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Substance abuse treatment, Health services, Managed care, Medicine, business.industry, business, Mental health treatment, Substance abuse, medicine.disease, Psychiatry, and medicine.medical_specialty

Psychiatry and Mental health, Brief Psychiatric Rating Scale, Medicine, business.industry, business, Public health, medicine.medical_specialty, Multivariate analysis, Schizophrenia, medicine.disease, Dual diagnosis, Substance abuse, Psychiatry, Severity of illness, and Social environment

Objective This study examined the relationships of substance abuse, use of community-based services, and symptom severity among rural and urban residents with schizophrenia in the six months after discharge from short-term inpatient care. Methods At baseline and six-month follow-up, symptom severity of 139 subjects was assessed using the Brief Psychiatric Rating Scale (BPRS), and substance abuse status was determined using the Structured Clinical Interview for DSM-III-R (SCID). Subjects' reports of mental health service use were confirmed by record review. Results Although, on average, BPRS scores indicated symptom improvement between baseline and follow-up, symptoms worsened for 27 percent of subjects. Multivariate analysis, adjusted for baseline symptom severity, indicated poorer outcomes for rural residents, substance abusers, and subjects who did not use community services. Symptoms of rural substance abusers who used no community services were worse at follow-up than those of any other subgroup. Nearly half of all subjects had less than monthly contact with community services. The greater likelihood of symptom worsening among rural residents was attributed to their less frequent use of community services. Conclusions The findings reinforce the importance of ensuring involvement in community-based services for individuals with comorbid schizophrenia and substance use disorders. Promotion of service use by persons with a dual diagnosis may be particularly critical to the well-being of rural residents with schizophrenia.

Psychiatry and Mental health, Metabolic syndrome, medicine.disease, medicine, Blood pressure, Public health, medicine.medical_specialty, Psychiatry, Epidemiology, business.industry, business, Dyslipidemia, Waist, Body mass index, Overweight, and medicine.symptom

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/m 2 ), 52% were obese (BMI ≥30.0 kg/m 2 ), 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 (

Psychiatry and Mental health, Gerontology, State hospital, Family medicine, medicine.medical_specialty, medicine, Payment, media_common.quotation_subject, media_common, Mental health, Health economy, Hospital admission, business.industry, business, Bed days, Public health, and Chart review

Objective; in 1990 the state of Arkansas shifted financial responsibility for state hospital services to community mental health centers; through a policy known as "bed buy-back," centers now authorize all state hospital admissions and prospectively purchase bed days for their patients. Characteristics of patients hospitalized before and after implementation of the policy were examined to determine how the policy affected hospital admission rates, types of patients admitted, and the amount of contact between CMHC and hospital staff about admitted patients, as well as how these elements were affected differently in rural and urban areas. Methods: Changes in the types of patients admitted over the 13 months before and 14 months after the change in financing were studied through retrospective chart review of 648 patients. Administrative data were used to examine changes in numbers of admissions for 30 months before and 26 months afterward. Data were analyzed by piecewise regression, leastsquares, and logisti...

Psychiatry and Mental health, Mental health, Public health, medicine.medical_specialty, medicine, Workforce, business.industry, business, Community health, Local community, General medical services, Psychiatry, Reimbursement, Referral, and Family medicine

Objective: This study provides national data on community mental health centers’ (CMHCs’) capacity to screen for and address their clients’ general medical conditions. Methods: A survey was distributed to members of the National Council for Community Behavioral Healthcare, the oldest and largest association of CMHCs. Results: Among the 181 CMHCs responding to the survey, more than two-thirds reported having protocols or procedures to screen for common medical problems (hypertension, obesity, dyslipidemia, and diabetes). However, only one-half could provide treatment or referral for those conditions, and less than one-third could provide general medical services on site. Barriers to providing general medical services included problems in reimbursement, workforce limitations, physical plant constraints (for example, lack of available space or equipment), and lack of options for referrals to local community medical providers. Conclusions: Although most CMHCs had the capacity to screen for common medical conditions, they reported a variety of barriers to providing medical care for those problems either on site or via referral. (Psychiatric Services 59:917–920, 2008)

Psychiatry and Mental health, Health care, business.industry, business, Gerontology, Mental health, Managed Competition, Mental illness, medicine.disease, medicine, Case management, Population, education.field_of_study, education, Purchasing, Public health, medicine.medical_specialty, and Nursing

Many concerns have been raised about the special problems of providing care for severely mentally ill persons in a reformed health care system based on managed competition. The authors describe what will likely be basic features of the reformed system and discuss potential problems in serving this population. The authors recommend the development of special mental health maintenance organizations (MHMOs) that would serve only persons with severe mental illness. The MHMO would emphasize case management in the community and would provide a fixed point of responsibility for clinical care of these patients. Two methods of reimbursing MHMOs are proposed. Each region's health insurance purchasing cooperative ( HIPC) could reimburse the MHMO on a capitated risk-adjusted basis. Alternatively, HIPCs could require the general health plan to operate or contract for MHMOs. In each case, the HIPC would provide quality-of-care oversight and assign a team to act as a gatekeeper for referrals to the MHMO.

Psychiatry and Mental health, Managed care, Mental health care, Medicine, business.industry, business, Psychotherapist, Mental health, Public health, medicine.medical_specialty, Claims data, Ambulatory, Pharmacotherapy, and Retrospective design

OBJECTIVE: This exploratory study examined utilization and costs among depressed patients in two treatment models—integrated treatment, in which psychotherapy and pharmacotherapy were provided by a psychiatrist, and split treatment, in which pharmacotherapy was provided by a psychiatrist and psychotherapy by a nonphysician psychotherapist. METHODS: A quasi-experimental retrospective design was used to compare claims data from a national managed mental health care organization for 191 patients in integrated treatment and 1,326 in split treatment. RESULTS: During the 18-month study, patients receiving integrated treatment used significantly fewer outpatient sessions and had significantly lower treatment costs, on average, than those in split treatment. Integrated treatment appeared to be associated with a pattern of utilization characterized by frequent treatment episodes in contrast to that of split treatment, which was characterized by more sessions with fewer breaks of 90 days or more. CONCLUSIONS: The r...

Psychiatry and Mental health, Schizophrenia, medicine.disease, medicine, Diagnosis of schizophrenia, Substance abuse, Comorbidity, Clinical psychology, Psychosis, Brief Psychiatric Rating Scale, Medical record, Alcohol abuse, Psychiatry, medicine.medical_specialty, business.industry, and business

Objective: The study examined the effect of medication noncompliance and substance abuse on symptoms of schizophrenia. Met!wds: Short-term inpatients with a diagnosis of schizophrenia were enrolled in a longitudinal outcomes study and continued to receive standard care after discharge. At baseline and six-month follow-up, Brief Psychiatric Rating Scale (BPRS) scores and data on subjects’ reported medication compliance, drug and alcohol abuse, usual living arrangements, and observed side effects were obtained. The number of outpatient contacts during the follow-up period was obtained from medical records. Relationships between the dependent variables-medication noncompliance and follow-up BPRS scores-and the independent variables were analyzed using logistic and linear regression models. Results: Medication noncompliance was significantly associated with substance abuse. Subjects who abused substances, had no outpatient contact, and were noncompliant with medication had significantly greater symptom severity than other groups. Conclusions: Substance abuse is strongly associated with medication noncompliance among patients with schizophrenia. The combination of substance abuse, medication noncompliance, and lack of outpatient contact appears to define a particularly high-risk group. (Psychiatric Services

Psychiatry and Mental health, Medicine, business.industry, business, Health economy, Salud mental, Private sector, Cost analysis, Public sector, Economic growth, Health services, and Mental health

Public Health, Environmental and Occupational Health, Health Policy, Physical therapy, medicine.medical_specialty, medicine, business.industry, business, Outcome measures, Managed care, Quality management system, Behavioral healthcare, Clinical Practice, Treatment outcome, and Interactive voice response

This study examined the use of outcome reports sent to clinicians by a managed behavioral healthcare organization to monitor patient progress and its relation to treatment outcome. Results showed that clinicians who reported using outcome information had patients who also reported greater improvement at 6 months from baseline. Improvement per session was greatest among patients whose clinicians reported reading the outcome report and using outcome measures in their clinical practice. Using baseline and ongoing measures to assess patient improvement can provide clinicians with feedback during treatment, which may lead to better clinical outcomes and enable quality management systems in managed care to flag high-risk cases and identify failure of adequate improvement.

Health Policy, Medicine, business.industry, business, Outpatient service, Managed care, Family medicine, medicine.medical_specialty, Public health, Health economics, Conditional logistic regression, Operations management, Provider type, Authorization, and Prior authorization

This study examines how preauthorization affects outpatient behavioral health utilization under managed care by comparing plans with similar benefits, but differing in the number of visits authorized. The authors compare plans primarily authorizing in increments of 5 visits to plans authorizing in increments of 10 visits. They analyze the likelihood of terminating outpatient service between the two groups using conditional logistic regression. Results suggest that patients whose treatment is authorized in increments of 5 sessions are nearly 3 times more likely to terminate treatment at exactly the fifth visit than if their treatment is authorized in increments of 10 sessions conditional on being in treatment until the 5th visit. The likelihood of termination peaks in both the 5- and 10-session authorization at the 10th visit, but the difference is not statistically significant. The authorization effect differs by provider type and is weaker among psychiatrists than among nonphysician providers.

Health Policy, Inpatient care, Antipsychotic, medicine.medical_treatment, medicine, Diagnosis of schizophrenia, Chlorpromazine, medicine.drug, Emergency medicine, medicine.medical_specialty, business.industry, business, Severity of illness, Schizophrenia, medicine.disease, Guideline, Veterans Affairs, and Psychiatry

Few studies have examined the variations among individual physicians in prescribing antipsychotics for schizophrenia. This study examined clinical practice variations in the route and dosage of antipsychotic medication prescribed for inpatients with schizophrenia by 11 different psychiatrists. The sample consisted of 130 patients with a DSM-III-R diagnosis of schizophrenia who had received inpatient care at a state hospital or Veterans Affairs medical center in the southeastern United States in 1992-1993. Mixed-effects regression models were developed to explore the influence of individual physicians and hospitals on route of antipsychotic administration (oral or depot) and daily antipsychotic dose, controlling for patient case-mix variables (age, race, sex, duration of illness, symptom severity, and substance-abuse diagnosis). The average daily antipsychotic dose was 1092 +/- 892 chlorpromazine mg equivalents. Almost half of the patients (48%) were prescribed doses above or below the range recommended by current practice guidelines. The proportion of patients prescribed depot antipsychotics was significantly different at the 2 hospitals, as was the antipsychotic dose prescribed at discharge. Individual physicians and patient characteristics were not significantly associated with prescribing practices. These data, which were obtained before clinical practice guidelines were widely disseminated, provide a benchmark against which to examine more current practice variations in antipsychotic prescribing. The results raise several questions about deviations from practice guidelines in the pharmacological treatment of schizophrenia. To adequately assess quality and inform and possibly further develop clinical practice guideline recommendations for schizophrenia, well-designed research studies conducted in routine clinical settings are needed.

General Medicine, Medicine, business.industry, business, Comorbidity, medicine.disease, Substance abuse, MEDLINE, Mental illness, Prevalence of mental disorders, Clinical psychology, Substance use, Psychiatry, and medicine.medical_specialty

Research on the prevalence, patterns, and course of substance use disorders in severe mental illness gives key insights into the complex interaction of substance use and mental disorder. Understanding the literature on comorbidity has implications for the design of clinical services and for the direction of future research in the field.

Health Policy, Medicine, business.industry, business, Nursing, Schizophrenia, medicine.disease, Longitudinal observation, Medical education, Mental health, Multidisciplinary approach, Data collection, Mentally ill, Clinical care, and MEDLINE

To advance effectiveness research in mental health, we need common, standardized, validated instruments that can be used easily in routine practice settings. The Schizophrenia Outcomes Module is a relatively brief, comprehensive instrumentfor monitoring and assessing the outcomes of treatment for schizophrenia in clinical care settings. The module was developed with the guidance of a multiinstitutional, multidisciplinary expert panel; the clinical and theoretical considerations that framed the expert panel's deliberations and determined the module's content and characteristics are described Initialfield testing of the instrument involved longitudinal observation of 100 individuals with schizophrenia over a 6-month period. To our knowledge, it is the only brief and easily administered instrument that encompasses the four major outcome domains defined by the National Institute of Mental Health's Plan for Research on the Severely Mentally Ill. As such, it is a promising toolfor effectiveness research in schizophrenia.