Feasibility of an Open Dialogue-Inspired Approach for Young Adults with Psychosis in a Public Hospital System.

The objective was to determine the feasibility of an Open Dialogue-inspired approach in a metropolitan, public hospital setting with predominately African American participants. Participants were ages 18-35, experienced psychosis within the past month, and involved at least one support person in their care. We evaluated domains of feasibility including implementation, adaptation, practicality, acceptability, and limited-efficacy. An organizational change model (Addressing Problems Through Organizational Change) facilitated implementation. Clinicians received three trainings and ongoing supervision. Network meetings were successfully implemented with good self-reported fidelity to principles of dialogic practice. Some adaptations (less frequent meetings and no home visits) were necessary. A subset of individuals completed research assessments over 12 months. Qualitative interviews with participants suggested the intervention was acceptable. Symptom and functional outcomes were preliminary but trended toward improvement. Implementation was feasible with relatively brief training, organizational change processes, and context-specific adaptations. Lessons learned can assist in planning a larger research study.

Building Bridges Between Evidence and Policy in Mental Health Services Research: Introducing the Policy Review Article Type.

Although it is widely accepted that patients do better when evidence-based health care practices are used, there is less acknowledgment of the positive outcomes associated with evidence-based policy making. To address the need for high-quality evidence to inform mental health policies, Psychiatric Services has recently launched a new article format: the Policy Review. This review type defines a specific policy-relevant issue affecting behavioral health systems, describes current knowledge and limitations, and discusses policy implications. Reviews can focus on mental health policies or examine how other health or social policies affect people with mental illness or substance use disorders. This brief overview of the need for a policy review article type describes differences between evidence-based policy making and practices and looks at research approaches focused on evidence-based policy making, as well as legislative and other efforts to support it. Broad guidelines for potential submissions are also provided.

Mental Health Policy in the Era of COVID-19.

The response to the global COVID-19 pandemic has important ramifications for mental health systems and the patients they serve. This article describes significant changes in mental health policy prompted by the COVID-19 crisis across five major areas: legislation, regulation, financing, accountability, and workforce development. Special considerations for mental health policy are discussed, including social determinants of health, innovative technologies, and research and evaluation. These extraordinary advances provide an unprecedented opportunity to evaluate the effects of mental health policies that may be adopted in the post-COVID-19 era in the United States.

Office Visits to Monitor Stimulant Medication Safety and Efficacy: Recommended Care.

The clinical guidance based on the research article, "Specific Components of Pediatricians' Medication-Related Care Predict Attention-Deficit/Hyperactivity Disorder Improvement," published in the June 2017 issue,1 might be premature. The authors, Epstein et al., suggest that "Physicians do not need to necessarily rely on office visits to monitor medication response and side effects in the week(s) after initially prescribing medication, but instead could use phone calls or email correspondence to check in with the family" (p. 489). However, this advice has the potential to be misinterpreted that phone or email contact is acceptable clinical practice to monitor stimulant medication safety and efficacy, especially during the maintenance phase. It also could be erroneously interpreted that phone or email contact is sufficient for follow-up care for children receiving medication treatment for attention-deficit/hyperactivity disorder (ADHD) for national quality measures.

When to recommend cognitive behavioral therapy.

Consider CBT for patients who you suspect have anxiety or trauma-related disorders. The benefits of this short-term, goal-oriented approach are detailed in this review and in the accompanying evidence-based table.

Recent trends in stimulant medication use among U.S. children.

OBJECTIVE: Stimulant medications, such as methylphenidate and amphetamines, are commonly prescribed to treat attention deficit hyperactivity disorder. Stimulant use increased fourfold from 1987 (0.6%) to 1996 (2.4%) among subjects 18-year-old and younger in the U.S. The aim of this study was to determine whether pediatric use of stimulants continued to rise during the period 1997-2002. METHOD: The Medical Expenditure Panel Survey (MEPS) database for the years 1997-2001 was analyzed. The MEPS is a yearly survey of a nationally representative sample of civilian, noninstitutionalized U.S. households, conducted by the U.S. Agency for Health Care Research and Quality. Previously reported estimates from the 1996 MEPS and the 1987 National Medical Expenditure Survey, the predecessor to MEPS, were also replicated to compare recent trends to changes between 1987 and 1996. RESULTS: The prevalence use of stimulants among subjects under 19 years of age was 2.7% (95% C.I. 2.3-3.1) in 1997 and 2.9% (95% C.I. 2.5-3.3) in 2002, with no statistically significant change during these 6 years. Likewise, when pooling data across years and comparing the rate in 1997-1998 (2.8%) with the rate in 2001-2002 (3.0%), no statistically significant changes emerged. Use was highest among 6-12 year olds (4.8% in 2002), as compared with 3.2% among 13-19 year olds and 0.3% among children under 6. An estimated 2.2 million (95% C.I. 1.9-2.6) children received stimulant medication in 2002 as compared to 2.0 million (95% C.I. 1.7-2.3) in 1997. CONCLUSIONS: The steep increase in the utilization of stimulants among children 18 years and younger that occurred over the 1987-1996 period attenuated in the following years through 2002, and has remained stable among very young children.

National estimates of antidepressant medication use among U.S. children, 1997-2002.

OBJECTIVE: A threefold increase in the use of antidepressants has been reported among children (18 years old and younger) between 1987 (0.3%) and 1996 (1.0%). The aim of this study was to determine whether pediatric use of antidepressants continued to rise at a national level during the period 1997-2002. METHOD: The Medical Expenditure Panel Survey (MEPS) database for the years 1997-2002 was analyzed. The MEPS is a yearly survey of a nationally representative sample of civilian, noninstitutionalized U.S. households, conducted by the U.S. Agency for Healthcare Research and Quality. Overall response rate ranged between 64% and 68%. RESULTS: An estimated 1.4 million (95% confidence interval [CI] 1.1-1.7) children received antidepressant medication in 2002 as compared to 0.9 million (95% CI 0.7-1.2) in 1997 (p = .01). The percentage of users increased from 1.3% (95% CI 0.9-1.6) in 1997 to 1.8% (95% CI 1.5-2.1) in 2002 (p < .01). Adolescent use (2.1% in 1997 versus 3.9% in 2002 (p < .001) accounted for the increase, with no change among children younger than 13 years. Also among adolescents, the use rate remained stable during the 2000-2002 period. The increase was caused by use of selective serotonin reuptake inhibitors and other newer antidepressants, whereas use of TCAs remained stable in adolescents (p = .84) and declined in prepubertal children (p = .04). Antidepressant use was similar among males and females and higher among whites than blacks and Hispanics. CONCLUSIONS: Nationwide, the use of selective serotonin reuptake inhibitor antidepressant medications continued to increase in adolescents in the late 1990s and until the year 2000, with no further increase through 2002, and remained stable in prepubertal children.

The impacts of mental health parity and managed care in one large employer group: a reexamination.

Although the impacts of carve-outs to managed behavioral health care organizations (MBHOs) and parity mandates on costs are largely settled in the literature, their impacts on access are less clear. Here we reexamine a study published by Samuel Zuvekas and colleagues in this journal, which found that the number of people receiving mental health/substance abuse treatment increased by almost 50 percent after the introduction of mental health parity and an MBHO. Using multivariate panel data methods, we now suggest that secular trends were largely responsible for this increase.

Spillover effects of benefit expansions and carve-outs on psychotropic medication use and costs.

This paper extends the previous literature examining the impacts of managed behavioral health care carve-outs and mental health parity mandates on mental health and substance abuse (MH/SA) specialty treatment use and costs by considering the effects on psychotropic prescription medication costs. We use multivariate panel data methods to remove underlying secular growth trends, driven by increased demand for improved MH/SA treatment related to pharmaceutical innovations. We find that psychotropic medication costs continued to increase after the introduction of a substantial benefit expansion and carve-out to a managed behavioral health organization (MBHO), offsetting large declines in inpatient specialty MH/SA costs. However, we find evidence that the MBHO may have restrained growth in prescription medication spending.

Approaches to multisite clinical trials: the National Institute of Mental Health perspective.

The Division of Services and Intervention Research of the National Institute of Mental Health (NIMH) utilizes a variety of methodologies and approaches in the development of its clinical trials program. In this article, we describe the need for large multisite trials; the mechanisms for addressing this need; and the various approaches that have been used. In the course of carrying out this initiative, we have created opportunities for the Institute and its trial investigators to receive advice and input from the field. We describe the role and function of the trial coordinating center and NIMH staff. We identify the first steps to be taken in the initiation of a trial and highlight the opportunity for ancillary studies. Finally, we enumerate some of the pitfalls of large clinical trials and discuss measures taken to anticipate and address them.