Medication Management Visits Research Articles

Engaging African-American Veterans in Mental Health Care: Patients' Perspectives.

Despite growing interest in patient engagement, the concept remains poorly defined. Moreover, patients' perspectives on engagement are lacking, particularly those of minority patients. A better understanding of patients' views and what influences their engagement in health services will facilitate better patient education and implementation practices to enhance patient participation in health care. This article addresses patients' perspectives of facilitators and barriers to engagement in outpatient mental health services. Forty-nine African-American veterans with mental illness receiving routine medication management visits were interviewed. Qualitative data analysis was guided by a constructivist grounded theory approach. Participants identified several barriers and facilitators to engagement in mental health services, including patient as well as provider-related factors. Results emphasize the role of providers in facilitating sustained involvement of patients in their own care. Based on the findings, the authors offer a preliminary framework for patient engagement that encompasses patient and provider factors.

Consumer satisfaction with psychiatric services: The role of shared decision making and the therapeutic relationship.

Although dissatisfaction is a primary reason for disengagement from outpatient psychiatric care among consumers with serious mental illnesses, little is known about predictors of their satisfaction with medication management visits. The primary purpose of this study was to explore how dimensions of consumer preferences for shared decision making (i.e., preferences for obtaining knowledge about one's mental illness, being offered and asked one's opinion about treatment options, and involvement in treatment decisions) and the therapeutic relationship (i.e., positive collaboration and type of clinician input) were related to visit satisfaction. Participants were 228 Veterans with serious mental illnesses who completed a 19-item self-report questionnaire assessing satisfaction with visits to prescribers (524 assessments) immediately after visits. In this correlational design, a 3-level mixed model with the restricted maximum likelihood estimation procedure was used to examine shared decision-making preferences and therapeutic alliance as predictors of visit satisfaction. Preferences for involvement in treatment decisions was the unique component of shared decision making associated with satisfaction, such that the more consumers desired involvement, the less satisfied they were. Positive collaboration and prescriber input were associated with greater visit satisfaction. When consumers with serious mental illnesses express preferences to be involved in shared decision making, it may not be sufficient to only provide information and treatment options; prescribers should attend to consumers' interest in involvement in actual treatment decisions. Assessment and tailoring of treatment approaches to consumer preferences for shared decision making should occur within the context of a strong therapeutic relationship.

Extended-release naltrexone to prevent relapse among opioid dependent, criminal justice system involved adults: Rationale and design of a randomized controlled effectiveness trial

BackgroundExtended-release naltrexone (XR-NTX, Vivitrol®; Alkermes Inc.) is an injectable monthly sustained-release mu opioid receptor antagonist. XR-NTX is a potentially effective intervention for opioid use disorders and as relapse prevention among criminal justice system (CJS) populations. MethodsThis 5-site open-label randomized controlled effectiveness trial examines whether XR-NTX reduces opioid relapse compared with treatment as usual (TAU) among community dwelling, non-incarcerated volunteers with current or recent CJS involvement. The XR-NTX arm receives 6 monthly XR-NTX injections at Medical Management visits; the TAU group receives referrals to available community treatment options. Assessments occur every 2weeks during a 24-week treatment phase and at 12- and 18-month follow-ups. The primary outcome is a relapse event, defined as either self-report or urine toxicology evidence of ≥10days of opioid use in a 28-day (4week) period, with a positive or missing urine test counted as 5days of opioid use. ResultsWe describe the rationale, specific aims, and design of the study. Alternative design considerations and extensive secondary aims and outcomes are discussed. ConclusionsXR-NTX is a potentially important treatment and relapse prevention option among persons with opioid dependence and CJS involvement.ClinicalTrials.gov: NCT00781898

Rates of Psychiatrists’ Participation in Health Insurance Networks

Rates of Psychiatrists’ Participation in Health Insurance Networks

A pilot trial of injectable, extended-release naltrexone for the treatment of co-occurring cocaine and alcohol dependence.

There is a high co-occurrence of cocaine and alcohol use disorders, and patients with both of these problems are difficult to treat. There is a reasonable rationale and some empirical data to justify a pilot trial of an injectable, extended-release formulation of naltrexone for treating co-occurring cocaine and alcohol addiction. Eighty cocaine (n = 80) and alcohol dependent, treatment-seeking subjects were randomly assigned to receive either two monthly extended-release injections of naltrexone or two matching placebo injections in an 8-week clinical trial, with weekly medical management plus cognitive behavioral therapy visits. No differences in reduction in cocaine or alcohol use were observed between the injectable naltrexone and placebo groups during the 8-week trial. Injectable extended-release naltrexone, while an ideal method for ensuring medication adherence in these traditionally hard-to-treat patients, did not result in any measurable reduction in cocaine or alcohol use over the course of 8 weeks of treatment.

OR14-4 * EFFECTIVENESS OF EXTENDED-RELEASE NALTREXONE (XR-NTX) AMONG CRIMINAL JUSTICE-INVOLVED PERSONS WITH OPIOID USE DISORDERS

Introduction. XR-NTX is increasingly considered as a therapeutic option for opioid use disorders in criminal justice settings despite limited evidence for its effectiveness in this population. Methods. A 5-site open-label 24-week randomized effectiveness trial examined whether XR-NTX (6 monthly 380mg IM injections and Medical Management visits) reduced relapse compared with treatment-as-usual (TAU) among criminal justice-involved, opioid dependent participants. Assessments occurred every 2 weeks. The primary outcome of relapse was defined as 5 or more days of self-reported opioid use, or 2 or more self-reported days of opioid use plus a positive urine for opioids in a two week period (i.e. fortnight); missing urines were counted as positive. Results. 308 subjects randomized to XR-NTX (n = 153) and TAU (n = 155) did not differ at baseline; 87% reported lifetime heroin use. 282 of 308 have completed the 24-week treatment phase to date. XR-NTX subjects vs. TAU were less likely to relapse at any point (13% vs. 32%, p < 0.0001), have a lower rate of relapse fortnights (5% vs. 16%, p < 0.0001), and a longer median time-to-relapse (6 vs. 3 fortnights, Hazard Ratio 0.36, p < 0.0002). Conclusion. XR-NTX reduced opioid misuse among criminal justice-involved opioid dependent participants.

Psychiatry Resident Outpatient Clinic Supervision: How Training Directors Are Balancing Patient Care, Education, and Reimbursement

Recent literature on psychiatry resident outpatient clinic supervision is sparse. In designing outpatient supervision, training directors must balance optimization of patient care, education, and reimbursement. The authors sought to describe current practices for supervision within psychiatry resident outpatient clinics. Directors of US psychiatric residency training programs were surveyed to examine methods used for supervision and billing in psychiatry resident outpatient clinics. Seventy of 183 (38%) training directors responded. Most programs utilize live supervision for medication management visits, but psychotherapy supervision is more varied. Billing practices are variable among programs. This report is intended to help training directors consider options for optimizing patient care and resident education in their outpatient clinics, while maintaining financial solvency. Ultimately, programs should have a way of ensuring all patient cases have some form of ongoing supervision, with possible modification based on training level, resident ability, patient acuity, and appointment type.

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.

Project Impact: A pharmacotherapy pilot trial investigating the abstinence and treatment adherence of Latino light smokers

Light smoking is particularly prevalent among Latino smokers. Nicotine replacement (NRT) and varenicline are effective medications for smoking cessation for moderate-heavy smokers but have not been tested in light smokers, and thus, there are no treatment guidelines for use with light smokers. This pilot trial tested the efficacy of NRT and varenicline in increasing smoking abstinence among Latino light smokers. A 3-group (NRT, varenicline, and varenicline-placebo) randomized design was used, and Latino light smokers (≤10 cigarettes per day) received 12 weeks of treatment, which included a culturally informed behavioral health session and ongoing medication management visits. At follow-up, there were no abstinent participants in the placebo and NRT groups. However, 30% of participants in the varenicline group were abstinent at the 3-, 4-, and 6-month follow-up. This study represents the only investigation that specifically targets Latino light smokers using these treatments and characterizing their treatment adherence.

Economic Grand Rounds: Types of Practitioners and Outpatient Visits in a Private Managed Behavioral Health Plan

Economic Grand Rounds: Types of Practitioners and Outpatient Visits in a Private Managed Behavioral Health Plan

Best Practices: Disseminating Best Practices for Bipolar Disorder Treatment in a Correctional Population

Best Practices: Disseminating Best Practices for Bipolar Disorder Treatment in a Correctional Population

An Intervention for Treating Alcohol Dependence: Relating Elements of Medical Management to Patient Outcomes With Implications for Primary Care

Alcohol dependence, frequently seen in medical settings, is a major problem that affects the health and well-being of many individuals and their families. The purpose of this study was to examine the relationship between treatment outcomes and patient and clinician factors specifically associated with a medically oriented intervention given for the treatment of alcohol dependence. The intervention was developed for the National Institute on Alcohol Abuse and Alcoholism-sponsored COMBINE Study, a randomized controlled trial combining 2 medications, naltrexone and acamprosate, with Medical Management, with or without specialty alcohol treatment. We examined the effect of patient adherence to treatment (number of Medical Management visits, total minutes in treatment, alliance or therapeutic relationship with the clinician, patient satisfaction with treatment, and clinician adherence to the Medical Management protocol) on abstinence from alcohol, amount of heavy drinking, and clinical improvement during treatment. More Medical Management visits attended and less total time spent in Medical Management treatment was associated with more days of abstinence from alcohol, reductions in heavy alcohol drinking, and a higher likelihood of clinical improvement. The patients' positive perceptions of their alliance with their clinician and their satisfaction with treatment was significantly associated with more days of abstinence from alcohol during treatment. Two clinician factors clinician confidence in the Medical Management treatment and flexibility in delivering Medical Management were also associated with better patient outcomes. Medically trained clinicians with minimal specialty training in alcohol dependence treatments were able to deliver a brief and effective medication management intervention that was designed to be consistent with primary care practice.

Changes in the Quality of Care for Bipolar I Disorder During the 1990s

Changes in the Quality of Care for Bipolar I Disorder During the 1990s

Patterns of Adult Psychotherapy in Psychiatric Practice

Patterns of Adult Psychotherapy in Psychiatric Practice

Counseling the Culturally Diverse: Theory and Practice, 4th ed.

Back to table of contents Previous article Next article Book Forum: PsychotherapyFull AccessCounseling the Culturally Diverse: Theory and Practice, 4th ed.ARMANDO R. FAVAZZA, M.D., M.P.H., ARMANDO R. FAVAZZASearch for more papers by this author, M.D., M.P.H., Columbia, Mo.Published Online:1 Jun 2004https://doi.org/10.1176/appi.ajp.161.6.1137-aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail This hefty tome looks, feels, and reads like a textbook for graduate students in counseling psychology. Obviously, since this is its fourth incarnation, it has been very successful, and it is generally accepted as the best book in the field. The keys to its success are simple: it is comprehensive, clearly written, neatly divided into 20 chapters ending with sections on implications for clinical practice, and contains many clinical vignettes that balance the theoretical material.The book starts slowly, with a discussion of the “superordinate nature” of multicultural counseling, the politics of counseling and therapy, and sociopolitical considerations of trust and mistrust. Much of this section can be summed up by the authors’ contention thatthe power of racism, sexism, and homophobia is related to the invisibility of the powerful forces that control and dictate our lives. In a strange sort of way, we are all victims. Minority groups are victims of oppression. Majority group members are victims who are unwittingly socialized into the role of oppressor. (p. 72)Despite this ominous start, the book moves on to clinical material that really is quite practical. The authors argue correctly that a counselor/therapist dealing with culturally diverse clients needs to be adaptive and not tied down to traditional approaches, although I couldn’t help but chuckle at the suggestion that change-agent outreach programs may involve shooting basketball and playing billiards with clients. Thank God we psychiatrists have patients who, unlike clients, would most likely swoon or run away at the suggestion that we shoot a few hoops together. Just imagine the possibilities of such a scenario in the hands of the comedian Larry David in a episode of Curb Your Enthusiasm! But I digress.The section of the book that most fascinated me was on white racial identity development. Here the authors explore the responses of different people to the question, “What does it mean to be white?” In fact, I plan to spend an entire session of my cultural psychiatry seminar asking the residents to answer this question. The authors note thatwhiteness is transparent precisely because of its everyday occurrence and because Whites are taught to think of their lives as morally neutral, average, and ideal.…Persons of color find White culture quite visible because even though it is nurturing to White Euro-Americans, it may invalidate the lifestyles of multicultural populations. (p. 239)As a resource book for teaching about clinical competence, the book is terrific. Ideally, all psychiatrists should be familiar with the book’s contents, but I seriously doubt that, after a mind-numbing day of 15-minute medication management visits, there are many psychiatrists who have the will and strength to read this lengthy tome. More’s the pity, because through years of personal experiences I have learned that our pills tend to be more efficacious and our patients more compliant when we pay attention to cultural facts. If you go about things the right way, it’s amazing sometimes what can be accomplished in 15 minutes.By Derald Wing Sue and David Sue. New York, John Wiley & Sons, 2003, 507 pp., $80.95. FiguresReferencesCited byDetailsCited ByOrganic consumerism: A comparison between India and the USAJournal of Retailing and Consumer Services, Vol. 53 Volume 161Issue 6 June 2004Pages 1137-a-1138 Metrics PDF download History Published online 1 June 2004 Published in print 1 June 2004

Integrating outcomes research into clinical practice.

A cohort of 102 psychiatric outpatients with major depressive disorder were followed up for about two years. Prospective ratings were obtained at each medication management visit with two instruments that measured changes in symptoms. The mean time to recovery was very similar to that reported in the National Institute of Mental Health's Collaborative Depression Study. This finding supports the validity of using brief instruments to measure outcomes in routine clinical practice.

Reply

Back to table of contents Previous article Next article LetterFull AccessReplyArnold Werner, M.D., and Lance E. Anderson, M.D.Arnold WernerSearch for more papers by this author, M.D., and Lance E. AndersonSearch for more papers by this author, M.D.Published Online:1 Feb 1999https://doi.org/10.1176/ps.50.2.267aAboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail In Reply: Chen and her associates and Smith mistakenly seem to think that we are against telepsychiatry. They ignore what we said and misinterpret the purpose of our analysis, although they do not seem to quibble with our figures. In an era of excess enthusiasm for technologic solutions to systems problems, we have simply cautioned people to examine the cost of what they are doing.Chen and Smith support our contention that telepsychiatry is more likely to work in an integrated system. They then ignore the fact that we were describing the far more common problem of providing a service in an environment with many separate entities. They fail to address the problems we raised about costs. They also do not produce data to counter our analysis, and they sidestep our findings about the difficulties involved in decreasing costs in low-population, rural areas. Money comes from somewhere. There are no freebies from tax-funded sources. Our mental health center operates within a budget and covers costs for clinical services through Medicare, Medicaid, insurance, capitation funds, and managed care contracts. An expensive service or project can draw funds away from other services.For the cost of a telepsychiatry medication management visit, we can send a case worker out to see several patients; we can have the worker transport several patients to the center; we can have a primary care physician, nurse practitioner, or physician's assistant examine patients under our direction. Patients do not have telepsychiatry hookups in their homes; they have to go somewhere and see someone to use the service.Smith's uninformed comment about rural prejudice deserves a response. One of us (AW) along with several colleagues, has provided regular consultation and patient care to two rural mental health centers for more than 25 years. We have decreased hospitalization rates, set up care systems with on-site part-time psychiatrists, and trained and placed a large number of psychiatrists in rural communities. We reject the notion of a negative rural prejudice.Szeftel's welcome comments suggest the kind of detail and support that is necessary for a viable telepsychiatry service. The specialty setting certainly makes it easier to provide the service. We are uncertain how her program relates to services in rural areas. FiguresReferencesCited byDetailsCited ByNone Volume 50Issue 2 February 1999Pages 267a-268 Metrics History Published online 1 February 1999 Published in print 1 February 1999