Planning Patient-Centered Health Homes for Medicaid Psychiatric Patients at Greatest Risk for Intensive Service Use.

This study identified characteristics of Medicaid psychiatric patients at risk of hospitalizations and emergency department (ED) visits to identify their service delivery needs. A total of 4,866 psychiatrists were randomly selected from the AMA Physician Masterfile; 62 % responded, 32 % met eligibility criteria and reported on 1,625 Medicaid patients. Patients with schizophrenia, substance use disorders, suicidal and violent ideation/behavior, and psychotic, substance use, or manic symptoms were at high risk for intensive service use, along with homeless and incarcerated patients. Patients with schizophrenia or psychotic symptoms represented 37 % of patients, but used 73 % of all hospital days and 61 % of all ED visits. Patients with substance use problems comprised 21 % of patients, but used nearly half of all ED visits. Our findings highlight opportunities to enhance treatments and interventions, and inform the development of patient-centered health homes to address the needs of patients at high risk for intensive service use.

APIRE Practice Research Network: accomplishments, challenges, and lessons learned.

The Practice Research Network (PRN) was established in 1993 to bridge the gap between the science base and the clinical practice of psychiatry by expanding the generalizability of findings and involving clinicians in the development and conduct of research. It began as a nationwide network of psychiatrists and has evolved to conduct large-scale, clinical and policy research studies using randomly selected samples of psychiatrists from the AMA Physician Masterfile. This paper provides an overview of major PRN initiatives and the impact of these studies. It describes the benefits to clinicians of participating in PRN research, as well as strategies developed to address key challenges.

Expanding mental health services in low- and middle-income countries: A task-shifting framework for delivery of comprehensive, collaborative, and community-based care.

This paper proposes a framework for comprehensive, collaborative, and community-based care (C4) for accessible mental health services in low-resource settings. Because mental health conditions have many causes, this framework includes social, public health, wellness and clinical services. It accommodates integration of stand-alone mental health programs with health and non-health community-based services. It addresses gaps in previous models including lack of community-based psychotherapeutic and social services, difficulty in addressing comorbidity of mental and physical conditions, and how workers interact with respect to referral and coordination of care. The framework is based on task-shifting of services to non-specialized workers. While the framework draws on the World Health Organization's Mental Health Gap Action Program and other global mental health models, there are important differences. The C4 Framework delineates types of workers based on their skills. Separate workers focus on: basic psychoeducation and information sharing; community-level, evidence-based psychotherapeutic counseling; and primary medical care and more advanced, specialized mental health services for more severe or complex cases. This paper is intended for individuals, organizations and governments interested in implementing mental health services. The primary aim is to provide a framework for the provision of widely accessible mental health care and services.

Axis IV psychosocial problems among patients with psychotic or mood disorders with a cannabis use disorder comorbidity.

Among 1,610 patients with psychotic or mood disorders in routine psychiatric practice, odds ratios (crude and adjusted for age, education, gender, and race) quantified associations between the presence of comorbid cannabis abuse/dependence and seven psychosocial problems. Results revealed a higher prevalence of five of seven Axis IV psychosocial problems among patients who had a psychotic or mood disorder and a comorbid cannabis use disorder. The results underscore the need for careful screening and treatment of comorbid cannabis abuse/dependence among patients with psychotic or mood disorders given the prominent associated psychosocial impairments in this population.

Genetic analysis of the regulation of type IV pilus function by the Chp chemosensory system of Pseudomonas aeruginosa.

The virulence of the opportunistic pathogen Pseudomonas aeruginosa involves the coordinate expression of many virulence factors, including type IV pili, which are required for colonization of host tissues and for twitching motility. Type IV pilus function is controlled in part by the Chp chemosensory system, which includes a histidine kinase, ChpA, and two CheY-like response regulators, PilG and PilH. How the Chp components interface with the type IV pilus motor proteins PilB, PilT, and PilU is unknown. We present genetic evidence confirming the role of ChpA, PilG, and PilB in the regulation of pilus extension and the role of PilH and PilT in regulating pilus retraction. Using informative double and triple mutants, we show that (i) ChpA, PilG, and PilB function upstream of PilH, PilT, and PilU; (ii) that PilH enhances PilT function; and (iii) that PilT and PilB retain some activity in the absence of signaling input from components of the Chp system. By site-directed mutagenesis, we demonstrate that the histidine kinase domain of ChpA and the phosphoacceptor sites of both PilG and PilH are required for type IV pilus function, suggesting that they form a phosphorelay system important in the regulation of pilus extension and retraction. Finally, we present evidence suggesting that pilA transcription is regulated by intracellular PilA levels. We show that PilA is a negative regulator of pilA transcription in P. aeruginosa and that the Chp system functionally regulates pilA transcription by controlling PilA import and export.

Conserved and variable functions of the sigmaE stress response in related genomes.

Bacteria often cope with environmental stress by inducing alternative sigma (sigma) factors, which direct RNA polymerase to specific promoters, thereby inducing a set of genes called a regulon to combat the stress. To understand the conserved and organism-specific functions of each sigma, it is necessary to be able to predict their promoters, so that their regulons can be followed across species. However, the variability of promoter sequences and motif spacing makes their prediction difficult. We developed and validated an accurate promoter prediction model for Escherichia coli sigmaE, which enabled us to predict a total of 89 unique sigmaE-controlled transcription units in E. coli K-12 and eight related genomes. SigmaE controls the envelope stress response in E. coli K-12. The portion of the regulon conserved across genomes is functionally coherent, ensuring the synthesis, assembly, and homeostasis of lipopolysaccharide and outer membrane porins, the key constituents of the outer membrane of Gram-negative bacteria. The larger variable portion is predicted to perform pathogenesis-associated functions, suggesting that sigmaE provides organism-specific functions necessary for optimal host interaction. The success of our promoter prediction model for sigmaE suggests that it will be applicable for the prediction of promoter elements for many alternative sigma factors.

Use of depot antipsychotic medications for medication nonadherence in schizophrenia.

OBJECTIVES: To describe factors associated with initiation of depot antipsychotic medications in psychiatric outpatients with schizophrenia and recent medication nonadherence. METHODS: A national sample of psychiatrists reported on adult outpatients with schizophrenia who were nonadherent with oral antipsychotic medications in the last year. RESULTS: In total, 17.6% of psychiatrists initiated depot antipsychotic injections. Initiation was significantly and positively associated with public insurance, prior inpatient admission, proportion of time nonadherent, average or above average intellectual functioning, and living in a mental health residence. Use was inversely associated with using second-generation antipsychotics and other oral psychotropic medications prior to medication nonadherence. Psychiatrists who were male, nonwhite, and more optimistic about managing nonadherence were more likely to initiate depot injections. CONCLUSIONS: Initiation of depot injections is a joint function of patient, physician, treatment, and setting factors. Use of long-acting preparations in this population is uncommon despite clinical recommendations urging their use.

Psychiatric opinion and antipsychotic selection in the management of schizophrenia.

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.

Medicare Part D prescription drug benefits and administrative burden in the care of dually eligible psychiatric patients.

OBJECTIVE: With implementation of Medicare Part D, concerns were raised that patients with severe mental illness who were dually eligible for both Medicaid and Medicare benefits would be at clinical risk. In addition to concerns about medication access and continuity, there were concerns about administrative burden for physicians and their staffs. This study aimed to quantify the amount of administrative burden for psychiatrists and their staff related to Medicare Part D prescription drug plan administration in a national sample of dually eligible psychiatric patients and to identify factors associated with increased burden. METHODS: A total of 5,833 psychiatrists were randomly selected from the American Medical Association's Physicians Masterfile. Responses were obtained from 64% (N=3,247) with a mailed survey using practice-based survey research methods during the first four months of Medicare Part D implementation (January to April 2006); 1,183 psychiatrists met eligibility requirements. RESULTS: Psychiatrists and their staff spent 45 minutes in administrative tasks for every one hour of direct patient care for dually eligible patients. Drug plan features, including prior authorization and preferred drug formularies, and medication access problems were associated with increased administrative time. CONCLUSIONS: Results of this study indicate several drug plan features and medication access problems related to Part D implementation were associated with significant increases in administrative burden for psychiatrists and their staff, which may result in less time for direct patient care. Given the vulnerability of this high-risk population, this increased administrative burden may pose a significant risk to the overall quality of care for psychiatric patients.

Family contact and the management of medication non-adherence in schizophrenia.

We compare psychiatric management of antipsychotic non-adherence among schizophrenia outpatients with high and low levels of family contact. A national survey was conducted among a random sample of psychiatrists treating schizophrenia, providing data on 310 patients. Patients were stratified by level of family contact. Psychiatrists were more likely to use family interventions to manage non-adherence among patients with high family contact. Psychiatrists were significantly more likely to change antipsychotic dosing in patients with high family contact, though less likely to start depot antipsychotic medications. Family interventions appear to be commonly used in the psychiatric management of medication non-adherence in schizophrenia.

Medication access and continuity: the experiences of dual-eligible psychiatric patients during the first 4 months of the Medicare prescription drug benefit.

OBJECTIVE: This study attempted to systematically assess the experiences of Medicare and Medicaid "dual-eligible" psychiatric patients, including evaluating patients' access to medications and the administrative functioning of the program, during the first 4 months of the Medicare Part D prescription drug benefit. METHOD: Psychiatrists (N=5,833) were randomly selected from the American Medical Association's Physicians Masterfile. After exclusion of those not practicing and with undeliverable addresses, 64% responded; 35% met study eligibility criteria of treating at least one dual-eligible patient during their last typical workweek and reported clinically detailed information on one systematically selected patient. RESULTS: A total of 53.4% had at least one medication access problem to report between Jan. 1 and April 30, 2006. Although 9.7% experienced improved medication access, 22.3% discontinued or temporarily stopped taking medication because of prescription drug coverage or management issues, and 18.3% were previously stable but were required to switch medications. Among those with medication access problems, 27.3% experienced a significant adverse clinical event; 19.8% had an emergency room visit. Most drug plan features studied, including preferred drug/formulary lists, prior authorization, medication dosing/number limits, "fail-first" protocols, and requirements to switch to generics, were associated with significantly higher rates of medication access problems. CONCLUSIONS: The findings indicate consequential medication access problems for psychiatric patients during the implementation of Medicare Part D. Although Centers for Medicare and Medicaid Services policies were enacted to ensure access to protected classes of psychopharmacologic medications, the high rates of medication access problems observed indicate further refinement of these policies is needed.

Adding or switching antipsychotic medications in treatment-refractory schizophrenia.

OBJECTIVE: This study compared patients with schizophrenia whose antipsychotic medications were switched to manage treatment-resistant positive psychotic symptoms with those for whom another antipsychotic was added. Psychiatrists' characteristics and perceptions of effectiveness of the medication change on clinical outcomes were also reported. METHODS: Psychiatrists participating in a nationally representative mailed survey (N=209) reported on the clinical features, management, and response to the change in antipsychotic medication (added versus switched) of one adult patient with treatment-refractory schizophrenia under their care for at least one year. RESULTS: Thirty-three percent of patients were treated with an added antipsychotic medication. Compared with patients whose antipsychotic medications were switched, those with an added antipsychotic medication were more likely to be female, to have received care from the same psychiatrist for more than two years, and to have been recently prescribed an antidepressant. Compared with psychiatrists who switched antipsychotic prescriptions, those who added an antipsychotic reported that the change was less likely to reduce positive symptoms, improve functioning, and prevent hospitalization. Psychiatrists who added rather than switched antipsychotics reported more frequent attendance at educational programs sponsored by a pharmaceutical company. CONCLUSIONS: Consistent with other lines of research and practice guideline recommendations, psychiatrists perceive antipsychotic polypharmacy to be a generally ineffective strategy for treatment-resistant positive psychotic symptoms. In light of these findings, efforts to identify and implement more effective evidence-based pharmacologic approaches should be undertaken.

Issues in the registration of clinical trials.

Public concerns about the perils associated with incomplete or delayed reporting of results from clinical trials has heightened interest in trial registries and results databases. Here we review the current status of trial registration efforts and the challenges in developing a comprehensive system of trial registration and reporting of results. ClinicalTrials.gov, the largest trial registry with 36 249 trials from approximately 140 countries, has procedures in place to help ensure that records are valid and informative. Key challenges include the need to minimize inadvertent duplicate registrations, to ensure that interventions have unambiguous names, and to have a search engine that identifies all trials that meet a user's specifications. Recent policy initiatives have called for the development of a database of trial results. Several issues confound the implementation of such a database, including the lack of an accepted format or process for providing summaries of trial results to the public and concerns about disseminating data in the absence of independent scientific review.

Availability of Network Psychiatrists Among the Largest Health Insurance Carriers in Washington, D.C.

OBJECTIVE: Lack of access to mental health treatment remains a significant problem in the United States, even after implementation of mental health parity legislation. This study examined availability of psychiatrists listed in insurance carrier network provider databases in the Washington, D.C., area. METHODS: Contact information was obtained for 1,184 psychiatrists listed in online directories for three of the largest insurance carriers serving the Washington, D.C., area. The "mystery shopper" method was used to assess the accuracy of listed contact information, new outpatient appointment availability, and average wait times for 50 psychiatrists randomly selected from each insurance directory. RESULTS: Most (77%) physicians were successfully contacted, meaning that someone answered the phone or returned a voice mail message, and 51% of the psychiatrists had working telephone numbers verified to be correct. Fifteen percent of the psychiatrists were accepting new outpatients with the target insurance, with average wait times of 19 days; only 7% were able to schedule an appointment within two weeks. CONCLUSIONS: Inaccuracy of insurance provider directories significantly affected the ability of patients to obtain timely mental care.

Awareness of illness and nonadherence to antipsychotic medications among persons with schizophrenia.

OBJECTIVE: The purpose of this study was to assess the effects of patients' awareness of their illness on the clinical presentation, management, and course of nonadherence to antipsychotic medications among patients with schizophrenia. METHODS: A national survey was conducted of psychiatrists who were treating patients with schizophrenia. The survey was sent to 771 psychiatrists, of whom 534 responded, for a response rate of 69 percent. The psychiatrists were asked to report on presentation, management, and course for one adult patient with schizophrenia who had been under their care for at least one year and who had been nonadherent to oral antipsychotics at some point in the past year. Patients who were aware that they had a mental illness were compared with those who were not aware. RESULTS: Of the 534 respondent psychiatrists, 310 reported on an eligible patient, and 300 of these patients were classified by illness awareness. Ninety-seven patients, or 32 percent, were not aware that they had a mental illness. These patients who lacked awareness had significantly longer episodes of antipsychotic nonadherence, were more likely to completely cease taking the antipsychotic medication, were more likely to have severe positive symptoms, and were more likely to be psychiatrically hospitalized after nonadherence than those who were aware of their illness. Psychological interventions and several types of family interventions were significantly less effective among patients who lacked awareness. CONCLUSIONS: A lack of awareness of mental illness is common among patients with schizophrenia who are nonadherent to antipsychotics. Such nonadherence tends to be especially disruptive and unresponsive to simple commonly used psychological interventions.

Patterns of adult psychotherapy in psychiatric practice.

OBJECTIVE: Psychotherapy has long been recognized as a key component of psychiatric care. However, concerns have been raised about access to psychotherapy as a result of changes in the financing and management of care. This study examined patterns and predictors of receipt of psychotherapy among patients of psychiatrists. METHODS: Data were collected for 587 psychiatrists who participated in the American Psychiatric Institute for Research and Education's Practice Research Network 1999 Study of Psychiatric Patients and Treatments, which generated nationally representative data for 1,589 adult patients. RESULTS: Findings indicate that more than 66 percent of patients of psychiatrists received some form of psychotherapy from the psychiatrist or another provider in the past 30 days--56 percent from their psychiatrist and 10 percent from another clinician. Although 72 percent of patients with depression received psychotherapy, more than half of those with schizophrenia did not. CONCLUSIONS: A majority of patients of psychiatrists received psychotherapy from their psychiatrist. However, these rates varied by demographic, diagnostic, and health plan characteristics and by practice setting. Further research determining if these observed patterns of psychotherapy are related to differential outcomes is needed.

Diagnosis of PTSD by Army Behavioral Health Clinicians: Are Diagnoses Recorded in Electronic Health Records?

OBJECTIVE: The study sought to identify the extent to which posttraumatic stress disorder (PTSD) diagnoses are recorded in the electronic health record (EHR) in Army behavioral health clinics and to assess clinicians' reasons for not recording them and treatment factors associated with recording or not recording the diagnosis. METHODS: A total of 543 Army mental health providers completed the anonymous, Web-based survey. Clinicians reported clinical data for 399 service member patients, of whom 110 (28%) had a reported PTSD diagnosis. Data were weighted to account for sampling design and nonresponses. RESULTS: Of those given a diagnosis of PTSD by their clinician, 59% were reported to have the diagnosis recorded in the EHR, and 41% did not. The most common reason for not recording was reducing stigma or protecting the service member's career prospects. Psychiatrists were more likely than psychologists or social workers to record the diagnosis. CONCLUSIONS: Findings indicate that for many patients presenting with PTSD in Army behavioral health clinics at the time of the survey (2010), clinicians did not record a PTSD diagnosis in the EHR, often in an effort to reduce stigma. This pattern may exist for other diagnoses. Recent Army policy has provided guidance to clinicians on diagnostic recording practice. An important implication concerns the reliance on coded diagnoses in PTSD surveillance efforts by the U.S. Department of Defense (DoD). The problem of underestimated prevalence rates may be further compounded by overly narrow DoD surveillance definitions of PTSD.

Prevalence of Professional Burnout Among Military Mental Health Service Providers.

OBJECTIVE: Professional burnout is a well-documented occupational phenomenon, characterized by the gradual "wearing away" of an individual's physical and mental well-being, resulting in a variety of adverse job-related outcomes. It has been suggested that burnout is more common in occupations that require close interpersonal relationships, such as mental health services. METHODS: This study surveyed 488 mental health clinicians working with military populations about work-related outcomes, including level of professional burnout, job satisfaction, and other work-related domains. RESULTS: Approximately 21% (weighted) of the sample reported elevated levels of burnout; several domains were found to be significantly associated with burnout. CONCLUSIONS: Education about professional burnout symptoms and early intervention are essential to ensure that providers continue to provide optimal care for service members and veterans.

Availability of Mental Health Services Prior to Health Care Reform Insurance Expansions.

OBJECTIVES: This study sought to examine psychiatrists' perceptions of gaps in the availability of mental health and substance use services and their ability to spend sufficient time and provide enough visits to meet patients' clinical needs. METHODS: A cross-sectional probability survey of U.S. psychiatrists was fielded during September through December 2013 by using practice-based research methods, including distribution by priority mail. Psychiatrists (N=2,800) were randomly selected from the American Medical Association Physician Masterfile, and 1,188 of the 2,615 (45%) with deliverable addresses responded. Of those, 93% (N=1,099) reported currently treating psychiatric patients, forming the sample for this study. RESULTS: Thirty percent or more of psychiatrists reported being unable to provide or find a source for each of the following services in the past 30 days: psychotherapy, housing, supported employment, case management or assertive community treatment, and substance use treatment. Approximately 20% reported being unable to provide or find a source for inpatient treatment, psychosocial rehabilitation, general medical care, pharmacologic treatment, and child and adolescent treatment. Approximately half (52%) of psychiatrists reported not having enough time during patient visits, affecting 28% of patients. More than one-third (37%) reported being unable to provide enough visits to meet patients' clinical needs, affecting 24% of patients. CONCLUSIONS: Psychiatrists reported constrained availability of a range of mental health, substance use, and general medical services. In order for the Affordable Care Act to realize the promise of increased access to care, the infrastructure for mental health and substance use treatment, workforce, and services delivery may require significant enhancement.

Are Psychiatrists Ready for Health Care Reform? Findings From the Study of Psychiatric Practice Under Health Care Reform.

OBJECTIVE: This study sought to describe the extent to which psychiatrists, prior to insurance expansions under the Affordable Care Act (ACA), reported currently participating or being likely to participate in integrated services delivery models, to assume new roles, to accept new reimbursement structures, and to use electronic health records (EHRs). METHODS: A cross-sectional probability survey of U.S. psychiatrists was fielded from September to December 2013. In total, 2,800 psychiatrists were randomly selected from the AMA Physician Masterfile, and 45% responded. Of these, 93% (N=1,099) reported treating patients, forming the sample. RESULTS: Overall, 29% reported practicing in new ACA or integrated models, and 64% reported assuming at least one new role. Forty-two percent reported currently receiving a salary; other capitated and risk-based reimbursement was rarely used. Half (53%) reported current use of EHRs for clinical functions not limited to billing or practice management; only 21% reported participating in the Medicare or Medicaid EHR Incentive Program. Those who reported currently practicing or being very likely to practice in primary care or integrated treatment settings, to assume at least one ACA role, to receive a salary, or to use an EHR were younger and more racially-ethnically diverse and more likely to see Medicaid and public outpatient clinic patients Conclusions: Although substantial proportions of psychiatrists reported current practice in ACA services delivery models and ACA roles, the findings highlight opportunities for workforce development, training, and technical assistance to strengthen participation in these activities. The findings also underscore the need to prepare psychiatrists for merit-based payment reforms and use of EHRs.