Utilizing a CBPR approach to assess the impact of COVID-19 on individuals who receive publicly funded behavioral health services.

The coronavirus disease pandemic has highlighted significant gaps in community mental health services, placing vulnerable individuals at greater risk for mental health and substance use difficulties via disrupting their wellness journey. Guided by a wellness framework, a needs assessment was conducted among adult consumers of behavioral health services to understand their needs during the pandemic and to help develop and strengthen service delivery strategies. A team of three university researchers and four Consumer Researchers, who receive services at a publicly funded community mental health center, engaged in a community-based participatory project in which 13 focus groups were conducted with 51 consumers. Several themes emerged from a thematic analysis of transcripts regarding consumer well-being and healthcare needs, coping strategies employed, and the accessibility, benefits, and perception of clinical and support services during the pandemic. Results highlighted strengths in service delivery and areas in need of enhancement. Findings may inform similar community services that seek to enhance delivery of care among vulnerable populations.

Leading from the Middle: Practical Innovation in Public Mental Health.

Leaders in public mental health are responsible for ensuring the care environment is conducive to provider wellbeing, and ultimately patient care. Given the effects of stress and burnout, healthcare organizations must explore interventions to support their employees. The Leadership + Innovation Lab is a pilot project focused on enhancing leadership skills, innovation capacity, and peer connections among clinical managers. Participants executed individual or group projects to improve the care environment and co-created a peer consultation program. They reported increased connection with peers, innovation and leadership skills, and capacity to facilitate a better experience for their provider staff as a result of the program. This model can be used in other settings to help achieve the goals of the Quadruple Aim and improve communication.

The Connecticut Mental Health Center: Celebrating 50 Years of a Successful Partnership Between the State and Yale University.

September 28, 2016, marked the 50th anniversary of the Connecticut Mental Health Center, a state-owned and state-operated joint venture between the state and Yale University built and sustained with federal, state, and university funds. Collaboration across these entities has produced a wide array of clinical, educational, and research initiatives, a few of which are described in this column. The missions of clinical care, research, and education remain the foundation for an organization that serves 5,000 individuals each year who are poor and who experience serious mental illnesses and substance use disorders.

Financial Health and Mental Health Among Clients of a Community Mental Health Center: Making the Connections.

OBJECTIVES: This study evaluated financial challenges, satisfaction with financial-management supports, and interest in additional or alternative supports among clients of a mental health center. METHODS: Six focus groups were held with 39 clients of an urban community mental health center who reported having difficulty with their finances. Five focus groups were held with direct-care staff who provided services to the clients. Investigators used an inductive analytical approach to distill themes from notes taken during the focus groups. RESULTS: Clients emphasized the challenges of living in poverty and described using complex strategies to sustain themselves, including negotiating benefits systems, carefully planning purchases, and developing and relying on social relationships. They spoke of having uneven access to tools and services for managing their money, such as advice from direct-care staff, representative payees, and bank accounts, and had varying opinions about their value. Noting concerns similar to those of clients, direct-care staff expressed frustration at the lack of support services for helping clients manage their finances. Both clients and staff expressed the need for more services to help clients with their finances. CONCLUSIONS: Findings suggest a need for more services to support people with mental illness to manage their finances, particularly a more flexible and broader range of options than are provided by current representative-payee mechanisms.

General Medicine Training in Psychiatry Residency.

With growing awareness of the need for integrated health care settings, psychiatrists may be required to provide clinical care at the primary care and behavioral health interface. This article discusses the curricular changes that could enhance the development of psychiatrists as leaders in integrated primary and behavioral health care. Psychiatrists may be called upon to provide enhanced collaborative care services at primary care or behavioral health settings. This article focuses on the provision of integrated care in behavioral health settings, especially in the public sector. The authors review the additional training in general medicine that would facilitate these skills. They outline the principles and goals to be considered in building such a curriculum. They examine the curricular building blocks of such training and also discuss challenges in implementing these curricular changes. Finally, they discuss the implications of incorporating integrated health care training on the future of psychiatric practice.

Stakeholders' perspectives on community-based participatory research to enhance mental health services.

Historically, consumers of mental health services have not been given meaningful roles in research and change efforts related to the services they use. This is quickly changing as scholars and a growing number of funding bodies now call for greater consumer involvement in mental health services research and improvement. Amidst these calls, community-based participatory research (CBPR) has emerged as an approach which holds unique promise for capitalizing on consumer involvement in mental health services research and change. Yet, there have been few discussions of the value added by this approach above and beyond that of traditional means of inquiry and enhancement in adult mental health services. The purpose of this paper is to add to this discussion an understanding of potential multilevel and multifaceted benefits associated with consumer-involved CBPR. This is accomplished through presenting the first-person accounts of four stakeholder groups who were part of a consumer-involved CBPR project purposed to improve the services of a local community mental health center. We present these accounts with the hope that by illustrating the unique outcomes associated with CBPR, there will be invigorated interest in CBPR as a vehicle for consumer involvement in adult mental health services research and enhancement.

Status of general medicine training and education in psychiatry residency.

OBJECTIVE: With the current emphasis on integrated care, the role of psychiatrists is expanding to either directly provide medical care or coordinate its delivery. The purpose of this study was to survey general psychiatry programs on the extent of general medicine training provided during residency. METHODS: A short web-based survey was sent to 173 residency program directors to recruit participants for a larger survey. Thirty-seven participants were recruited and surveyed, and of these, 12 (32.4%) responded. The survey assessed the extent of general medicine training and didactics during and after the first postgraduate year and attitudes towards enhancing this training in residency. This study was approved by the local institutional review board. RESULTS: Seventy-five percent of programs require only the minimum 4 months of primary care in the first postgraduate year, and didactics during these months is often not relevant to psychiatry residents. Some programs offer elective didactics on chronic medical conditions in the fourth postgraduate year. Respondents are in favor of enhancing general medicine training in psychiatry but indicate some resistance from their institutions. CONCLUSIONS: These results suggest that very few programs require additional clinical training in relevant medical illnesses after the first postgraduate year. Respondents indicated favorable institutional support for enhancing training, but also expected resistance. The reasons for resistance should be an area of future research. Also important is to determine if enhancing medical didactics improves patient care and outcomes. The changing role of psychiatrists entails a closer look at resident curricula.

Prescription of second-generation antipsychotics: responding to treatment risk in real-world practice.

OBJECTIVE: This study sought to determine the extent of providers' sensitivity to the presence of cardiometabolic disorders in the selection of second-generation antipsychotics. METHODS: As part of an academic detailing effort conducted between October 2007 and May 2009, all psychiatric providers at a single Veterans Affairs medical center completed a survey for every new prescription of an on-patent second-generation antipsychotic. The survey documented the drug prescribed, patients' sociodemographic data, psychiatric and comorbid diagnoses, and reasons for the prescription. The association between obesity, hypertension, hyperlipidemia, diabetes, and cardiovascular disease and the choice of antipsychotics with varying levels of cardiometabolic risk was evaluated. RESULTS: Data consisted of 2,613 surveys completed by 259 providers. Olanzapine, with high cardiometabolic risk, and quetiapine and risperidone, with moderate risk, accounted for 79% of prescriptions. There was a significant (p<.001) association between the second-generation antipsychotic prescribed and obesity, hyperlipidemia, and diabetes but not hypertension or cardiovascular disease. The proportion of patients receiving olanzapine was only slightly smaller, by an average of 4 percentage points, among patients with cardiometabolic disorders than among patients without cardiometabolic disorders. The proportion of patients receiving aripiprazole, with little or no cardiometabolic risk, was consistently higher, by an average of only 2 percentage points, among patients with a cardiometabolic disorder versus without one. CONCLUSIONS: Although this study found a statistically significant sensitivity by providers to cardiometabolic risk, this sensitivity was neither robust nor uniformly statistically significant. More research into how providers use medication risk information when making treatment decisions may help improve the quality of care.

Prevalence of concomitant oral antipsychotic drug use among patients treated with long-acting, intramuscular, antipsychotic medications.

OBJECTIVE: Long-acting injectable (LAI) antipsychotic drugs are viewed as monotherapeutic alternatives to oral medications to promote medication adherence, but there have been no descriptive studies of concomitant use of oral and LAI medications. METHODS: A list of all patients receiving services from the Connecticut Mental Health Center from July 1, 2009, to June 30, 2010, was obtained from center administrative records, and those carrying an initial intake diagnosis of schizophrenia or schizoaffective disorder were identified. All team leaders were approached, and all clinicians were asked to identify patients on their case load prescribed LAIs during the time interval above. Also, all internal and external pharmacy orders were reviewed. Concomitancy was defined as simultaneous oral and LAI antipsychotic use at any time from July 1, 2009, to June 30, 2010. Data were culled from the medical records using a form (available on request) that recorded current LAI antipsychotic, reasons for LAI use, length of time on LAI, monthly dosage, and all concomitant oral antipsychotics, antidepressants, and anxiolytic agents. RESULTS: Among 124 patients on LAI medications, 57 (46%) received concomitant oral and LAI antipsychotics: 27 (47%) were prescribed LAI haloperidol, 19 (33%) LAI fluphenazine, and 11 (19%) risperidone microspheres. Logistic regression showed greater use of oral antipsychotic for both Hispanic ethnicity (odds ratio, 3.8; 95% confidence interval, 1.3-10.8) and alcohol abuse/dependence (odds ratio, 6.5; 95% confidence interval, 1.3-31.9), with no significant differences on other variables. There were no significant differences between LAI agents in rates of use of concomitant oral antipsychotic, anticholinergic, sedative/hypnotic, or mood stabilizer. Patients were more likely to be prescribed concomitant oral preparations of their LAI agent than another oral antipsychotic. Higher dosing of LAI treatments was associated with a significantly greater likelihood of use of oral psychotropics and anticholinergics. CONCLUSIONS: Almost one half of patients prescribed LAI antipsychotics receive oral antipsychotics and other oral psychotropics. This challenges the notion that LAIs are used as monotherapy in real-world settings. Concomitant oral and LAI antipsychotic prescriptions may represent a common practice of polypharmacy that merits further investigation.

Race and long-acting antipsychotic prescription at a community mental health center: a retrospective chart review.

OBJECTIVE: There has been concern that racial minorities are disproportionately prescribed long-acting injectable antipsychotic drugs. METHOD: Comprehensive administrative data and clinician survey were used to identify all patients with a DSM-IV diagnosis of schizophrenia who received long-acting antipsychotic prescriptions from July 2009 to June 2010 at a community mental health center. Charts were reviewed retrospectively to validate long-acting antipsychotic prescription (eg, medication, dosage) and merged with administrative data from all center patients documenting sociodemographic characteristics (ie, age, race, gender) and comorbid diagnoses. We used bivariate χ2, t tests, and multivariate logistic regression to compare the subsample of patients receiving long-acting injectable drugs (n = 102) to patients not receiving long-acting injectable drugs (n = 799) who were diagnosed with schizophrenia for the same period. RESULTS: White patients were significantly less likely to receive long-acting antipsychotic prescriptions than minority patients (OR = 0.52, P < .007); ie, nonwhites were 1.89 times more likely to receive such drugs. Age, gender, and comorbid diagnoses, including substance abuse, were unrelated to long-acting injectable prescription, and race/ethnicity was not associated with use of specific agents (haloperidol decanoate, fluphenazine decanoate, or risperidone microspheres) (P = .73). CONCLUSIONS: Racial minorities are more likely than other patients with schizophrenia to receive long-acting injectionable antipsychotics, a finding that suggests their prescribers may consider them less adherent to antipsychotic prescriptions.

Who is paying the price? Loss of health insurance coverage early in psychosis.

OBJECTIVE: Discontinuities in health insurance coverage may make it difficult for individuals early in psychosis to receive the services that are critical in determining long-term outcome. This study reports on the rates and continuity of insurance coverage among a cohort of early-psychosis patients enrolled in Specialized Treatment Early in Psychosis (STEP) at the Connecticut Mental Health Center. METHODS: Insurance status at baseline, six months, and 12 months was collected from 82 participants from a combination of self-reports, clinical chart review, clinician reports, and a database maintained by the state Department of Social Services. RESULTS: A total of 34 participants did not know whether they had health insurance or did not appear for follow-up assessments at six and 12 months. Among the remaining 48 participants, at baseline 18 had private insurance, 13 had public insurance, and 16 had no insurance. By the 12-month assessment, 13 (72%) privately insured and five (38%) publicly insured participants had lost coverage; less than one-third of the 48 participants (N=14) maintained continuous coverage. CONCLUSIONS: Specialty services for individuals experiencing early psychosis should address the difficulty of maintaining health insurance coverage during a period of illness in which continuity of care is critical to recovery.

Duration of pharmacotherapy with long-acting injectable risperidone in the treatment of schizophrenia.

Although long-acting injectable risperidone (LAIR) has been hypothesized to improve medication adherence compared to oral medications, data from real-world practice have yet to be presented on time to treatment discontinuation. Records of all new prescriptions for antipsychotic medication during the first 2 months of FY 2006 for VA patients diagnosed with schizophrenia (N = 11,821) were examined and duration of treatment with LAIR and oral antipsychotics were calculated for the next 2 years. Multivariable logistic regression was used to identify patient characteristics independently associated with receipt of LAIR. Proportional hazards models were used to compare the likelihood of discontinuing each of the medications as compared to LAIR. Altogether, 2.4% of the 11,821 new starts were prescribed LAIR, 44.6% of whom continued therapy for 540-720 days (18-24 months), less than the 77.1% of those on clozapine, 57.9% on oral conventional antipsychotics, 55.0% on olanzapine, and 49.5% on risperidone, but more than the 27.7% on aripiprazole. After adjusting for potentially confounding factors, patients who were initiated on LAIR were more likely to discontinue their medication than those who were initiated on oral first- or second-generation antipsychotics (SGAs) with the exception ziprasidone and aripiprazole. Less than half of patients on LAIR continued treatment for 18 months, a smaller proportion than of those started on most oral first- or second-generation antipsychotics, suggesting that for many patients with schizophrenia improved adherence from this treatment may not be sustained.

Developing a policy for second-generation antipsychotic drugs.

Second-generation antipsychotics (SGAs) have replaced older drugs in the treatment of schizophrenia; their costs in the United States have reached $13 billion a year. Recent research, however, shows that their net risk/benefit profiles are no better than some older, cheaper drugs. Stepped therapy, allowing exceptions with prior authorization and giving preference to generic drugs with low risk of both neurologic and metabolic side effects, could increase the cost-effectiveness and safety of antipsychotic drugs. Educational preparation and monitoring of adverse events would foster better acceptance of such procedures among providers, patients, and families. Research to evaluate these interventions would ideally precede their widespread implementation.

Antipsychotic use in the treatment of outpatients with schizophrenia in the VA from fiscal years 1999 to 2006.

OBJECTIVE: This study examined changes in prescribing patterns of antipsychotic medications to treat schizophrenia. METHODS: Pharmacy records for patients with schizophrenia were obtained from Department of Veterans Affairs databases. The proportion of patients prescribed specific second-generation antipsychotics or any first-generation antipsychotic was calculated per year. RESULTS: In fiscal year (FY) 2006, 78,849 veterans with schizophrenia were prescribed antipsychotic medication. For FY 1999 to FY 2006 the percentage of patients with schizophrenia who received first-generation antipsychotics decreased from 40.8% to 15.9%, but the percentage receiving olanzapine, after peaking at 32.0% in FY 2001, decreased to 19.0%. The percentage of patients given quetiapine increased from 2.5% to 18.8%; risperidone, from 25.5% to 29.7%. However, clozapine usage remained flat, at 2.0%-3.0%. Use of then-new ziprasidone and aripiprazole rose from 5.0% to 9.0%. CONCLUSIONS: Use of each antipsychotic newly marketed over eight years increased while use of risperidone was unchanged and use of olanzapine and the first-generation antipsychotics declined.

Identifying metabolic risks with antipsychotics and monitoring and management strategies.

Mental health providers have an especially important responsibility to monitor the physical changes that patients have in response to medication. The current public health focus is on adiposity as a major risk factor for diabetes, coronary heart disease, insulin resistance syndrome, metabolic syndrome, and other diseases. Adiposity has an adverse effect on insulin action, which can lead to a cycle in which insulin loses its ability to stop the breakdown of fat. Because type 2 diabetes takes approximately 2 decades to develop, patients with increased BMI can be at risk for adverse effects to their physical health for many years. Because of the possibility that some antipsychotic treatments can lead to weight gain and metabolic changes and possibly to severe physical illness, regular physical checks should be made.

Implementation of monitoring and management guidelines for second-generation antipsychotics.

It has long been known that psychiatric patients experience increased morbidity and mortality associated with a range of physical disorders. Lifestyle, inadequate health care, and a variety of other factors all contribute to the poor physical health of people with severe mental illness. Second-generation antipsychotics have gained widespread acceptance for the management of patients with schizophrenia and other forms of severe mental illness. While demonstrating several advantages over first-generation antipsychotics, second-generation antipsychotics have been found to cause or exacerbate several metabolic disorders, including diabetes, obesity, dyslipidemia, and metabolic syndrome. These disorders are closely linked and consistently associated with the development of cardiovascular disease, with varying prevalence rates depending on the second-generation antipsychotic used. As a result, several authoritative guidelines have been developed for the monitoring and management of metabolic disturbances in schizophrenia and other forms of severe mental illness. Specifically, the guidelines and recommendations generated from the Mount Sinai Conference on Medical Monitoring and the American Diabetes Association/American Psychiatric Association Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes call for a more integrated and cooperative approach between primary care physicians and mental health care providers to improve the quality of health care for people with severe mental illness. By routinely performing physical health monitoring, referrals, and/or treatment for patients with schizophrenia and other forms of severe mental illness, mental health care providers can take a lead role in transforming the current system of fragmented mental and physical health services into a system focused on early intervention, wellness, and recovery.

Generic fluoxetine and choice of antidepressant medication.

OBJECTIVE: In 2002 generic fluoxetine, the first generic product in a relatively expensive medication class, became available at Veterans Affairs medical centers at only 5% of its previous cost. This study examined whether its availability was associated with an increase in use compared with other medications. METHODS: All new starts of 15 antidepressants during fiscal year (FY) 2001 (before generic fluoxetine became available) and FY2003 were identified from administrative records, and the change in proportions of new starts across years was examined. RESULTS: Altogether, 55,673 patients had a new start on antidepressants in FY2001 and 48,002 had a new start in FY2003. The percentage of fluoxetine prescriptions (both branded and generic) rose only 1.2%--from 8.3% in FY2001 to 9.5% in FY2003. CONCLUSIONS: Only a small increase was found in the rate of new starts of fluoxetine in the year after its release as a low-cost generic. There appear to be untapped opportunities to realize savings for antidepressants with appropriate administrative mechanisms and incentives.

Metabolic monitoring for patients treated with antipsychotic medications.

OBJECTIVES: Metabolic side effects of antipsychotic treatment include weight gain, dyslipidemia and increased susceptibility to diabetes. Patients with schizophrenia have increased coronary heart disease mortality and reduced life expectancy. There is an urgent clinical need to monitor antipsychotic-treated patients for metabolic disturbance. Our objectives were to review published international monitoring guidelines, establish goals for metabolic monitoring, and make recommendations for practice. METHOD: We reviewed the major published consensus guidelines for metabolic monitoring of patients treated with antipsychotic medications and selectively reviewed practice guidelines for the management of diabetes, dyslipidemia, and hypertension. RESULTS: Patients with serious mental illness have markedly elevated rates of metabolic disturbance and limited access to general medical care. Monitoring, but not necessarily medical treatment of metabolic disorder, falls within the scope of psychiatric practice and should include screening for metabolic disturbance as well as tracking the effects of antipsychotic treatment. In addition, psychiatrists and psychiatric services should work toward facilitating patients' access to medical care. There is considerable consensus in the published guidelines. Areas of dissent include which patients to monitor, the utility of glucose tolerance testing, and the point at which to consider switching antipsychotics. CONCLUSION: We encourage clinicians to adopt a structured system for conducting and recording metabolic monitoring and to develop collaborations with family physicians, diabetes specialists, dieticians, and recreation therapists to facilitate appropriate medical care for antipsychotic-treated patients.

Predictors of antipsychotic medication change.

Atypical antipsychotics account for more than 60% of antipsychotic prescriptions written for the treatment of schizophrenia. While switching from one antipsychotic to another is a dynamic process, there has been no research on individual patient and institutional characteristics that predict antipsychotic switching. VA national administrative data were used to identify patients (n = 9660) with schizophrenia maintained on antipsychotic medication. Logistic regression was used to identify predictors of medication switching. Independent variables included information about service utilization, sociodemographic and clinical variables as well as institutional characteristics. This model was repeated for more specific switches between classes of medications and between specific medications. High levels of outpatient and inpatient service use were the most powerful predictors of switching. Sociodemographic, institutional, diagnostic, and functional measures were also predictive in some cases. Controlling for independent sociodemographic, diagnostic, and functional measures, frequency of clinical contact was the most robust predictor of switching antipsychotics.

Undiagnosed hyperglycemia in patients treated with atypical antipsychotics.

BACKGROUND: The use of atypical antipsychotics has been associated with abnormalities of glucose metabolism in patients with schizophrenia. This study was designed to determine the proportion of undiagnosed hyperglycemia in patients receiving a broad range of atypical antipsychotics. METHOD: All outpatients treated at an urban Veterans Affairs medical center who received a prescription for clozapine, risperidone, olanzapine, quetiapine, or ziprasidone were identified, and an attempt was made to obtain a fasting plasma glucose (FPG) test. Testing took place October 2000 to November 2002. Patients previously diagnosed as diabetic were excluded. RESULTS: Of the 647 patients who received antipsychotic prescriptions and were not diagnosed as diabetic, 494 (76.4%) had a random glucose result, while 153 (23.6%) had an FPG result. Within the FPG group, 107 (69.9%) had a normal FPG level, while 46 (30.1%) had an abnormally elevated FPG. There were no differences between these 2 groups in terms of race/ethnicity, age, body mass index, or comorbid diagnoses. However, significantly more patients receiving clozapine were found to have occult hyperglycemia (p = .001); no significant differences in the percentage of patients with FPG levels > or = 100 mg/dL and those with FPG levels < 100 mg/dL were observed for any of the other medications. CONCLUSION: Hyperglycemia is common in patients treated with atypical antipsychotics and thought to be euglycemic. Screening for elevated FPG is indicated for patients receiving atypical antipsychotics.