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Psychiatr Serv RSS feed - current issue contents and abstracts

Half Full or Half Empty? [Taking Issue] 1 Sep 2010

September 2010: This Month's Highlights [This Month's Highlights] 1 Sep 2010

Datapoints: Self-Reported Unmet Need for Mental Health Care After California's Parity Legislation [Columns] 1 Sep 2010

Mental Health Reforms in Europe: Challenges of Postgraduate Psychiatric Training in Europe: A Trainee Perspective [Columns] 1 Sep 2010

The European Federation of Psychiatric Trainees (EFPT) is an umbrella organization for trainee associations in 31 countries. A survey asked member countries about the three most important issues facing postgraduate training. Qualitative analysis grouped responses in five categories: implementation of new postgraduate curricula, poor working conditions, low recruitment of psychiatric trainees, insufficient training opportunities, and inadequate psychotherapy training. Disparities between countries lead to trainee migration, which worsens conditions in their home countries. The EFPT is in a unique position to obtain feedback and work with partner organizations to improve the standards of psychiatric training for European trainees.

Best Practices: Disseminating Best Practices for Bipolar Disorder Treatment in a Correctional Population [Columns] 1 Sep 2010

Use of medication treatment algorithms may facilitate clinical decision making, improve consistency, and reduce polypharmacy in the correctional setting. A feasibility study was conducted investigating use of Texas Implementation of Medication Algorithms (TIMA) guidelines for bipolar disorder in the Connecticut Department of Correction. Forty inmates with diagnoses of bipolar disorder were treated over a 12-week period adhering to the TIMA algorithm for bipolar disorder. Significant improvement was seen in the primary and secondary outcome measures (p<.001). This pilot project confirmed the feasibility of algorithm adaptation to the correctional setting and provided specific recommendations for successful dissemination of the TIMA algorithm for bipolar disorder in correctional settings.

Focus on Patient Management: Responsibly Managing Psychiatric Inpatient Refusal of Medical or Surgical Diagnostic Work-Up [Columns] 1 Sep 2010

This column uses the tools of normative ethics—analysis and argument—to provide a reasoned account of and to identify ethically justified responses by the psychiatrist to psychiatric inpatients' refusal of medical or surgical diagnostic work-up. There are three relevant ethical considerations when psychiatric inpatients refuse medical or surgical diagnostic tests: balancing autonomy with beneficence, surrogate decision making and confidentiality, and managing strong feelings. Assisted decision making and assent are key management strategies for promoting patients' autonomy and for protecting against adverse consequences of decision making.

Medicaid Beneficiaries Using Mental Health or Substance Abuse Services in Fee-for-Service Plans in 13 States, 2003 [Articles] 1 Sep 2010

OBJECTIVE: This study identified Medicaid beneficiaries using mental health or substance abuse services in fee-for-service plans in 13 states in 2003 (N=1,380,190) and examined their use of medical services. METHODS: Administrative and fee-for-service claims data from Medicaid Analytic eXtract files were analyzed to identify mutually exclusive groups of beneficiaries who used either mental health or substance abuse services and to describe patterns of medical service use. RESULTS: Overall, 11.7% of Medicaid beneficiaries were identified as using mental health or substance abuse services (10.9% and .7% used each of these services, respectively), with substantial variation across age and eligibility groups. Among beneficiaries using mental health services, 47.4% had visited an emergency room for any reason, 7.8% were treated for their disorder in inpatient settings, 13.8% received inpatient treatment for problems other than their mental or substance use disorders, and 70.4% received prescriptions for psychotropic medications. Among beneficiaries using substance abuse services, 60.7% had visited an emergency room, 12.6% were treated for their disorder in inpatient settings, 24.7% received other inpatient treatment, and 46.1% received prescriptions for psychotropic medications. Among beneficiaries not using either mental health or substance use services, 29.0% had visited an emergency room, 12.7% received inpatient treatment, and 10.1% received prescriptions for psychotropic medications. CONCLUSIONS: Beneficiaries who used mental health or substance abuse services entered general inpatient settings and visited emergency rooms more frequently than other beneficiaries.

Trends in the Duration of Emergency Department Visits, 2001-2006 [Articles] 1 Sep 2010

OBJECTIVE: This study estimated trends in the duration of emergency department visits from 2001 to 2006 and compared duration by presenting complaint—mental health related or non-mental health related. METHODS: Data on visits (N=193,077) were from the National Hospital Ambulatory Medical Care Survey Emergency Department databases. Visits were classified as mental health visits if the primary reason for the visit was a common mental health symptom or disorder, a problem related to substance use, suicidal behaviors, or a need for counseling. Regression models were adjusted for year, diagnosis type, discharge status, payment source, demographic characteristics, receipt of medical care during the visit, mode of arrival, and immediacy of need for treatment. RESULTS: The duration of all emergency department visits increased at an annual rate of 2.3%. Trends were similar for mental health visits and non-mental health visits. Throughout the period the average duration of mental health visits exceeded the average duration of non-mental health visits by 42% (p<.001). This difference was related to the longer durations of mental health visits ending in transfer and visits by persons with serious mental illness or substance use disorders. CONCLUSIONS: From 2001 to 2006, the duration of emergency department visits made by patients presenting with mental health complaints and visits made by all other patients increased at similar rates. However, the longer visits for certain groups of mental health patients suggest that emergency departments incur higher costs in connection with the delivery of services to persons in need of acute stabilization.

Assessing the STIRR Model of Best Practices for Blood-Borne Infections of Clients With Severe Mental Illness [Articles] 1 Sep 2010

OBJECTIVES: People with co-occurring severe mental illness and a substance use disorder are at markedly elevated risk of infection from HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV), but they generally do not receive basic recommended screening or preventive and treatment services. Barriers to services include lack of programs offered by mental health providers and client refusal of available services. Clients from racial-ethnic minority groups are even less likely to accept recommended services. The intervention tested was designed to facilitate integrated infectious disease programming in mental health settings and to increase acceptance of such services among clients. METHODS: A randomized controlled trial (N=236) compared enhanced treatment as usual (control) with a brief intervention to deliver best-practice services for blood-borne diseases in an urban sample of clients with co-occurring disorders who were largely from racial-ethnic minority groups. The "STIRR" intervention included Screening for HIV and HCV risk factors, Testing for HIV and hepatitis, Immunization against hepatitis A and B, Risk reduction counseling, and medical treatment Referral and support at the site of mental health care. RESULTS: Clients randomly assigned to the STIRR intervention had high levels (over 80%) of participation and acceptance of core services. They were more likely to be tested for HBV and HCV, to be immunized against hepatitis A virus and HBV, and to increase their knowledge about hepatitis and reduce their substance abuse. However, they showed no reduction in risk behavior, were no more likely to be referred to care, and showed no increase in HIV knowledge. Intervention costs were $541 per client (including $234 for blood tests). CONCLUSIONS: STIRR appears to be efficacious in providing a basic, best-practice package of interventions for clients with co-occurring disorders.

Findings of a U.S. National Cardiometabolic Screening Program Among 10,084 Psychiatric Outpatients [Articles] 1 Sep 2010

OBJECTIVE: A national cardiometabolic screening program for patients in a variety of public mental health facilities, group practices, and community behavioral health clinics was funded by Pfizer Inc. between 2005 and 2008. METHODS: A one-day, voluntary metabolic health fair in the United States offered patients attending public mental health clinics free cardiometabolic screening and same-day feedback to physicians from a biometrics testing third party that was compliant with the Health Insurance Portability and Accountability Act. RESULTS: This analysis included 10,084 patients at 219 sites; 2,739 patients (27%) reported having fasted for over eight hours. Schizophrenia or bipolar disorder was self-reported by 6,233 (62%) study participants. In the overall sample, the mean waist circumference was 41.1 inches for men and 40.4 inches for women; 27% were overweight (body mass index [BMI] 25.0–29.9 kg/m²), 52% were obese (BMI ≥30.0 kg/m²), 51% had elevated triglycerides (≥150 mg/dl), and 51% were hypertensive (≥130/85 mm Hg). In the fasting sample, 52% had metabolic syndrome, 35% had elevated total cholesterol (≥200 mg/dl), 59% had low levels of high-density lipoprotein cholesterol (<40 mg/dl for men or <50 mg/dl for women), 45% had elevated triglycerides (≥150 mg/dl), and 33% had elevated fasting glucose (≥100 mg/dl). Among the 1,359 fasting patients with metabolic syndrome, 60% were not receiving any treatment. Among fasting patients who reported treatment for specific metabolic syndrome components, 33%, 65%, 71%, and 69% continued to have elevated total cholesterol, low levels of high-density lipoprotein, high blood pressure, and elevated glucose levels, respectively. CONCLUSIONS: The prevalence of metabolic syndrome and cardiometabolic risk factors, such as overweight, hypertension, dyslipidemia, and glucose abnormalities, was substantial and frequently untreated in this U.S. national mental health clinic screening program.

Effects of Adopting a Smoke-Free Policy in State Psychiatric Hospitals [Articles] 1 Sep 2010

OBJECTIVE: The aim of this study was to investigate how adopting a smoke-free policy in state psychiatric hospitals affected key factors, including adverse events, smoking cessation treatment options, and specialty training for clinical staff about smoking-related issues. METHODS: Hospitals were surveyed in 2006 and 2008 about their smoking policies, smoking cessation aids, milieu management, smoking cessation treatment options, and aftercare planning and referrals for smoking education. Comparisons were made between hospitals that went smoke-free between the two time periods (N=28) and those that did not (N=42). RESULTS: Among hospitals that changed to a smoke-free policy, the proportion that reported adverse events decreased by 75% or more in three areas: smoking or tobacco use as a precursor to incidents that led to seclusion or restraint, smoking-related health conditions, and coercion or threats among patients and staff. Hospitals that did not adopt a smoke-free policy cited several barriers, including resistance from staff, patients, and advocates. CONCLUSIONS: Although staff were concerned that implementing a smoke-free policy would have negative effects, this was not borne out. Findings indicated that adopting a smoke-free policy was associated with a positive impact on hospitals, as evidenced by a reduction in negative events related to smoking. After adoption of a smoke-free policy, fewer hospitals reported seclusion or restraint related to smoking, coercion, and smoking-related health conditions, and there was no increase in reported elopements or fires. For hospitals adopting a smoke-free policy in 2008, there was no significant difference between 2006 and 2008 in the number offering nicotine replacement therapies or clinical staff specialty training. Results suggest that smoking cessation practices are not changing in the hospital as a result of a change in policy.

Self-Help and Community Mental Health Agency Outcomes: A Recovery-Focused Randomized Controlled Trial [Articles] 1 Sep 2010

OBJECTIVE: Self-help agencies (SHAs) are consumer-operated service organizations managed as participatory democracies. Members are involved in all aspects of organizational management, because a premise of SHAs is that organizationally empowered individuals become more empowered in their own lives, which promotes recovery. The study sought to determine the effectiveness of combined SHA and community mental health agency (CMHA) services in assisting recovery for persons with serious mental illness. METHODS: A weighted sample of new clients seeking CMHA services was randomly assigned to regular CMHA services or to combined SHA-CMHA services at five proximally located pairs of SHA drop-in centers and county CMHAs. Member-clients (N=505) were assessed at baseline and at one, three, and eight months on five recovery-focused outcome measures: personal empowerment, self-efficacy, social integration, hope, and psychological functioning. Scales had high levels of reliability and independently established validity. Outcomes were evaluated with a repeated-measures multivariate analysis of covariance. RESULTS: Overall results indicated that combined SHA-CMHA services were significantly better able to promote recovery of client-members than CMHA services alone. The sample with combined services showed greater improvements in personal empowerment (F=3.99, df=3 and 491, p<.008), self-efficacy (F=11.20, df=3 and 491, p<.001), and independent social integration (F=12.13, df=3 and 491, p<.001). Hopelessness (F=4.36, df=3 and 491, p<.005) and symptoms (F=4.49, df=3 and 491, p<.004) dissipated more quickly and to a greater extent in the combined condition than in the CMHA-only condition. CONCLUSIONS: Member-empowering SHAs run as participatory democracies in combination with CMHA services produced more positive recovery-focused results than CMHA services alone.

Perceived Coercion Among Jail Diversion Participants in a Multisite Study [Articles] 1 Sep 2010

OBJECTIVE: Although jail diversion is considered an appropriate and humane response to the disproportionately high volume of people with mental illness who are incarcerated, little is known regarding the perceptions of jail diversion participants, the extent to which they feel coerced into participating, and whether perceived coercion reduces involvement in mental health services. This study addressed perceived coercion among participants in postbooking jail diversion programs in a multisite study and examined characteristics associated with the perception of coercion. METHODS: Data collected in interviews with 905 jail diversion participants from 2003 to 2005 were analyzed with random-effects proportional odds models. RESULTS: Ten percent of participants reported a high level of coercion, and another 26% reported a moderate level of coercion. Having a drug charge was associated with lower perceived coercion to enter the program. In addition, an interaction between sexual abuse and substance abuse indicated that recent sexual abuse was associated with higher levels of perceived coercion, but only among those without current substance abuse. At the 12-month follow-up (N=398), variables associated with higher perceived coercion to receive behavioral health services included spending more time in jail and higher perceived coercion at baseline. The amount of behavioral health service use was not predicted by perceived coercion at baseline. Rather, being older, having greater symptom severity, and having a history of sexual abuse but no substance abuse and no history of physical abuse were associated with higher levels of outpatient service use. CONCLUSIONS: Overall, one-third of jail diversion participants reported some level of perceived coercion. Important determinants of perceived coercion included charge type, length of time in jail, and sexual abuse history. Engagement in treatment was not affected by perceived coercion.

The Role of Religion in the Well-Being of Older Adults With Schizophrenia [Articles] 1 Sep 2010

OBJECTIVES: This study examined a community sample of older adults with schizophrenia to determine whether there were differences in religiousness with their age peers, to examine the relationship between religiousness and psychotic symptoms, and to see whether religiousness has direct or stress-buffering effects on quality of life. METHODS: The schizophrenia group consisted of 198 community-dwelling persons aged 55 and older who developed schizophrenia before age 45.A community comparison group (N=113) was recruited using randomly selected block groups. A seven-item religiousness scale was developed that consisted of three dimensions (salience, coping, and attendance). An adaptation of Pearlin and colleagues' Stress Process Model was used to examine the direct and buffering effects of religiousness on quality of life. RESULTS: Persons with schizophrenia had significantly lower levels of religiousness than their age peers, although this was due to less frequent religious attendance (four times a year versus once a month). Religiousness was not significantly associated with psychotic symptoms, nor did it have any buffering effects on the relationship between psychosis and quality of life. Religiousness had a significant, albeit modest, independent additive effect on quality of life, and it did not have any buffering effects on the four stressors that were significantly associated with quality of life. CONCLUSIONS: Religiousness may have a favorable impact on the quality of life of older adults with schizophrenia, and it must be considered along with other therapeutically important agents.

Validation of Brief Screening Tools for Mental Disorders Among New Zealand Prisoners [Articles] 1 Sep 2010

OBJECTIVE: This study aimed to validate brief intake screens for serious mental illnesses among New Zealand male prisoners. METHODS: A prospective survey of consecutively admitted male remanded and sentenced prisoners was conducted across two New Zealand sites. Participants completed the Brief Jail Mental Health Screen (BJMHS) and the English Mental Health Screen (EMHS) upon prison admission. The validation standard, the Mini International Neuropsychiatric Interview (MINI), was completed for all positive screens and a random selection of negative screens. RESULTS: A total of 1,292 brief screens and 530 MINI screens were completed. Fifty-one percent of the participants met MINI criteria for one of five targeted major mental disorders. In this study, the BJMHS performed with lower sensitivity, higher specificity, a lower false-positive rate, a significantly higher false-negative rate, and a much higher referral rate than in the validating U.S. study. And in this study the EMHS performed with lower sensitivity, less specificity, higher false-positive and false-negative rates, and a moderately higher overall referral rate than in the validating U.K. study. For the BJMHS and EMHS, the majority of false-negative cases involved a mood disorder and few involved psychosis. CONCLUSIONS: Although the BJMHS and EMHS did not perform well in terms of screening for MINI diagnoses, they appeared to be good at identifying a core group of prisoners who are psychotic and most likely to require urgent or semi-urgent intervention by mental health services. The most favorable clinical outcomes were achieved by defining a positive screen as one in which either the EMHS or the BJMHS criteria were fulfilled.

Staff and Consumer Perspectives on Defining Treatment Success and Failure in Assertive Community Treatment [Brief Reports] 1 Sep 2010

OBJECTIVE: Although assertive community treatment (ACT) has been consistently recognized as effective, there has been little research as to what constitutes success in ACT. The purpose of this study was to understand how ACT consumers and staff define treatment success and failure and to examine whether definitions varied between staff and consumers. METHODS: Investigators conducted semistructured interviews with 25 staff and 23 consumers from four ACT teams. RESULTS: Across perspectives, success and failure were most clearly related to consumer factors. Other themes included having basic needs met, being socially involved, and taking medications. Reduced hospitalizations were mentioned infrequently. Consumers were more likely than staff to identify the level or type of treatment as defining success and failure, whereas staff were more likely than consumers to discuss substance abuse when defining failure and improved symptoms when defining success. CONCLUSIONS: Success in ACT should be viewed more broadly than reduced hospitalizations and include domains such as social involvement.

Validating the Empowerment Scale With a Multisite Sample of Consumers of Mental Health Services [Brief Reports] 1 Sep 2010

OBJECTIVE: Empowerment is a key aspect of recovery and a common term in the mental health field, but there are few consistent definitions or validated measures of the construct. This study conducted psychometric testing on the Empowerment Scale, a widely used measure in the field. METHODS: As part of the Consumer-Operated Multi-Site study funded by the Substance Abuse and Mental Health Services Administration, consumers with a psychiatric disability were administered the Empowerment Scale along with several other scales to measure clinical status and psychosocial factors. RESULTS: Analyses produced five factors with acceptable fit statistics. The total scale demonstrated excellent reliability and validity. CONCLUSIONS: Analyses provide additional evidence that the total Empowerment Scale score is a reliable, valid measure; subscales of the scale appear less robust. Empowerment is considered an essential factor in recovery-oriented programs and systems, and the use of psychometrically sound measures such as the Empowerment Scale therefore may be useful to evaluators.

Short-Term Impact of Preferred Drug List Changes on Health Care Use and Medicaid Costs: Injectable Risperidone [Brief Reports] 1 Sep 2010

OBJECTIVE: This study assessed short-term effects of the removal of injectable risperidone long-acting therapy from the Florida Medicaid preferred drug list (PDL) in April 2006. METHODS: A difference-in-difference approach was used to contrast changes (60 days pre and post) in health care utilization and costs of Medicaid recipients who were receiving risperidone long-acting therapy when the policy was changed (N=247) and of a matched sample who received risperidone long-acting therapy in April 2005 (non-PDL, N=247). RESULTS: The policy change was associated with increased acute care events. Whereas acute care events declined for the non-PDL group, involuntary commitments and total acute care events increased for the PDL group, as did expenditures for crisis-related events. Medicaid pharmacy costs fell for both groups, but total expenditures did not decline significantly for the PDL group. CONCLUSIONS: The PDL restriction was associated with increased acute care events and did not reduce short-term Medicaid program expenditures.

Cognitive-Behavioral Therapy as an Adjunct to Second-Generation Antipsychotics in the Treatment of Schizophrenia [Brief Reports] 1 Sep 2010

OBJECTIVE: This study determined whether adding cognitive-behavioral therapy to treatment for outpatients with schizophrenia would be more effective than the use of second-generation antipsychotics alone. Thirty-three patients were randomly assigned to receive either second-generation antipsychotics alone (N=18) or second-generation antipsychotics plus cognitive-behavioral therapy (N=15). METHODS: All patients received pharmacotherapy from a single provider and in a predetermined standard manner. Psychopathology ratings were done at baseline, at the end of treatment (12 weeks) and three months after completion of treatment (24 weeks). RESULTS: Twenty-five (76%) patients completed baseline and 12-week evaluations, and 17 (68%) patients who finished treatment also completed evaluations at 24 weeks. At the end of treatment persons in the second-generation antipsychotics plus cognitive-behavioral therapy group were rated as having less severe delusions than patients in the group receiving second-generation antipsychotics only, and this difference was maintained three months after treatment ended. CONCLUSIONS: Adding cognitive-behavioral therapy may help with reducing the severity of delusions among patients with schizophrenia.

Pathways to Recovery, a Peer-Led Group Intervention [Frontline Reports] 1 Sep 2010

Recovery Is Up to You, a peer-run course [Frontline Reports] 1 Sep 2010

Sources of Bias in Guideline Development [Letters] 1 Sep 2010

Screening for Personality Disorders Among Chinese Prison Inmates [Letters] 1 Sep 2010

New Kaiser Commission Resources on Health Care Reform [News & Notes] 1 Sep 2010

News Briefs [News & Notes] 1 Sep 2010

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