High-quality Mental Health Services Research Articles (Page 4)

Experts Outline Costs, Barriers To High-Quality Depression Treatment

Managed care organizational complexity and access to high-quality mental health services: Perspective of U.S. primary care physicians

Back to table of contents Previous article Next article Special Section on Long-Term CareFull AccessMental Health Services in Nursing Homes: Introduction to Special SectionMarion Zucker Goldstein, M.D.Marion Zucker GoldsteinSearch for more papers by this author, M.D.Published Online:1 Nov 2002https://doi.org/10.1176/appi.ps.53.11.1389AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail A multidisciplinary consensus conference on providing optimal mental health services in long-term care was held June 22 to 24, 2000, in Washington, D.C. The conference, on which this special section is based, was conceived and implemented by a steering committee whose members represented the American Association for Geriatric Psychiatry, the American Psychiatric Association, the American Society for Consultant Pharmacists, the American Psychological Association, the American Geriatrics Society, the American College of Health Care Administrators, and the National Association of Directors of Nursing Administration.Barriers to research and to the implementation of findings that would improve the quality of life of the increasing number of nursing home patients and their families remain most difficult to penetrate (1). Despite these barriers, considerable advances have been made in our knowledge of the assessment, incidence, and prevalence of psychiatric disorders and the inordinate unmet need for mental health services in nursing homes.To overcome barriers to high-quality mental health services in nursing homes, insight into the systems in which they occur is vital (2). An understanding of governmental agencies, oversights, and payment policies as well as clarification of the role and competencies of primary care physicians, psychiatrists, psychologists, pharmacists, social workers, nurses, and administrators is essential. The authors of the five articles in this special section address these issues.Stephen J. Bartels, M.D., M.S., and his coauthors (see page 1390) reviewed the literature on the effectiveness of optimal models of service delivery in nursing homes and on provider surveys. Although they advocate more rigorous outcome studies on the optimal intensity of services, composition of interdisciplinary teams, competencies, and cost-effectiveness, their review confirms that most effective interventions blend consultation with the training and education of primary care physicians and frontline nursing staff.In the second article, Cameron J. Camp, Ph.D., and his colleagues (see page 1397) define the various subtypes of inappropriate behaviors observed among persons with dementia and the unmet needs reflected by such behaviors. This well-referenced analysis of individualized needs assessments is interspersed with an equally well-supported rationale for interventions that are proven to be effective. The authors confirm that much education is necessary to bring the advances made by research into the practice arena and highlight the need for future research.Next, Marisue Cody, Ph.D., R.N., and her colleagues (see page 1402) address barriers that arise from nursing home organization and structure and that are compounded by external barriers from regulatory agencies and legal and economic constraints. The authors give specific recommendations related to communications and environmental adaptations that can overcome internal barriers. The need to overhaul staffing patterns, education, and reimbursements is an ongoing outcry of all who wish to improve conditions in nursing homes. The authors also discuss their recommendation that nursing homes adopt a risk management approach similar to that used by hospitals.In the fourth article J. Michael Ryan, M.D., and his colleagues—a fellow psychiatrist and two pharmacists—address the use of psychotropic, antidepressant, anticonvulsant, and cholinesterase-inhibiting medications from both a historical and a regulatory perspective (see page 1407). They bring readers up-to-date on the outcomes of several randomized, placebo-controlled studies that provide an evidence base for various prescribing decisions. Whether and how this research proceeds will depend on federal, state, and local governments and on the pharmaceutical industry. The lack of interface between pharmacologic and nonpharmacologic treatments is apparent and regrettable.Finally, Joel E. Streim M.D., and his coauthors discuss regulatory oversight, payment policy, and quality improvement in the provision of mental health services in nursing homes (see page 1414). The many acronyms that have been generated by government agencies over the past 15 years are clearly explained within their evolving contexts. The authors clarify the roles of the psychiatrist, the psychologist, and the social worker in budgetary processes, including denial of medically necessary medical mental health services. They explain concisely how assessment, quality measures, and payment policy must be coordinated so that nursing home patients can have access to medical mental health services when "medically necessary." They point out that mental health providers must be offered appropriate financial incentives to work in nursing homes.Dr. Goldstein, guest editor of this special section, is associate professor of psychiatry in the division of geriatric psychiatry at the School of Medicine and Biomedical Sciences at the State University of New York at Buffalo. Send correspondence to her at the Erie County Medical Center, Department of Psychiatry, 462 Grider Street, Buffalo, New York 14215 (e-mail, [email protected]).

To discuss issues relevant to treating young African American children with disruptive behavior disorders. We treat behavior disorders, correlates of behavior disorders, and special differences between African American and Caucasian children that could lead to or explain behavior problems. The majority of the information on young children diagnosed with disruptive behavior disorders has been obtained primarily from Caucasian children and families. Unfortunately, this reliance on Caucasian data neglects the unique needs of minorities and may lessen the quality of the services that they receive. Omission of ethnic concerns becomes even more salient with the increasing ethnic diversity among children and families in the United States. We suggest future research and clinical directions that will ultimately assist clinicians to provide high-quality mental health services to African American children.

To determine the rate and predictors of unmet need for recognition of common mental disorders in Australian general practice. Cross-sectional national audit of general practices throughout Australia in 1998-1999. 46 515 ambulatory care patients attending 386 GPs. Prevalence of common mental disorders--12 items from the 34-item SPHERE self-report questionnaire and associated classification system; prevalence of recognition of mental disorders by GPs--GPs reporting whether patients had depression, anxiety, mixed depression/anxiety, somatoform, or other psychological disorder; predictors of unmet need for recognition of mental disorders--self-report questions about demography for patients and GPs, and about practice organisation for GPs. Reported recognition of psychological disorders by GPs; actual prevalence of disorders; and patient, GP and practice characteristics predicting the failure to recognise disorders. GPs did not recognise mental disorder in 56% (11922/21210) of patients. These comprised 46% (5134/11060) of patients in the higher level of mental disorders, and (in the second level of disorders) 58% (2906/5036) of patients with predominantly psychological symptoms, and 76% (3882/5114) of those with predominantly somatic symptoms. Patients more likely to have their need for psychological assessment met had the following characteristics: middle-aged (odds ratio [OR], 1.76; 95% CI, 1.59-1.96), female (OR, 1.19; 95% CI, 1.12-1.27), Australian-born (OR, 1.16; 95% CI, 1.08-1.24), unemployed (OR, 1.75; 95% CI, 1.64-1.89), single (OR, 1.52; 95% CI, 1.41-1.61), presenting with mainly psychological symptoms (OR, 3.54; 95% CI, 3.28-3.81), and presenting for psychological reasons (OR, 4.20; 95% CI, 3.02-5.82). Characteristics of doctors associated with meeting patients' need for assessment were being aged over 35 years (OR, 1.51; 95% CI, 1.09-2.08), having an interest in mental health (OR, 1.27; 95% CI, 1.15-1.41), having had previous mental health training (OR, 1.29; 95% CI, 1.15-1.45), being in part-time practice (OR, 1.23; 95% CI, 1.09-1.39), seeing fewer than 100 patients per week (OR, 1.29; 95% CI, 1.13-1.47), working in practices with fewer than 2000 patients (OR, 1.28; 95% CI, 1.13-1.45) and working in regional centres (OR, 1.16; 95% CI, 1.05-1.28). Unmet need for recognition of common mental disorders remains high. Predictors of unmet need include a somatic symptom profile and practitioner and organisational characteristics which impede the provision of high quality mental health services.

Back to table of contents Previous article Next article Book ReviewFull AccessManagement and Supervision of Jail Inmates With Mental DisordersMelissa G. Warren, Ph.D.Melissa G. WarrenSearch for more papers by this author, Ph.D.Published Online:1 Nov 2000https://doi.org/10.1176/appi.ps.51.11.1458AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Drapkin's book outlines the main functions that a mental health service must perform in a jail, and it does so in a highly accessible fashion. As the number of people incarcerated in U.S. jails and prisons continues to rise steeply, sheriffs and other correctional administrators find it necessary not only to house offenders with serious mental disorders safely but also to identify and treat them.This book is a valuable tool for jail administrators who want to build a program or audit an existing one, for community-based mental health providers who are asked to serve a jailed population, and for medical and mental health care staff who work in jails. Drapkin developed this book not only to be useful but also to help combat one of the greatest obstacles to high-quality mental health services in jails—the professional isolation of the staff. Professional staff who work in correctional facilities often feel that they are on the periphery of their disciplines. They find that information does not pass easily through the walls of a custodial institution.Many thoughtful touches are evident in the format of the book. It includes forms that can be copied, and the loose-leaf binder permits users to rearrange material or add supplements as their service changes and professional standards evolve.The scope of Drapkin's book is comprehensive. Chapters or sections on the law that specifies the minimum standards for medical treatment in jails, on screening new admissions to a jail, and on suicide prevention, medication management, crisis intervention, and specialized housing units are well written and comprehensible to a reader with no prior correctional experience or legal knowledge. The book furnishes ready-to-use policies and procedures for gathering clinical information and for triaging, to name only two of many areas covered. It has sample behavioral treatment plans for use with jail inmates with character disorders who exhibit antisocial, borderline, or paranoid features and engage in repeated, goal-directed self-injury by cutting.The strength of the book is also its weakness. Like Oedipus, who tried mightily to avoid a bad outcome, this book may lead well-intentioned users, seduced by its accessibility and comprehensiveness, down the path to misfortune. In the face of demands to handle larger jail populations with no concomitant increases in staff and space, administrators and treatment providers are told to above all avoid major, preventable error. The kinds of errors that result in successful lawsuits against municipalities and their correctional facilities can be made by capable people if they adopt the forms and implement the practices so well described in the book in the absence of qualified staff practicing within their areas of competence.Such situations are most likely to occur in smaller jails, and most jails in the U.S. are small. Small jails aren't likely to hire a consultant to tell them how to establish mental health services that will keep them out of legal trouble, nor do they typically have the full array of specialists needed to perform medical screenings, assess risk for suicide, and diagnose and treat people who are mentally ill. The book's comprehensiveness and utility could tempt a well-intentioned person to proceed without qualified staff, relying too heavily on the book.For example, the guide contains a list of psychotropic medications and their recommended dosages. In addition to management and supervision plans for inmates with antisocial, borderline, and paranoid disorders, the book offers sections on identifying and managing depression, bipolar disorder, and schizophrenia. Is the user supposed to diagnose, medicate, and treat these disorders on the basis of this comprehensive guide? Might someone do just that in a pinch? All of the pertinent information is here; nothing important is missing. Similarly, sample policies and procedures cover important areas quite well, but their success depends wholly on how they are implemented. In the absence of a larger body of contextual information, derived from experience, training, or both, a little knowledge might be a dangerous thing.Dr. Warren is managing editor of the American Psychologist. She has 16 years of experience in service delivery, research, training, and other areas in the corrections field.by Martin Drapkin; Kingston, New Jersey, Civic Research Institute, 1999, 352 pages, loose-leaf, $125 FiguresReferencesCited byDetailsCited ByNone Volume 51Issue 11 November 2000Pages 1458-1458 Metrics History Published online 1 November 2000 Published in print 1 November 2000

BACKGROUND: Within the past decade, the mental health care system in the United States has undergone a significant transformation in terms of delivery, financing and work force configuration. Contracting between managed care organizations (MCOs) and providers has become increasingly prevalent, paralleling the trend in health care in general. These managed care carve-outs in behavioral health depend on networks of providers who agree to capitated rates or discounted fees for service for those patients covered by the carve-out contracts. Moreover, the carve-outs use a broader array of mental health providers than is typically found in traditional indemnity plans, encourage time-limited versus long-term treatments and favor providers who are engaged in outpatient care. This phenomenal growth in managed behavioral health care over the past decade includes the rapid growth and quick consolidation of mental health MCOs. The period 1992-1998 shows steady and substantial annual increases in the number of enrollees in mental health MCOs, the figure more than doubling from 78.1 million people in 1992 to a projected 156.6 million in 1998, or 70% of insured lives. Moreover, these vast numbers of enrollees are becoming increasingly consolidated into a smaller number of firms. In 1997, 12 companies controlled nearly 85% of the managed behavioral health care market, with 60% of the market held by the three largest firms. STUDY AIMS: This article reviews empirical data and draws policy implications from the literature on managed behavioral health care in the United States. Starting with spending and spending trend estimates that show the average annual growth rate of mental health expenditures to be lower than that of health care expenditures in general over the past decade, the author examines utilization and price factors that may account for managed-care-induced cost reductions in behavioral health care, with special attention to hospital use patterns, fee discounting and the supply and earnings patterns of various types of mental health provider. In addition, data on staffing ratios and provider mixes of health maintenance organizations and mental health MCOs are reviewed as they reveal at least part of the dynamics of reconfiguration of the mental health work force in this era of managed care. CONCLUSIONS: As measured by changes in utilization and price, widespread application of "classic" managed care techniques such as preadmission review (gatekeeping), concurrent review, case management, standardized clinical guidelines and protocols, volume purchase of services and fee discounting appears to have led to significant cost reductions for providers of both impatient and outpatient mental health services. However, amidst a complex flux of market variables such as risk shifting, changing financial incentives and intensity of competition, not all of the reduction or slowdown in spending can be clearly and purely attributed to managed care. The data on the ongoing reconfiguration of the mental health work force are clearer in their implications: with an oversupply of all types of mental health providers, managed care has significant potential to increase the incidence of provider substitutions and spur the growth of integrated group practices. IMPLICATIONS FOR FURTHER RESEARCH: The current body of empirical and policy literature in mental health economics suggests several salient areas of follow-up. Is the proportionately greater impact of managed care on the annual growth rate of mental health care spending a temporary phenomenon or does it signal an enduring difference in the rates of increase between behavioral health care and health care in general? Beyond industry downsizing, what are the substitutions among mental health providers that are going on, and will go on, to produce cost-effective practices? What are the new financial or risk-sharing arrangements between providers and MCOs that will produce appropriate and high-quality mental health services?

The Economics Of Pain: Mental Health Care Costs Among Minorities

The literature on psychopathology among children in family foster care published in the last 20 years was reviewed to estimate prevalence and types of psychopathology in this population. A comprehensive computerized database was searched for the period 1974 through 1994, with emphasis on recent literature. Available evidence suggests that the prevalence of psychopathology among children in family foster care is higher than would be expected from normative data, even when this population is compared with children who have backgrounds of similar deprivation. As for the types of psychopathology in this population, the only apparent trend is the predominance of externalizing disorders, such as disruptive behavior disorders. A combination of social, psychological, and biological factors may render children in family foster care highly vulnerable to psychopathology.