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.

A Window of Opportunity: Visions and Strategies for Behavioral Health Policy Innovation.

Objective: The New York City's Thrive (ThriveNYC) and the Los Angeles County Health Neighborhood Initiative (HNI) are two local policies focused on addressing the social determinants of behavioral health as a preventive strategy for improving health service delivery. On January 29, 2016, leaders from both initiatives came together with a range of federal agencies in health care, public health, and policy research at the RAND Corporation in Arlington, Virginia. The goal of this advisory meeting was to share lessons learned, consider research and evaluation strategies, and create a dialogue between stakeholders and federal funders - all with the purpose to build momentum for policy innovation in behavioral health equity. Methods: This article analyzes ethnographic notes taken during the meeting and in-depth interviews of 14 meeting participants through Kingdon's multiple streams theory of policy change. Results: Results demonstrated that stakeholders shared a vision for behavioral health policy innovation focused on community engagement and social determinants of health. In addition, Kingdon's model highlighted that the problem, policy and politics streams needed to form a window of opportunity for policy change were coupled, enabling the possibility for behavioral health policy innovation. Conclusions: The advisory meeting suggested that local policy makers, academics, and community members, together with federal agents, are working to implement behavioral health policy innovation.

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.

Learning to be interprofessional advocates in the public sector.

Engaging in advocacy is an ethical responsibility for behavioral health professionals, as reflected in professional competencies across disciplines and in personal accounts of wanting to affect change at various levels of patients'/clients' and communities' ecologies. However, the literature is replete with examples of barriers to routine advocacy engagement, including lack of an organized structure into which efforts can be embedded. There exists the desire among behavioral health professionals to engage in more advocacy work, yet a shared sense of not knowing how to incorporate this work into existing professional roles. One way to address these barriers is to establish more collaborative advocacy work environments within the public sector settings that employ behavioral health professionals. This article offers the first descriptive account of developing, implementing, and maintaining such a collaborative interprofessional advocacy workgroup. To that end, this case study is one example of such a group, the Atlanta Behavioral Health Advocates, based within the Emory University School of Medicine in the Department of Psychiatry and Behavioral Sciences and situated also within Grady Health System, a public health care system. This paper details our experiences forming and engaging in this group, which we believe can serve as a model for others developing similar advocacy workgroups in public sector settings. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Examining the role of funders in ensuring value and reducing waste in research: An organizational case-study of the Patient-Centered Outcomes Research Institute.

International experts have recommended actions that funders can take to improve the value of research investments. They state that self-assessment and public sharing are the basis for accountability and improvement. We examined our policies and practice to determine the extent to which the Patient-Centered Outcomes Research Institute's (PCORI) policies and practices as a research funder align with international best practice recommendations. A self-audit of current policies and practice against 17 recommendations and 35 sub-recommendations representing five major stages of research production, based on adapted methods used for self-assessment by another funder, was performed.  Fit of existing PCORI policies and practices with 35 sub-recommendations, qualitative assessment of adequacy (area of strength; area of partial strength; area of growth; not applicable) for 17 recommendations for five stages of research production was assessed. Of the 17 recommendations, 15 were applicable to PCORI's research mission and focus.  PCORI has policies and practices in place for all elements of six recommendations ("area of strength") and policies that address each element but with some still in active development for three ("area of partial strength"). PCORI is partially addressing six of the 15 relevant recommendations ("area of growth"). Areas for growth include making study protocols publicly available, improving policies on data sharing, and enhancing collaboration with other funders to reduce redundant funding. A voluntary consortium of international funders is underway to encourage further progress, including additional self-assessment and public sharing for accountability. These findings indicate PCORI has undertaken efforts to align its funding practices with international recommendations to ensure the value of public dollars invested in research.  Further efforts will likely require additional coordination and collaboration between funders and stakeholders.

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.

Cost shifting under managed behavioral health care.

OBJECTIVE: The study examined whether a managed behavioral health care organization (MBHO) shifted treatment costs. METHODS: Four years of claims data (1991-1995) from an insurer that introduced an MBHO in 1992 to control treatment costs were analyzed. Although the MBHO was not at direct financial risk for specialty mental health treatment, it faced incentives related to reputation and contract renewal to shift costs to primary care treatment or prescription drugs. It was hypothesized that if cost shifting occurred, an increase would be noted in the use of psychotropic medications without concurrent use of specialty mental health treatment. Simple t tests and a generalized estimating equations probit specification were used to test this hypothesis. Separate tests were performed for use of any psychotropic medication, any newer antidepressant, and any stimulant in a large employer group that simultaneously implemented parity coverage (75,360 enrollees) and a group of smaller employers that did not (9,228 enrollees). RESULTS: The use of any psychotropic medication rose 64% in relative terms (p<.001) over the four-year period among enrollees of the large employer group and by 87% in the smaller groups (p<.001). In general, there were downward secular trends in the use of psychotropic medications without specialty care. Introduction of the MBHO was not significantly associated with the use of psychotropic medication alone. For newer antidepressants, introduction of the MBHO was associated in the large group with a 2.4 (p=.003) absolute percentage point decrease in medication use alone. CONCLUSIONS: No evidence was found to suggest that the MBHO shifted treatment costs.

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.

Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice.

OBJECTIVE: Selective serotonin reuptake inhibitors (SSRIs) are widely used to treat depression, but the rates, timing, and baseline predictors of remission in "real world" patients are not established. The authors' primary objectives in this study were to evaluate the effectiveness of citalopram, an SSRI, using measurement-based care in actual practice, and to identify predictors of symptom remission in outpatients with major depressive disorder. METHOD: This clinical study included outpatients with major depressive disorder who were treated in 23 psychiatric and 18 primary care "real world" settings. The patients received flexible doses of citalopram prescribed by clinicians for up to 14 weeks. The clinicians were assisted by a clinical research coordinator in the application of measurement-based care, which included the routine measurement of symptoms and side effects at each treatment visit and the use of a treatment manual that described when and how to modify medication doses based on these measures. Remission was defined as an exit score of or=50% in baseline QIDS-SR score. RESULTS: Nearly 80% of the 2,876 outpatients in the analyzed sample had chronic or recurrent major depression; most also had a number of comorbid general medical and psychiatric conditions. The mean exit citalopram dose was 41.8 mg/day. Remission rates were 28% (HAM-D) and 33% (QIDS-SR). The response rate was 47% (QIDS-SR). Patients in primary and psychiatric care settings did not differ in remission or response rates. A substantial portion of participants who achieved either response or remission at study exit did so at or after 8 weeks of treatment. Participants who were Caucasian, female, employed, or had higher levels of education or income had higher HAM-D remission rates; longer index episodes, more concurrent psychiatric disorders (especially anxiety disorders or drug abuse), more general medical disorders, and lower baseline function and quality of life were associated with lower HAM-D remission rates. CONCLUSIONS: The response and remission rates in this highly generalizable sample with substantial axis I and axis III comorbidity closely resemble those seen in 8-week efficacy trials. The systematic use of easily implemented measurement-based care procedures may have assisted in achieving these results.

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.

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.

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.

Guidance for New Motivational Interviewing Trainers When Training Addiction Professionals: Findings from a Survey of Experienced Trainers.

Evidence-based practices, such as motivational interviewing (MI), are not widely used in community alcohol and drug treatment settings. Successfully broadening the dissemination of MI will require numerous trainers and supervisors who are equipped to manage common barriers to technology transfer. The aims of the our survey of 36 MI trainers were: 1) to gather opinions about the optimal format, duration, and content for beginning level addiction-focused MI training conducted by novice trainers and 2) to identify the challenges most likely to be encountered during provision of beginning-level MI training and supervision, as well as the most highly recommended strategies for managing those challenges in addiction treatment sites. It is hoped that the findings of this survey will help beginning trainers equip themselves for successful training experiences.