Challenges encountered in the conduct of Optimal Health: A patient-centered comparative effectiveness study of interventions for adults with serious mental illness.

BACKGROUND: The aim of patient-centered comparative effectiveness research is to conduct stakeholder-driven investigations that identify which interventions are most effective for which patients under specific circumstances. Conducting this research in real-world settings comes with unique experiences and challenges. We provide the study design, challenges confronted, and the solutions we devised for Optimal Health, a stakeholder-informed patient-centered comparative effectiveness study focused on the needs of seriously mentally ill individuals receiving case management services in community mental health centers across Pennsylvania. METHODS: Optimal Health, supported by the Patient-Centered Outcomes Research Institute, is a cluster-randomized trial of two evidence-based interventions for improving health and wellness across 11 provider sites. Participants were followed for 18-24 months, with repeated measurements of self-reported health status and activation in care and administrative measurements of primary and specialty health service utilization. Health-related quality of life, engagement in care, and service utilization are to be compared via random effects mixed models. Stakeholders were, and continue to be, engaged via focus groups, interviews, and stakeholder advisory board meetings. A learning collaborative model was used to support shared learning and implementation fidelity across provider sites. RESULTS: From 1 November 2013 through 15 July 2014, we recruited 1229 adults with serious mental illness, representing 85.1% of those eligible for study participation. Of these, 713 are in the Provider-Supported arm of the study and 516 in Patient Self-Directed Care. Across five data collection time points, we retained 86% and 83% of the participants in the Provider-Supported and Self-Directed arms, respectively. LESSONS LEARNED: Lessons learned relate to estimation of the size of our study population, the value of multiple data sources, and intervention training and implementation. The use of historical claims data can lead to an overestimation of eligible participants and, subsequently, a reduced study sample and an imbalance between intervention arms. Disruptions in continuity of care in real-world settings can pose challenges to on-site self-report data collection, although the inclusion of multiple data sources in study design can improve data completeness. Geographic dispersion of rural provider sites and staff turnover can lead to training and intervention fidelity challenges that can be overcome with the use of a "train-the-trainer" model, "wellness champions," and the use of a Learning Collaborative approach. Stakeholder engagement in mitigating these challenges proved to be critical to study progress. CONCLUSION: Conducting real-world patient-centered comparative effectiveness research in healthcare systems that care for seriously mentally ill persons is an important yet challenging undertaking, one which requires flexibility in identifying potential adaptations within all major study phases. Advice from a wide range of stakeholders is critical in development of successful strategies.

Effectiveness of a Staff Promoted Wellness Program to Improve Health in Residents of a Mental Health Long-Term Care Facility.

The current study describes physical and mental health outcomes during a health promotion program for individuals with serious mental illness (SMI). A sample of 43 adults in a long-term residential facility volunteered for an individualized, healthy lifestyle program designed to promote physical activity and combat premature mortality among individuals with SMI. Nurses and residential counselors were trained in the program and encouraged to work collaboratively with the program's personal trainers. Weekly nutrition and activity logs were obtained over the year-long evaluation. Assessments of physical and psychological health indicators were collected quarterly. Qualitative data through focus groups described staff experience. Self-report of moderate and vigorous physical activity improved over time as did fitness level as measured through a walking challenge (p = .001). Significant decreases in weight (p < .001), BMI (p = .001), and total cholesterol (p < .001) were observed from baseline through 12 months. Mean recovery scores (RMQ) were significantly higher between baseline and all time points (p < .001). Participants reported decreasing levels of depression (PHQ-9) by the 12-month time point (p < .001). Staff encouraged participation in physical activity and observed improved motivation and socialization among participants. A health promotion program with participation encouraged by health care staff is effective for increasing physical activity and improving physical and mental health outcomes in individuals with SMI in long-term residential care.

Predictors of adequate depression treatment among Medicaid-enrolled youth.

PURPOSE: To determine if Medicaid-enrolled youth with depressive symptoms receive adequate acute treatment, and to identify the characteristics of those receiving inadequate treatment. METHODS: We used administrative claims data from a Medicaid-enrolled population in a large urban community to identify youth aged 6-24 years who started a new episode of treatment for a depressive disorder between August 2006 and February 2010. We examined rates and predictors of minimally adequate psychotherapy (four visits in first 12 weeks) and pharmacotherapy (filled antidepressant prescription for 84 of the first 144 days) among youth with a new treatment episode during the study period (n = 930). RESULTS: Fifty-nine percent of depressed youth received minimally adequate psychotherapy, but 13 % received minimally adequate pharmacotherapy. Youth who began their treatment episode with an inpatient psychiatric stay for depression and racial minorities were significantly less likely to receive minimally adequate pharmacotherapy and significantly more likely to receive inadequate overall treatment. CONCLUSIONS: While the majority of youth appear to be receiving minimally adequate acute care for depression, a substantial number are not. Given current child mental health workforce constraints, efforts to substantially improve the provision of adequate care to depressed youth are likely to require both quality improvement and system redesign efforts.

Use of a computerized medication shared decision making tool in community mental health settings: impact on psychotropic medication adherence.

Healthcare reform emphasizes patient-centered care and shared decision-making. This study examined the impact on psychotropic adherence of a decision support center and computerized tool designed to empower and activate consumers prior to an outpatient medication management visit. Administrative data were used to identify 1,122 Medicaid-enrolled adults receiving psychotropic medication from community mental health centers over a two-year period from community mental health centers. Multivariate linear regression models were used to examine if tool users had higher rates of 180-day medication adherence than non-users. Older clients, Caucasian clients, those without recent hospitalizations, and those who were Medicaid-eligible due to disability had higher rates of 180-day medication adherence. After controlling for sociodemographics, clinical characteristics, baseline adherence, and secular changes over time, using the computerized tool did not affect adherence to psychotropic medications. The computerized decision tool did not affect medication adherence among clients in outpatient mental health clinics. Additional research should clarify the impact of decision-making tools on other important outcomes such as engagement, patient-prescriber communication, quality of care, self-management, and long-term clinical and functional outcomes.

Mental health services for children of substance abusing parents: voices from the community.

This qualitative study explores how to improve services for children of parents with Substance Use Disorders (SUD) with unmet mental health needs. Focus groups were conducted with parents and caregivers to identify perceived barriers to services, including: (1) attitudes and beliefs about mental health care, (2) inadequacies in mental health services, (3) children's ambivalence about treatment, and (4) parental disagreement and lack of involvement. Peer support, afterschool activities, and family counseling were identified as potential improvements. This information can serve as a foundation and guide to develop services for the underserved population of children and adolescents of substance abusing parents.

Promoting collaborative psychiatric care decision-making in community mental health centers: Insights from a patient-centered comparative effectiveness trial.

OBJECTIVE: Mental health service-users face important medication decisions; yet not all are active participants in the decision-making process. Little is known about which technology-supported interventions might effectively promote collaborative decision-making in psychiatric care. We compared the effectiveness of two technology-supported collaborative care decision-making approaches. METHOD: We used a cluster-randomized design with a mixed-methods approach. Participants were Medicaid-enrolled adults receiving psychiatric care in participating community mental health centers. Measurement-based care used computerized systematic symptom and medication screenings to inform provider decision-making. Person-centered care supported participants in completing computerized Health Reports and preparing to work with providers on collaborative decision-making about psychiatric care. Primary study outcomes included the patient experience of medication management and shared decision-making during psychiatric care. Analyses examined the impact of both approaches and explored moderating variables. We used qualitative methods to understand participation and implementation experiences. RESULTS: Across 14 sites 2,363 participants enrolled (1,162 in measurement-based care, 1,201 in person-centered care). We observed statistically significant improvements in patient experience of medication management scores for both study arms; however, the clinical significance of this change was minor. We found no significant changes for shared decision-making. Qualitative interviews revealed a range of factors associated usefulness of intervention assessment, provider-service-user communication, and site-level logistics. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: We observed modest positive findings related to our patient-centered outcomes. We identified important implementation facilitators and barriers that can inform the implementation of future comparative effectiveness patient-centered research. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Community-based behavioral health administrator perspectives on sustainability of Dialectical Behavior Therapy: a qualitative evaluation.

BACKGROUND: Substantial resources have been invested in evidence-based practice (EBP) implementation in community settings; however, research suggests that EBPs do not always sustain over time. METHOD: This qualitative study explored the perspectives of 13 community behavioral health agency leaders regarding the sustainability of an EBP 25 to 28 months following the original training period. Administrators from 10 agencies were interviewed to understand the complexities of the implementation process, sustainability of Dialectical Behavior Therapy, and their recommendations to enhance implementation and sustainability. RESULTS: A content analysis revealed five emergent themes: treatment model opinions, resource concerns, staff selection/ turnover, population characteristics, and recommendations for future implementation. CONCLUSIONS: These themes likely would be helpful in informing the design of future implementation and sustainability initiatives sensitive to the challenges of integrating EBPs in community settings.

Increasing minority research participation through collaboration with community outpatient clinics: the STEP-BD Community Partners Experience.

BACKGROUND: Minority populations have been under-represented in mental health research studies. The systematic treatment enhancement program for bipolar disorder developed the Community Partners Program (CPP) to address this issue in a large, prospective treatment study of persons with bipolar disorder. PURPOSE: The primary goal of CPP was to develop a community-based infrastructure for studying bipolar disorder that would enhance the ethnic/racial and socioeconomic diversity of participants. METHODS: Selected academic sites partnered with local clinics (n = 6 partnerships in five cities). This report describes the conceptualization, implementation, and qualitative evaluation of CPP, as well as quantitative analysis of clinical and sociodemographic differences between the samples recruited at academic versus community sites. RESULTS: Quantitative analysis of the 155 participants from the six partnerships revealed enrollment of 45% from minority populations (vs. 15% in academic sites). Significant sociodemographic differences were evident not only between academic and community sites, but within minority and non-minority groups across site types. Notably, clinical differences were not evident between participants from academic and community sites. Review of qualitative data suggests that certain factors around implementation of research protocols may enhance community participation. CONCLUSIONS: Moving research recruitment and participation into community sites was more successful in increasing minority enrollment than efforts to attract such individuals to academic sites. Recommendations for creating and maintaining academic/community partnerships are given. LIMITATIONS: Several important variables were not considered including mood severity, hospitalization, or treatment differences. Minority participants were grouped by combining African American and Hispanics, which may have obscured subgroup differences. A derivation of standard qualitative methods was used in this study.

Psychosocial treatments for bipolar depression: a 1-year randomized trial from the Systematic Treatment Enhancement Program.

CONTEXT: Psychosocial interventions have been shown to enhance pharmacotherapy outcomes in bipolar disorder. OBJECTIVE: To examine the benefits of 4 disorder-specific psychotherapies in conjunction with pharmacotherapy on time to recovery and the likelihood of remaining well after an episode of bipolar depression. DESIGN: Randomized controlled trial. SETTING: Fifteen clinics affiliated with the Systematic Treatment Enhancement Program for Bipolar Disorder. Patients A total of 293 referred outpatients with bipolar I or II disorder and depression treated with protocol pharmacotherapy were randomly assigned to intensive psychotherapy (n = 163) or collaborative care (n = 130), a brief psychoeducational intervention. INTERVENTIONS: Intensive psychotherapy was given weekly and biweekly for up to 30 sessions in 9 months according to protocols for family-focused therapy, interpersonal and social rhythm therapy, and cognitive behavior therapy. Collaborative care consisted of 3 sessions in 6 weeks. MAIN OUTCOME MEASURES: Outcome assessments were performed by psychiatrists at each pharmacotherapy visit. Primary outcomes included time to recovery and the proportion of patients classified as well during each of 12 study months. RESULTS: All analyses were by intention to treat. Rates of attrition did not differ across the intensive psychotherapy (35.6%) and collaborative care (30.8%) conditions. Patients receiving intensive psychotherapy had significantly higher year-end recovery rates (64.4% vs 51.5%) and shorter times to recovery than patients in collaborative care (hazard ratio, 1.47; 95% confidence interval, 1.08-2.00; P = .01). Patients in intensive psychotherapy were 1.58 times (95% confidence interval, 1.17-2.13) more likely to be clinically well during any study month than those in collaborative care (P = .003). No statistically significant differences were observed in the outcomes of the 3 intensive psychotherapies. CONCLUSIONS: Intensive psychosocial treatment as an adjunct to pharmacotherapy was more beneficial than brief treatment in enhancing stabilization from bipolar depression. Future studies should compare the cost-effectiveness of models of psychotherapy for bipolar disorder. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00012558.

Intensive psychosocial intervention enhances functioning in patients with bipolar depression: results from a 9-month randomized controlled trial.

OBJECTIVE: Psychosocial interventions are effective adjuncts to pharmacotherapy in delaying recurrences of bipolar disorder; however, to date their effects on life functioning have been given little attention. In a randomized trial, the authors examined the impact of intensive psychosocial treatment plus pharmacotherapy on the functional outcomes of patients with bipolar disorder over the 9 months following a depressive episode. METHOD: Participants were 152 depressed outpatients with bipolar I or bipolar II disorder in the multisite Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study. All patients received pharmacotherapy. Eighty-four patients were randomly assigned to intensive psychosocial intervention (30 sessions over 9 months of interpersonal and social rhythm therapy, cognitive behavior therapy [CBT], or family-focused therapy), and 68 patients were randomly assigned to collaborative care (a 3-session psychoeducational treatment). Independent evaluators rated the four subscales of the Longitudinal Interval Follow-Up Evaluation-Range of Impaired Functioning Tool (LIFE-RIFT) (relationships, satisfaction with activities, work/role functioning, and recreational activities) through structured interviews given at baseline and every 3 months over a 9-month period. RESULTS: Patients in intensive psychotherapy had better total functioning, relationship functioning, and life satisfaction scores over 9 months than patients in collaborative care, even after pretreatment functioning and concurrent depression scores were covaried. No effects of psychosocial intervention were observed on work/role functioning or recreation scores during this 9-month period. CONCLUSIONS: Intensive psychosocial treatment enhances relationship functioning and life satisfaction among patients with bipolar disorder. Alternate interventions focused on the specific cognitive deficits of individuals with bipolar disorder may be necessary to enhance vocational functioning after a depressive episode.

Predictors of timely follow-up care among medicaid-enrolled adults after psychiatric hospitalization.

OBJECTIVE: This study examined whether predictors of timely follow-up care after inpatient psychiatric discharge in non-Medicaid populations also predicted timely follow-up care among Medicaid-enrolled adults. METHODS: The study examined the rates of seven- and 30-day follow-up care for 6,730 Medicaid-enrolled adults discharged from inpatient psychiatric facilities during 2004 and 2005 by using claims data from the largest Medicaid managed behavioral health organization in a large mid-Atlantic state. The relationship between predictor variables and timely aftercare was examined by using multiple logistic regression. RESULTS: Thirty percent of individuals received follow-up care within seven days, and 49% received follow-up care within 30 days. After the analysis controlled for age and gender, those receiving clinical services in the 30 days before hospitalization were significantly more likely to receive follow-up care within seven days (odds ratio [OR]=3.59, 95% confidence interval [CI]=3.20-4.03) than individuals with longer inpatient stays (ten or more days) (OR=1.34, CI=1.15-1.57) and individuals from urban communities (OR=1.18, CI=1.05-1.34). African Americans (OR=.69, CI=.60-.78), individuals with co-occurring behavioral health and substance use disorders (OR=.78, CI=.68-.89), individuals involuntarily admitted (OR=.79, CI=.68-.91), and individuals discharged against medical advice (OR=.59, CI=.39-.87) were significantly less likely than their comparison groups to receive follow-up care within seven days. Thirty-day follow-up care results were similar. CONCLUSIONS: Patient sociodemographic, clinical, and service utilization characteristics predicted timely follow-up care. Efforts to improve follow-up care utilization should target higher-risk individuals while developing and evaluating interventions to address specific barriers in these groups.

Connected Care: improving outcomes for adults with serious mental illness.

OBJECTIVES: To evaluate the effectiveness of Connected Care-a care coordination effort of physical and behavioral health managed care partners in Pennsylvania-on acute service use among adult Medicaid beneficiaries with serious mental illness (SMI). STUDY DESIGN: We examined changes in service utilization using a difference-in-differences model, comparing study group with a comparison group, and conducted key informant interviews to better understand aspects of program implementation. METHODS: We compared the difference in service use rates between baseline year and 2-year intervention period for the Connected Care group (n = 8633) with the difference in rates for the comparison group (n = 10,514), confirming results using a regression adjustment. RESULTS: Mental health hospitalizations (per 1000 members per month) decreased for the Connected Care group from 41.1 to 39.6, while increasing for the comparison group from 33.8 to 37.2 (P = .04). All-cause readmissions within 30 days decreased nearly 10% for Connected Care while increasing slightly for the comparison group (P < .01), with a similar pattern observed for 60- and 90-day all-cause readmissions. No differences were observed in physical health hospitalizations, drug and alcohol admissions, or ED use. Data from qualitative stakeholder interviews illuminated facilitators and barriers of implementing Connected Care. CONCLUSIONS: Payer-level healthcare information sharing can help identify members who could benefit from care coordination services, inform care management activities, and assist with pharmacy management. Results can inform state, health plan, and provider efforts around integration of care for individuals with SMI and improve care efficiencies and quality, which is especially important in this time of Medicaid expansion.

Brief Critical Time Intervention to Reduce Psychiatric Rehospitalization.

OBJECTIVE: The study investigated the association between implementation of a brief critical time intervention (BCTI) model and occurrence of early and long-term psychiatric readmission of adults with serious mental illness. METHODS: A sample of 149 adults with a psychiatric inpatient readmission within 30 days of a prior psychiatric hospitalization was referred to an acute level of service coordination (ASC) available at six provider organizations implementing BCTI. Activities important to the delivery of BCTI were monitored and supported. A comparison cohort of 224 adults served by ASC at the same organizations before implementation of BCTI was derived from administrative data. Frequencies of behavioral health service utilization and readmission rates for the intervention and comparison cohorts within 30 and up to 180 days of the prior readmission were compared. RESULTS: Utilization rates of mental health and substance use disorder services were similar for both cohorts postdischarge. The proportion of individuals readmitted within 30 days of a discharge was lower for the BCTI cohort (28%) than the comparison cohort (47%) (p<.001). Longer-term readmission rates also were lower in the BCTI cohort but were not significantly different from the comparison cohort (44% versus 52%). With analyses controlling for patient characteristics and service utilization, individuals in the comparison cohort were 2.83 times more likely to be readmitted within 30 days than those who received BCTI (p<.001). CONCLUSIONS: BCTI was associated with decreased early readmission rates, suggesting that this model may be an effective approach to improve continuity of care for this population.

Evaluation of an implementation initiative for embedding Dialectical Behavior Therapy in community settings.

We examined the effectiveness of Dialectical Behavior Therapy (DBT) training in community-based agencies. Data were gathered at four time points over a 2-year period from front-line mental health therapists (N=64) from 10 community-based agencies that participated in a DBT implementation initiative. We examined change on therapist attitudes toward consumers with Borderline Personality Disorder (BPD), confidence in the effectiveness of DBT, and use of DBT model components. All measures were self-report. Participating in DBT training was associated with positive changes over time, including improved therapist attitudes toward consumers with BPD, improved confidence in the effectiveness of DBT, and increased use of DBT components. Therapists who had the lowest baseline scores on the study outcomes had the greatest self-reported positive change in outcomes over time. Moreover, there were notable positive correlations in therapist characteristics; therapists who had the lowest baseline attitudes toward individuals with BPD, confidence in the effectiveness of DBT, or who were least likely to use DBT modes and components were the therapists who had the greatest reported increase over time in each respective area. DBT training with ongoing support resulted in changes not commonly observed in standard training approaches typically used in community settings. It is encouraging to observe positive outcomes in therapist self-reported skill, perceived self-efficacy and DBT component use, all of which are important to evidence-based treatment (EBT) implementation. Our results underscore the importance to recognize and target therapist diversity of learning levels, experience, and expertise in EBT implementation.

Facilitators and barriers associated with implementation of evidence-based psychotherapy in community settings.

OBJECTIVE Despite widespread use of individual outpatient psychotherapies among community mental health centers (CMHCs), few studies have examined implementation of these psychotherapies. This exploratory qualitative study identified key themes associated with the implementation of an empirically supported psychotherapy in CMHCs. METHODS The authors conducted semistructured interviews with 12 key informants from four CMHCs that had implemented interpersonal and social rhythm therapy (IPSRT). Their responses were categorized into key themes. RESULTS Five major themes were identified: pretraining familiarity with IPSRT, administrative support for implementation, IPSRT fit with usual practice and clinic culture, implementation team and plan, and supervision and consultation. Discussion of these themes varied among participants from clinics considered successful or unsuccessful implementers. CONCLUSIONS Participants identified both key themes and several strategies for facilitating implementation. The findings suggest that when these key factors are present, outcome-enhancing treatments can be implemented and sustained, even in clinics with limited resources.

Concurrent mental health therapy among medicaid-enrolled youths starting antipsychotic medications.

OBJECTIVE: The use of antipsychotic medications among children and adolescents has increased substantially in recent years, predominantly in disorders for which effective psychosocial interventions exist. The authors of this study examined the extent to which youths being prescribed antipsychotic medications were receiving concurrent mental health therapy. METHODS: Using administrative data, the authors identified 6,110 Medicaid-enrolled youths starting antipsychotic medications from November 1, 2006, through October 31, 2009, and identified youths who had received any concurrent mental health therapy. Multivariate regression models were used to examine the relationship between concurrent therapy and sociodemographic and clinical variables. RESULTS: Sixty-eight percent (N=4,155) of youths starting antipsychotic medications received concurrent therapy. Multivariate regression findings are that concurrent therapy was more common with younger children, recently hospitalized youths, children from urban communities, youths from racial-ethnic minority groups, children with an antipsychotic-indicated diagnosis, and youths eligible for Medicaid because of family income. CONCLUSIONS: The finding that 68% of youths starting antipsychotic medications received concurrent therapy suggests that for a majority of children, these medications complemented rather than substituted for nonpharmacologic interventions. However, with almost one-third of youths not receiving concurrent therapy, a better understanding of the factors contributing to the lack of concurrent therapy for youths starting antipsychotic medications is needed. Children and families should be aware of and have access to effective psychosocial treatments for disorders such as attention-deficit hyperactivity disorder and depression that are common among children receiving antipsychotic medications.

Treatment of attention-deficit hyperactivity disorder: patterns of evolving care during the first treatment episode.

OBJECTIVE: This study sought to better understand factors associated with different patterns of treatment among children starting treatment for attention-deficit hyperactivity disorder (ADHD). METHODS: Factors associated with service utilization and pharmacy claims data for 2,077 Medicaid-enrolled children aged six to 12 who started treatment for ADHD between October 2006 and December 2007 in a large mid-Atlantic state were investigated by using logistic regressions and Cox proportional hazard models. RESULTS: A total of 45% of children started ADHD treatment with a psychosocial intervention alone, 41% of children started treatment with medication alone, and 14% of children started treatment with a combination of both treatments. By the end of the treatment episode, 42% of children who initiated treatment with psychosocial interventions alone had added medication. Within six months of starting treatment, approximately 40% of children had discontinued treatment. Among those who continued receiving treatment, a majority received medication, either alone or with a psychosocial intervention. Treatment with a psychosocial intervention was significantly more likely to be initiated among nonwhite versus white children and among younger versus older children. Younger versus older children and African-American versus Caucasian children were significantly more likely to drop out of treatment sooner. CONCLUSIONS: During the first episode of treatment for ADHD, the interventions children received frequently changed, suggesting dissatisfaction with initial treatment. Further research is needed to better understand what underlies the patterns of evolving care so that all families seeking care for children with ADHD may receive preferred and effective treatment.

Use of outcomes information in child mental health treatment: results from a pilot study.

OBJECTIVE: This study examined parents and clinicians' use in treatment sessions of routinely collected information on child functioning for children receiving ambulatory mental health treatment. METHODS: Information was obtained from 1,215 Child Outcomes Surveys completed at ten provider organizations. The Child Outcomes Survey is a collaboratively developed brief strength-based measure of child functioning and therapeutic relationship. This study examined parent-clinician discussion of information obtained in the survey from the previous session. Chi square tests were used to examine the association between sociodemographic and clinical covariates and parent-clinician discussion of information. RESULTS: In the measure that assessed the extent to which parents discussed the information about their child's functioning in the prior session with their clinician, 61% of parents reported high levels of discussion, 25% of parents reported moderate levels of discussion, and 14% reported low levels of discussion. Parents of boys, Latino children, and children of "other" races were significantly more likely to report high levels of discussion than other parents. Levels of discussion about the results of the previous Child Outcomes Survey were positively and significantly associated with successful child functioning and therapeutic relationship with clinicians. CONCLUSIONS: The findings of high rates of use of outcomes data routinely gathered with a very brief measure are encouraging given prior reports of challenges in using such information in treatment sessions. The successful treatment of children and families requires an ongoing and effective partnership between parents and clinicians, and the results suggest how important routine conversations about the progress of children in treatment can be. Further research is needed to understand the impact of gathering and using such data on the process and outcomes of mental health treatment for children and families.

Predictors of adequate depression treatment among Medicaid-enrolled adults.

OBJECTIVE: To determine whether Medicaid-enrolled depressed adults receive adequate treatment for depression and to identify the characteristics of those receiving inadequate treatment. DATA SOURCE: Claims data from a Medicaid-enrolled population in a large mid-Atlantic state between July 2006 and January 2008. STUDY DESIGN: We examined rates and predictors of minimally adequate psychotherapy and pharmacotherapy among adults with a new depression treatment episode during the study period (N=1,098). PRINCIPAL FINDINGS: Many depressed adults received either minimally adequate psychotherapy or pharmacotherapy. Black individuals and individuals who began their depression treatment episode with an inpatient psychiatric stay for depression were markedly less likely to receive minimally adequate psychotherapy and more likely to receive inadequate treatment. CONCLUSIONS: Racial minorities and individuals discharged from inpatient treatment for depression are at risk for receiving inadequate depression treatment.

One-year treatment outcomes of African-American and Hispanic patients with bipolar I or II disorder in STEP-BD.

OBJECTIVE: Few studies have compared treatment outcomes of African-American, Hispanic, and non-Hispanic white patients with bipolar disorder. The U.S. Systematic Treatment Enhancement Program for Bipolar Disorder compared one-year outcomes for bipolar I or II disorder from each of these racial-ethnic groups. METHODS: African Americans (N=155) were retrospectively compared with a matched group of non-Hispanic whites (N=729), and Hispanics (N=152) were compared with a separate matched group of non-Hispanic whites (N=822). Response and recovery outcomes were examined. Survival analysis was used to compare time to treatment response for depression (Montgomery-Asberg Depression Rating Scale) and mania (Young Mania Rating Scale) as well as global assessment of functioning (Global Assessment of Functioning). RESULTS: For manic and depressive symptoms, time to response and proportion of responders were similar across groups. Over the study year the proportion of days well was similar across groups. A smaller proportion of African Americans met criteria for improved global functioning. Depression response among African Americans with psychotic symptoms was slower than the response among African Americans without psychotic symptoms and among non-Hispanic whites with or without psychotic symptoms. No differences between Hispanics and non-Hispanic whites in response times and recovery were observed. CONCLUSIONS: Results are consistent with U.S. clinical trials for other psychiatric disorders, which have reported similar outcomes for ratings of primary symptoms. Baseline psychotic symptoms are likely a significant contributor when African Americans with bipolar disorder are slow to recover. These results may be less generalizable to uninsured patients.