Assessing the Evidence Base for School-Based Promotion and Prevention Interventions: Introduction to the Series.

Schools are an important component in the mental health system of care for youths. Teachers and other school staff have unique opportunities to promote emotional wellness and prevent mental health conditions. Although numerous programs are available, identifying evidence-based and effective options is a significant challenge. This introduction lays out the rationale and methodology of the Assessing the Evidence Base (AEB) Series, a collection of systematic reviews of school-based mental health promotion and prevention approaches recommended by the National Academies of Sciences, Engineering, and Medicine for students in kindergarten through grade 12. Authors of the current AEB Series used the rating criteria derived from the 2014 AEB Series, which provided systematic reviews of a wide spectrum of interventions for mental and substance use disorders. Like its predecessor, the current series upholds a high standard of scientific rigor while ensuring that the information is easily accessible to various stakeholders in education, behavioral health, and communities. It describes the universal features included in each systematic review, such as a rating of the level of evidence for interventions, intervention program components, identification of interventions that have yielded positive outcomes for students from underserved populations, and a review of cost data. The AEB systematic reviews will serve as an important tool for decision makers involved in managing limited resources for various programs in school-based mental health services by synthesizing large bodies of research for use by leaders in education and behavioral health.

Helping People Denied Disability Benefits for a Mental Health Impairment: The Supported Employment Demonstration.

Social Security Administration demonstration projects that are intended to help people receiving disability benefits have increased employment but not the number of exits from disability programs. The Supported Employment Demonstration (SED) is a randomized controlled trial (RCT) of services for individuals with mental health problems before they enter disability programs. The SED aims to provide health, employment, and other support services that help them become self-sufficient and avoid entering disability programs. The target population is people who have been denied Social Security disability benefits for a presumed psychiatric impairment. Thirty community-based programs across the United States serve as treatment sites; inclusion in the SED was based on the existence of high-fidelity employment programs that use the individual placement and support model, the ability to implement team-based care, and the willingness to participate in a three-armed RCT. In the SED trial, one-third of 2,960 participants receive services as usual, one-third receive services from a multidisciplinary team that includes integrated supported employment, and one-third receive services from a similar team that also includes a nurse care coordinator for medication management support and medical care. The goals of the study are to help people find employment, attain better health, and delay or avoid disability program entry. This article introduces the SED.

Mental Health Parity and Addiction Equity Act and the Use of Outpatient Behavioral Health Services in the United States, 2005-2016.

Objectives. To assess the impact of the 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) on mental and substance use disorder services in the private, large group employer-sponsored insurance market in the United States. Methods. We analyzed data from the IBM MarketScan Commercial Database from January 2005 through September 2015 by using population-level interrupted time series regressions to determine whether parity implementation was associated with utilization and spending outcomes. Results. MHPAEA had significant positive associations with utilization of mental and substance use disorder outpatient services. A spending decomposition analysis indicated that increases in utilization were the primary drivers of increases in spending associated with MHPAEA. Analyses of opioid use disorder and nonopioid substance use disorder services found that associations with utilization and spending were not attributable only to increases in treatment of opioid use disorder. Conclusions. MHPAEA is positively associated with utilization of outpatient mental and substance use disorder services for Americans covered by large group employer-sponsored insurance. Public Health Implications. These trends continued over the 5-year post-MHPAEA period, underscoring the long-term relationship between this policy change and utilization of behavioral health services.

Barriers Faced by Physicians in Screening for Substance Use Disorders Among Adolescents.

OBJECTIVE: This study identifies key barriers faced by primary care providers (PCP) in implementation of screening, brief intervention, and referral to treatment (SBIRT) services for substance use disorders among adolescents. METHODS: The authors used mixed methods, including 12 key informant interviews and a survey with 75 PCPs, to identify key barriers to PCP implementation of SBIRT services. RESULTS: Time constraints, challenges related to parental involvement, a perceived lack of effectiveness of brief intervention services, and lack of training in providing brief intervention were barriers to screening and brief intervention. Referral to treatment was frequently perceived as a challenge. Increased reimbursement and dedicated resources were important interventions for improving screening rates. CONCLUSIONS: Increased reimbursement could support workflow enhancements to improve the consistency of SBIRT procedures and alleviate time constraints. Consistent SBIRT applications for all adolescents could also be supported by increasing PCP training in brief intervention.

Thiol disulphide homeostasis in patients with acute myocardial infarction (AMI).

OBJECTIVE: To investigate novel oxidative stress marker thiol disulphide homeostasis in patients with acute myocardial infarction.. METHODS: The case-control study was conducted at Yildirim Beyazit University, Ankara, Turkey, between October 26, 2015 and January 26, 2016. It comprised patients of ST elevation myocardial infarction, and healthy individuals. Troponin levels, native thiol, total thiol, and disulphide were compared among the groups. Results: Of the 128 subjects, 98(76.5%) were patients and 30(23.43%) were controls. Disulphide levels were lower in the patients compared to the controls (p<0.001).As troponin levels increased, native thiol, total thiol and disulphide levels in patients decreased (p<0.05). RESULTS: Of the 128 subjects, 98(76.5%) were patients and 30(23.43%) were controls. Disulphide levels were lower in the patients compared to the controls (p<0.001).As troponin levels increased, native thiol, total thiol and disulphide levels in patients decreased (p<0.05). CONCLUSIONS: Native thiol and total thiol levels may be used as a novel oxidative stres marker in patients with acute myocardial infarction.

Federal Policies and Programs to Expand Employment Services Among Individuals with Serious Mental Illnesses.

Previous studies suggest that providing employment services to individuals with serious mental illnesses can help them obtain competitive, real-world employment. However, these services are still not easily accessible to this population. This paper provides a brief summary of recent federal initiatives that may influence widespread implementation of employment services. While there is an increasing recognition of the need to remove barriers and provide supported employment services to individuals with mental illnesses, a wide-spread coordination across Federal polices, financing and regulatory changes are necessary to promote measurable and lasting effects on the broad availability of employment services among this population.

"Big Eight" Recommendations for Improving the Effectiveness of the U.S. Behavioral Health Care System.

The purpose of this Open Forum is to highlight strategies that can be implemented by federal health care policy makers to improve the delivery of effective behavioral health care services in the public and private sectors. The recommendations can be accomplished by using existing funds or authorities allocated to federal agencies dealing with the behavioral health system. These recommendations do not require new or additional funding and focus on strategies with a track record for success. The strategies described require relatively small changes but have the potential for big impacts.

Characteristics of Hospital Emergency Room Visits for Mental and Substance Use Disorders.

OBJECTIVE: This study compared characteristics of visits to emergency rooms (ERs) for mental and substance use disorders and for physical health conditions to establish a baseline against which to measure changes after full implementation of the Affordable Care Act (ACA) and parity legislation. METHODS: The retrospective, cross-sectional analysis fit a logistic regression model to pooled data comprising 193,526 observations from National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2005 to 2011. RESULTS: ER visits for mental or substance use disorders increased from 27.9 per 1,000 ER visits in 2005 to 35.1 in 2011. Homeless persons and nursing home residents had the highest rates of such visits-173.7 and 95.2 per 1,000 ER visits, respectively, in 2011. CONCLUSIONS: Understanding differences in profiles of ER visits on the basis of the reason for the visit can inform the design of more cost-effective policies to guide ER intake, after further implementation of the ACA and parity legislation.

Policy Implications of the Mental Health Treatment Study.

The Social Security Administration's Mental Health Treatment Study (MHTS) produced positive mental health, employment, and quality of life outcomes for people on Social Security Disability Insurance (SSDI). The investigators discuss major policy implications. First, because integrated, evidence-based mental health and vocational services produced clinical and societal benefits, the authors recommend further service implementation for this population. Second, because provision of these services did not reduce SSDI rolls, the authors recommend future research on prevention (helping people avoid needing SSDI) rather than rehabilitation (helping beneficiaries leave SSDI). Third, because integrating mental health, vocational, and general medical services was extremely difficult, the authors recommend a multifaceted approach that includes streamlined funding and infrastructure for training and service integration. Fourth, because insurance coverage for people with disabilities during the MHTS (pre-Affordable Care Act) was chaotic, the authors recommend that financing strategies emphasize functional-not just traditional clinical-outcomes.

Individual Placement And Support Services Boost Employment For People With Serious Mental Illnesses, But Funding Is Lacking.

The majority of people with serious mental illnesses want to work. Individual placement and support services, an evidence-based supported employment intervention, enables about 60 percent of people with serious mental illnesses who receive the services to gain competitive employment and improve their lives, but the approach does not lead to fewer people on government-funded disability rolls. Yet individual placement and support employment services are still unavailable to a large majority of people with serious mental illnesses in the United States. Disability policies and lack of a simple funding mechanism remain the chief barriers. A recent federal emphasis on early-intervention programs may increase access to employment services for people with early psychosis, but whether these interventions will prevent disability over time is unknown.

Spontaneous rapid resolution of acute subdural hematoma in children.

BACKGROUND: Spontaneous rapid resolution of acute subdural hematoma developing secondary to trauma has been reported in the literature, yet it is very rare in pediatric population. The aim of the present review is to analyze mechanisms, characteristics, and outcomes of pediatric acute subdural hematoma cases with spontaneous rapid resolution in conjunction with an exemplary case of ours. CASE DESCRIPTION: A 3-year-old boy was admitted to our emergency department following mild head trauma secondary to a fall from 2 m. He was alert and has a GCS of 15. He had no motor or sensorial deficit on neurological examination. On the emergent brain computed tomography image, an acute subdural hematoma over left frontoparietal lobe was observed. There was a midline shift of 8.3 mm and the width of the hematoma at the thickest portion was 11.2 mm. Surgery was postponed with a close neurological follow-up of the patient in pediatric intensive care unit, due to his well neurological status without any increased ICP findings. On the fourth hour follow-up head CT image, amount of midline shift and hematoma thickness were observed to have regressed dramatically. At the second week, the hematoma resorbed totally with only conservative approach, and he was discharged to home in well status. DISCUSSION AND CONCLUSION: Analysis of 12 pediatric patients revealed a mean and median ages of 6.87 and 3.9 years, respectively (range = 8 months-18 years). Causes for ASH development were fall, traffic accident, struggle, and child abuse. Main clinical presentations were with depressed sensorium, coma, stupor, drowsiness, headache, motor weakness, lethargy, and seizure. Close follow-up with conservative treatment should be mode of approach in pediatric patients with ASH, if neurological and radiological findings are favorable. However, if patients' neurological status deteriorates after admission to hospital, surgery should be conveyed with no further delay.

Increasing earnings of social security disability income beneficiaries with serious mental disorder.

BACKGROUND: Persons with severe and persistent mental disorders (SPMD) have extremely low earnings levels and account for 29.1 percent of all U.S. Social Security Disability Income (SSDI) disabled worker beneficiaries under age 50. Social insurance and disability policy experts pointed to several factors that may contribute to this situation, including disincentives and obstacles in the SSDI program, as well as lack of access to evidence-based behavioral-health interventions. In response, the Social Security Administration (SSA) funded the Mental Health Treatment Study (MHTS) demonstration that included 2,238 beneficiaries of SSDI whose primary reason for disability is SPMD. The demonstration, implemented in 23 different localities, consisted of two evidence-based services (individual placement and support supported employment (IPS-SE), systematic medication management (SMM)), and provision or coverage of additional behavioral-health services (OBH). STUDY AIMS: This study focused on estimating MHTS intervention effects on earnings in the intervention period (two-years). The main outcome variable was self-reported average monthly earnings. METHODS: Subjects were randomly assigned to intervention or control groups. Data were drawn from the baseline survey, seven follow-up quarterly surveys, a final follow-up survey, and SSA administrative data. In all surveys, respondents were asked about earnings prior to the interview. Dependent variables were average past-30-days earnings reported in all follow-up surveys, similar averages for the first four follow-ups and for the last four follow-ups, fraction of surveys with prior earnings above SSA's substantial gainful activity (SGA) threshold, and final-follow-up earnings for the past 90 days. Regression analyses compared earnings of intervention vs. control group subjects. Covariates included baseline values of: (i) beneficiary demographic and social characteristics; (ii) beneficiary physical and mental health indicators; (iii) beneficiary recipiency history; (iv) beneficiary pre-recruitment and baseline earnings; and (v) local labor-market unemployment rates. RESULTS: Results show significant positive MHTS earnings impacts. Estimated annual increases of earnings range from USD791 (based on the 2-year average) to USD1,131 (based on the final quarter of Year 2). Effects on the fraction of quarters with earnings exceeding SGA are positive and significant but very small in magnitude. DISCUSSION: The consistent increase in earnings impacts over the study period suggests the possibility of even larger impacts with longer-term interventions. The moderate size of the intervention impacts may partly be explained by a study population that already had an average of 9 years on SSDI, and whose labor-supply decisions continued to be affected by concerns about possible loss of benefits. Limitations are that (i) earnings effects of specific intervention components cannot be estimated since all treatment subjects received the same package of services, and (ii) study results may not generalize to the majority of the beneficiary population due to selection effects in beneficiaries' participation decisions. IMPLICATIONS: Replication of the MHTS on a broader scale should show similar positive earnings impacts for a substantial number of beneficiaries with characteristics similar to the study population. Future studies should consider reducing policy barriers to labor supply of persons with SPMD. Future studies should consider longer-term interventions, or at least measuring impacts for follow-up periods greater than two years.

Do not turn out the lights on the public mental health system when the ACA is fully implemented.

When all of the insurance and health care reforms of the ACA are fully implemented, some public financing needs for behavioral health services will remain. This commentary outlines a number of the residual functions of the public mental health system in an ACA world, and it identifies opportunities for expansions of service areas not covered by traditional insurance or the health delivery reforms for behavioral health services within the scope of the ACA.

Assisting Social Security Disability Insurance beneficiaries with schizophrenia, bipolar disorder, or major depression in returning to work.

OBJECTIVE: People with psychiatric impairments (primarily schizophrenia or a mood disorder) are the largest and fastest-growing group of Social Security Disability Insurance (SSDI) beneficiaries. The authors investigated whether evidence-based supported employment and mental health treatments can improve vocational and mental health recovery for this population. METHOD: Using a randomized controlled trial design, the authors tested a multifaceted intervention: team-based supported employment, systematic medication management, and other behavioral health services, along with elimination of barriers by providing complete health insurance coverage (with no out-of-pocket expenses) and suspending disability reviews. The control group received usual services. Paid employment was the primary outcome measure, and overall mental health and quality of life were secondary outcome measures. RESULTS: Overall, 2,059 SSDI beneficiaries with schizophrenia, bipolar disorder, or depression in 23 cities participated in the 2-year intervention. The teams implemented the intervention package with acceptable fidelity. The intervention group experienced more paid employment (60.3% compared with 40.2%) and reported better mental health and quality of life than the control group. CONCLUSIONS: Implementation of the complex intervention in routine mental health treatment settings was feasible, and the intervention was effective in assisting individuals disabled by schizophrenia or depression to return to work and improve their mental health and quality of life.

Economic grand rounds: financing first-episode psychosis services in the United States.

Adequate financing is essential to implementing services for individuals experiencing a first episode of a psychotic illness. Recovery After an Initial Schizophrenia Episode (RAISE), a project sponsored by the National Institute of Mental Health, is providing a practical test of the implementation and effectiveness of first-episode services in real-world settings. This column describes approaches to financing early intervention services that are being used at five of 18 U.S. sites participating in a clinical trial of a team-based, multielement RAISE intervention. The authors also describe new options for financing that will become available as the Affordable Care Act (ACA) is implemented more fully. The ACA will rationalize coverage of first-episode services, but the all-important Medicaid provisions will also require individual state action to implement services optimally.

Implications of Middle School Behavior Problems for High School Graduation and Employment Outcomes of Young Adults: Estimation of a Recursive Model.

The potentially serious adverse impacts of behavior problems during adolescence on employment outcomes in adulthood provide a key economic rationale for early intervention programs. However, the extent to which lower educational attainment accounts for the total impact of adolescent behavior problems on later employment remains unclear As an initial step in exploring this issue, we specify and estimate a recursive bivariate probit model that 1) relates middle school behavior problems to high school graduation and 2) models later employment in young adulthood as a function of these behavior problems and of high school graduation. Our model thus allows for both a direct effect of behavior problems on later employment as well as an indirect effect that operates via graduation from high school. Our empirical results, based on analysis of data from the NELS, suggest that the direct effects of externalizing behavior problems on later employment are not significant but that these problems have important indirect effects operating through high school graduation.

Depression and the onset of chronic illness in older adults: a 12-year prospective study.

The relationship between depression and development of chronic illness among older adults is not well understood. This study uses data from the Health and Retirement Study to evaluate the relationship between depression at baseline and new onset of chronic illnesses including cancer, heart problems, arthritis, and diabetes. Analysis controlling for demographics (age, gender, race, education), health risk indicators (BMI and smoking), functional limitations (gross motor index, health limitations for work), and income show that working-age older people (ages 50-62) with depression at baseline are at significantly higher risk to develop diabetes, heart problems, and arthritis during the 12-year follow-up. No significant association was found between depression and cancer. Prevention efforts aimed at chronic illnesses among the elderly should recognize the mind-body interaction and focus on preventing or alleviating depression.

Dysphagia due to diffuse idiopathic skeletal hyperostosis of the cervical spine.

Diffuse idiopathic skeletal hyperostosis (DISH) or Forestier's disease is a common disorder of unknown etiology that is characterized by ossification of the anterior longitudinal ligament of the spine and various extra-spinal ligaments. We present the case of a 54-year-old woman with progressive dysphagia due to DISH of the cervical spine, which is a relatively rare pathology in neurosurgical practice. The cervical osteophytes extending from C2 to C4 and external compression of the pharyngoesophageal segment by the large osteophytes were demonstrated by X-ray, magnetic resonance imaging, and computed tomography. Surgical removal of the large osteophytes and a shortterm nonsteroidal anti-inflammatory drug regimen led to the resolution of dysphagia. The clinical manifestations, diagnosis, and treatment of this unusual condition are discussed.

Enhancing the net benefits of disseminating efficacious prevention programs: a note on target efficiency with illustrative examples.

We consider the implementation, in a non-research setting, of a new prevention program that has previously been evaluated in a randomized trial. When the target population for the implementation is heterogeneous, the overall net benefits of the implementation may differ substantially from those reported in the economic evaluation of the randomized trial, and from those that would be realized if the program were implemented within a selected subgroup of the target population. This note illustrates a simple and practical approach to targeting that can combine risk-factor results from the literature with the overall cost-benefit results from the program's randomized trial to maximize the expected net benefit of implementing the program in a heterogeneous population.