes during the study period. Prior-month alcohol use was reported by 90 men (70%) and 180 women (62%). Of these patients, heavy drinking (five or more drinks on one occasion) was reported by 37 men (41%) and 41 women (23%). Prior-month cannabis use was reported by 17 men (13%) and 32 women (11%). CONCLUSIONS: Computerized intake systems that include alcohol and drug screening can be integrated into outpatient psychiatric settings. Heavy drinking and use of nonprescribed drugs are commonly reported, which provides an important intervention opportunity.

[Letters] Revisiting the MacArthur Study

Lamberti, J. S. — 2008-03-31

[Letters] Revisiting the MacArthur Study: Reply

Torrey, E. F., Stanley, J. — 2008-03-31

[Letters] Do Consumers Use the Word "Recovery"?

Piat, M., Sabetti, J., Couture,, A. — 2008-03-31