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Dickerson JF, Feeny DH, Clarke GN, MacMillan AL, Lynch FL. Evidence on the longitudinal construct validity of major generic and utility measures of health-related quality of life in teens with depression. Qual Life Res 2017; 27:447-454. [PMID: 29149441 DOI: 10.1007/s11136-017-1728-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE To examine the longitudinal construct validity in the assessment of changes in depressive symptoms of widely used utility and generic HRQL instruments in teens. METHODS 392 teens enrolled in the study and completed HRQL and diagnostic measures as part of the baseline interview. HRQL measures included EuroQol (EQ-5D-3L), Health Utilities Index Mark 2 (HUI2) and Mark 3 (HUI3), Quality of Well-Being Scale (QWB), Pediatric Quality of Life Inventory (PEDS-QL), RAND-36 (SF-6D), and Quality of Life in Depression Scale (QLDS). Youth completed follow-up interviews 12 weeks after baseline. Sixteen youth (4.1%) were lost to follow-up. We examined correlations between changes in HRQL instruments and the Children's Depression Rating Scale-Revised (CDRS-R) and assessed clinically meaningful change in multi-attribute utility HRQL measures using mean change (MC) and standardized response mean (SRM) among youth showing at least moderate (20%) improvement in depression symptomology. RESULTS Spearman's correlation coefficients demonstrated moderate correlation between changes in CDRS-R and the HUI2 (r = 0.38), HUI3 (r = 0.42), EQ-5D-3L (r = 0.36), SF-6D (r = 0.39), and PEDS-QL (r = 0.39) and strong correlation between changes in CDRS-R and QWB (r = 0.52) and QLDS (r = - 0.71). Effect size results are also reported. Among multi-attribute utility measures, all showed clinically meaningful improvements in the sample of youth with depression improvement (HUI2, MC = 0.20, SRM = 0.97; HUI3, MC = 0.32, SRM = 1.17; EQ-5D-3L, MC = 0.08, SRM = 0.51; QWB, MC = 0.11, SRM = 0.86; and SF-6D, MC = 0.12, SRM = 1.02). CONCLUSIONS Findings support the longitudinal construct validity of included HRQL instruments for the assessment of change in depression outcomes in teens. Results of this study can help inform researchers about viable instruments to include in economic evaluations for this population.
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Lynch FL, Dickerson JF, Pears KC, Fisher PA. Cost Effectiveness of a School Readiness Intervention for Foster Children. CHILDREN AND YOUTH SERVICES REVIEW 2017; 81:63-71. [PMID: 29276324 PMCID: PMC5737933 DOI: 10.1016/j.childyouth.2017.07.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Many young children in foster care suffer from emotional and behavior problems due to neglect and abuse. These problems can lead to difficulties in school, and functioning in school is linked to long-term health and development. Early intervention to reduce emotional and behavioral issues can help children successfully transition to school, which can improve long-term outcomes. However, communities need information on relative costs and benefits associated with programs to make informed choices. The objective of this study was to assess cost effectiveness, over 12 months, of the Kids in Transition to School (KITS) intervention compared to usual services available to children in a foster care control group (FCC). METHOD Randomized controlled trial of 192 children in foster care entering kindergarten who were randomized to KITS (n = 102) or FCC (n = 90). KITS includes school readiness groups and parent training over 4 months. Main outcomes were days free from internalizing symptoms (IFD), days free from externalizing behavior (EFD), intervention costs, public agency costs, and incremental cost effectiveness. RESULTS KITS significantly increased IFD and EFD compared to FCC. Average total cost of the intervention was $932 per family. The intervention did not significantly impact usual services. Average incremental cost effectiveness was $64 per IFD and $63 per EFD. CONCLUSIONS The cost of KITS is comparable to, or less than, similar programs, and the intervention is likely to provide significant emotional and behavioral benefits and improvements in school readiness for young children in foster care.
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Prabhakar D, Peterson EL, Hu Y, Rossom RC, Lynch FL, Lu CY, Waitzfelder BE, Owen-Smith AA, Williams LK, Beck A, Simon GE, Ahmedani BK. Dermatologic Conditions and Risk of Suicide: A Case-Control Study. PSYCHOSOMATICS 2017; 59:58-61. [PMID: 28890116 DOI: 10.1016/j.psym.2017.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 08/02/2017] [Accepted: 08/02/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients diagnosed with skin conditions have a higher risk of comorbid psychiatric conditions and suicide-related outcomes such as suicidal ideations and behaviors. There is paucity of evidence in the US general population about the risk of suicide death in patients with dermatologic conditions. METHODS We conducted a retrospective case-control study to investigate the risk of suicide death in patients receiving care for dermatologic conditions. This study involved 8 US health systems. A total of 2674 individuals who died by suicide (cases) were matched with 267,400 general population control individuals. RESULTS After adjusting for age, sex, and any mental health or substance use condition, we did not find an association between death by suicide and any skin condition including conditions where clinicians are generally concerned about the risk such as acne (adjusted odds ratio [aOR] = 1.04, p = 0.814), atopic dermatitis (aOR = 0.77, p = 0.28), and psoriasis (aOR = 0.91, p = 0.64). CONCLUSION This case-control study provides no evidence of increased risk of death by suicide in individuals with major skin disorders in the US general population.
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Weersing VR, Brent DA, Rozenman MS, Gonzalez A, Jeffreys M, Dickerson JF, Lynch FL, Porta G, Iyengar S. Brief Behavioral Therapy for Pediatric Anxiety and Depression in Primary Care: A Randomized Clinical Trial. JAMA Psychiatry 2017; 74:571-578. [PMID: 28423145 PMCID: PMC5539834 DOI: 10.1001/jamapsychiatry.2017.0429] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Anxiety and depression affect 30% of youth but are markedly undertreated compared with other mental disorders, especially in Hispanic populations. OBJECTIVE To examine whether a pediatrics-based behavioral intervention targeting anxiety and depression improves clinical outcome compared with referral to outpatient community mental health care. DESIGN, SETTING, AND PARTICIPANTS This 2-center randomized clinical trial with masked outcome assessment conducted between brief behavioral therapy (BBT) and assisted referral to care (ARC) studied 185 youths (aged 8.0-16.9 years) from 9 pediatric clinics in San Diego, California, and Pittsburgh, Pennsylvania, recruited from October 6, 2010, through December 5, 2014. Youths who met DSM-IV criteria for full or probable diagnoses of separation anxiety disorder, generalized anxiety disorder, social phobia, major depression, dysthymic disorder, and/or minor depression; lived with a consenting legal guardian for at least 6 months; and spoke English were included in the study. Exclusions included receipt of alternate treatment for anxiety or depression, presence of a suicidal plan, bipolar disorder, psychosis, posttraumatic stress disorder, substance dependence, current abuse, intellectual disability, or unstable serious physical illness. INTERVENTIONS The BBT consisted of 8 to 12 weekly 45-minute sessions of behavioral therapy delivered in pediatric clinics by master's-level clinicians. The ARC families received personalized referrals to mental health care and check-in calls to support accessing care from master's-level coordinators. MAIN OUTCOMES AND MEASURES The primary outcome was clinically significant improvement on the Clinical Global Impression-Improvement scale (score ≤2). Secondary outcomes included the Pediatric Anxiety Rating Scale, Children's Depression Rating Scale-Revised, and functioning. RESULTS A total of 185 patients were enrolled in the study (mean [SD] age, 11.3 [2.6] years; 107 [57.8%] female; 144 [77.8%] white; and 38 [20.7%] Hispanic). Youths in the BBT group (n = 95), compared with those in the ARC group (n = 90), had significantly higher rates of clinical improvement (56.8% vs 28.2%; χ21 = 13.09, P < .001; number needed to treat, 4), greater reductions in symptoms (F2,146 = 5.72; P = .004; Cohen f = 0.28), and better functioning (mean [SD], 68.5 [10.7] vs 61.9 [11.9]; t156 = 3.64; P < .001; Cohen d = 0.58). Ethnicity moderated outcomes, with Hispanic youth having substantially stronger response to BBT (76.5%) than ARC (7.1%) (χ21 = 14.90; P < .001; number needed to treat, 2). Effects were robust across sites. CONCLUSIONS AND RELEVANCE A pediatric-based brief behavioral intervention for anxiety and depression is associated with benefits superior to those of assisted referral to outpatient mental health care. Effects were especially strong for Hispanic participants, suggesting that the protocol may be a useful tool in addressing ethnic disparities in care. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01147614.
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Kauffman TL, Wilfond BS, Jarvik GP, Leo MC, Lynch FL, Reiss JA, Richards CS, McMullen C, Nickerson D, Dorschner MO, Goddard KAB. Design of a randomized controlled trial for genomic carrier screening in healthy patients seeking preconception genetic testing. Contemp Clin Trials 2017; 53:100-105. [PMID: 27940182 PMCID: PMC5274557 DOI: 10.1016/j.cct.2016.12.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 11/30/2016] [Accepted: 12/03/2016] [Indexed: 11/30/2022]
Abstract
Population-based carrier screening is limited to well-studied or high-impact genetic conditions for which the benefits may outweigh the associated harms and costs. As the cost of genome sequencing declines and availability increases, the balance of risks and benefits may change for a much larger number of genetic conditions, including medically actionable additional findings. We designed an RCT to evaluate genomic clinical sequencing for women and partners considering a pregnancy. All results are placed into the medical record for use by healthcare providers. Through quantitative and qualitative measures, including baseline and post result disclosure surveys, post result disclosure interviews, 1-2year follow-up interviews, and team journaling, we are obtaining data about the clinical and personal utility of genomic carrier screening in this population. Key outcomes include the number of reportable carrier and additional findings, and the comparative cost, utilization, and psychosocial impacts of usual care vs. genomic carrier screening. As the study progresses, we will compare the costs of genome sequencing and usual care as well as the cost of screening, pattern of use of genetic or mental health counseling services, number of outpatient visits, and total healthcare costs. This project includes novel investigation into human reactions and responses from would-be parents who are learning information that could both affect a future pregnancy and their own health.
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Korngiebel DM, McMullen CK, Amendola LM, Berg JS, Davis JV, Gilmore MJ, Harding CO, Himes P, Jarvik GP, Kauffman TL, Kennedy KA, Simpson DK, Leo MC, Lynch FL, Quigley DI, Reiss JA, Richards CS, Rope AF, Schneider JL, Goddard KAB, Wilfond BS. Generating a taxonomy for genetic conditions relevant to reproductive planning. Am J Med Genet A 2016; 170:565-73. [PMID: 26889673 DOI: 10.1002/ajmg.a.37513] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 10/22/2015] [Indexed: 01/20/2023]
Abstract
As genome or exome sequencing (hereafter genome-scale sequencing) becomes more integrated into standard care, carrier testing is an important possible application. Carrier testing using genome-scale sequencing can identify a large number of conditions, but choosing which conditions/genes to evaluate as well as which results to disclose can be complicated. Carrier testing generally occurs in the context of reproductive decision-making and involves patient values in a way that other types of genetic testing may not. The Kaiser Permanente Clinical Sequencing Exploratory Research program is conducting a randomized clinical trial of preconception carrier testing that allows participants to select their preferences for results from among broad descriptive categories rather than selecting individual conditions. This paper describes (1) the criteria developed by the research team, the return of results committee (RORC), and stakeholders for defining the categories; (2) the process of refining the categories based on input from patient focus groups and validation through a patient survey; and (3) how the RORC then assigned specific gene-condition pairs to taxonomy categories being piloted in the trial. The development of four categories (serious, moderate/mild, unpredictable, late onset) for sharing results allows patients to select results based on their values without separately deciding their interest in knowing their carrier status for hundreds of conditions. A fifth category, lifespan limiting, was always shared. The lessons learned may be applicable in other results disclosure situations, such as incidental findings.
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Cummings JR, Lynch FL, Rust KC, Coleman KJ, Madden JM, Owen-Smith AA, Yau VM, Qian Y, Pearson KA, Crawford PM, Massolo ML, Quinn VP, Croen LA. Health Services Utilization Among Children With and Without Autism Spectrum Disorders. J Autism Dev Disord 2016; 46:910-20. [PMID: 26547921 DOI: 10.1007/s10803-015-2634-z] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Using data from multiple health systems (2009-2010) and the largest sample to date, this study compares health services use among youth with and without an autism spectrum disorder (ASD)-including preventive services not previously studied. To examine these differences, we estimated logistic and count data models, controlling for demographic characteristics, comorbid physical health, and mental health conditions. Results indicated that youth with an ASD had greater health care use in many categories, but were less likely to receive important preventive services including flu shots and other vaccinations. An improved understanding of the overall patterns of health care use among this population could enable health systems to facilitate the receipt of appropriate and effective health care.
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Lynch FL, Croen LA, Owen-Smith A, Davis RL, Hanson GC, Crawford PM, Ruse KC, Qian YX. Early Identification of Autism Spectrum Disorders Using Patterns of Service Use Prior to Diagnosis. J Patient Cent Res Rev 2016. [DOI: 10.17294/2330-0698.1375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Clarke G, DeBar LL, Pearson JA, Dickerson JF, Lynch FL, Gullion CM, Leo MC. Cognitive Behavioral Therapy in Primary Care for Youth Declining Antidepressants: A Randomized Trial. Pediatrics 2016; 137:e20151851. [PMID: 27244782 PMCID: PMC4845864 DOI: 10.1542/peds.2015-1851] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Health care providers have few alternatives for youth depression other than antidepressants. We examined whether brief cognitive behavioral therapy (CBT) is a viable alternative in primary care. METHODS A total of 212 adolescents aged 12 to 18 with major depression who had recently declined or quickly discontinued new antidepressant treatment were randomized to self-selected treatment as usual (TAU) control condition or TAU plus brief individual CBT. Blinded evaluators followed youth for 2 years. The primary outcome was time to major depression diagnostic recovery. RESULTS CBT was superior to the control condition on the primary outcome of time to diagnostic recovery from major depression, with number needed to treat from 4 to 10 across follow-up. A similar CBT advantage was found for time to depression diagnosis response, with number needed to treat of 5 to 50 across time points. We observed a significant advantage for CBT on many secondary outcomes over the first year of follow-up but not the second year. Cohen's d effect sizes for significant continuous measures ranged from 0.28 to 0.44, in the small to medium effect range. Most TAU health care services did not differ across conditions, except for psychiatric hospitalizations, which occurred at a significantly higher rate in the control condition through the first year of follow-up. CONCLUSIONS Observed results were consistent with recent meta-analyses of CBT for youth depression. The initial year of CBT superiority imparted an important clinical benefit and may reduce the risk of future recurrent depression episodes.
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Weersing VR, Shamseddeen W, Garber J, Hollon SD, Clarke GN, Beardslee WR, Gladstone TR, Lynch FL, Porta G, Iyengar S, Brent DA. Prevention of Depression in At-Risk Adolescents: Predictors and Moderators of Acute Effects. J Am Acad Child Adolesc Psychiatry 2016; 55:219-26. [PMID: 26903255 PMCID: PMC4783159 DOI: 10.1016/j.jaac.2015.12.015] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 11/20/2015] [Accepted: 01/13/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess predictors and moderators of a cognitive-behavioral prevention (CBP) program for adolescent offspring of parents with depression. METHOD This 4-site randomized trial evaluated CBP compared to usual community care (UC) in 310 adolescents with familial (parental depression) and individual (youth history of depression or current subsyndromal symptoms) risk for depression. As previously reported by Garber and colleagues, a significant prevention effect favored CBP through 9 months; however, outcomes of CBP and UC did not significantly differ when parents were depressed at baseline. The current study expanded on these analyses and examined a range of demographic, clinical, and contextual characteristics of families as predictors and moderators and used recursive partitioning to construct a classification tree to organize clinical response subgroups. RESULTS Depression onset was predicted by lower functioning (hazard ratio [HR] = 0.95, 95% CI = 0.92-0.98) and higher hopelessness (HR = 1.06, 95% CI = 1.01-1.11) in adolescents. The superior effect of CBP was diminished when parents were currently depressed at baseline (HR = 6.38, 95% CI = 2.38-17.1) or had a history of hypomania (HR = 67.5, 95% CI = 10.9-417.1), or when adolescents reported higher depressive symptoms (HR = 1.04, 95% CI = 1.00-1.08), higher anxiety (HR = 1.05, 95% CI = 1.01-1.08), higher hopelessness (HR = 1.10, 95% CI = 1.01-1.20), or lower functioning (HR = 0.94, 95% CI = 0.89-1.00) at baseline. Onset rates varied significantly by clinical response cluster (0%-57%). CONCLUSION Depression in adolescents can be prevented, but programs may produce superior effects when timed at moments of relative wellness in high-risk families. Future programs may be enhanced by targeting modifiable negative clinical indicators of response. CLINICAL TRIAL REGISTRATION INFORMATION Prevention of Depression in At-Risk Adolescents; http://clinicaltrials.gov/; NCT00073671.
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Leo MC, McMullen C, Wilfond BS, Lynch FL, Reiss JA, Gilmore MJ, Himes P, Kauffman TL, Davis JV, Jarvik GP, Berg JS, Harding C, Kennedy KA, Simpson DK, Quigley DI, Richards CS, Rope AF, Goddard KAB. Patients' ratings of genetic conditions validate a taxonomy to simplify decisions about preconception carrier screening via genome sequencing. Am J Med Genet A 2016; 170:574-82. [PMID: 26792268 DOI: 10.1002/ajmg.a.37477] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 10/28/2015] [Indexed: 12/27/2022]
Abstract
Advances in genome sequencing and gene discovery have created opportunities to efficiently assess more genetic conditions than ever before. Given the large number of conditions that can be screened, the implementation of expanded carrier screening using genome sequencing will require practical methods of simplifying decisions about the conditions for which patients want to be screened. One method to simplify decision making is to generate a taxonomy based on expert judgment. However, expert perceptions of condition attributes used to classify these conditions may differ from those used by patients. To understand whether expert and patient perceptions differ, we asked women who had received preconception genetic carrier screening in the last 3 years to fill out a survey to rate the attributes (predictability, controllability, visibility, and severity) of several autosomal recessive or X-linked genetic conditions. These conditions were classified into one of five taxonomy categories developed by subject experts (significantly shortened lifespan, serious medical problems, mild medical problems, unpredictable medical outcomes, and adult-onset conditions). A total of 193 women provided 739 usable ratings across 20 conditions. The mean ratings and correlations demonstrated that participants made distinctions across both attributes and categories. Aggregated mean attribute ratings across categories demonstrated logical consistency between the key features of each attribute and category, although participants perceived little difference between the mild and serious categories. This study provides empirical evidence for the validity of our proposed taxonomy, which will simplify patient decisions for results they would like to receive from preconception carrier screening via genome sequencing.
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Brent DA, Brunwasser SM, Hollon SD, Weersing VR, Clarke GN, Dickerson JF, Beardslee WR, Gladstone TRG, Porta G, Lynch FL, Iyengar S, Garber J. Effect of a Cognitive-Behavioral Prevention Program on Depression 6 Years After Implementation Among At-Risk Adolescents: A Randomized Clinical Trial. JAMA Psychiatry 2015; 72:1110-8. [PMID: 26421861 PMCID: PMC4635056 DOI: 10.1001/jamapsychiatry.2015.1559] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Adolescents whose parents have a history of depression are at risk for developing depression and functional impairment. The long-term effects of prevention programs on adolescent depression and functioning are not known. OBJECTIVE To determine whether a cognitive-behavioral prevention (CBP) program reduced the incidence of depressive episodes, increased depression-free days, and improved developmental competence 6 years after implementation. DESIGN, SETTING, AND PARTICIPANTS A 4-site randomized clinical trial compared the effect of CBP plus usual care vs usual care, through follow-up 75 months after the intervention (88% retention), with recruitment from August 2003 through February 2006 at a health maintenance organization, university medical centers, and a community mental health center. A total of 316 participants were 13 to 17 years of age at enrollment and had at least 1 parent with current or prior depressive episodes. Participants could not be in a current depressive episode but had to have subsyndromal depressive symptoms or a prior depressive episode currently in remission. Analysis was conducted between August 2014 and June 2015. INTERVENTIONS The CBP program consisted of 8 weekly 90-minute group sessions followed by 6 monthly continuation sessions. Usual care consisted of any family-initiated mental health treatment. MAIN OUTCOMES AND MEASURES The Depression Symptoms Rating scale was used to assess the primary outcome, new onsets of depressive episodes, and to calculate depression-free days. A modified Status Questionnaire assessed developmental competence (eg, academic or interpersonal) in young adulthood. RESULTS Over the 75-month follow-up, youths assigned to CBP had a lower incidence of depression, adjusting for current parental depression at enrollment, site, and all interactions (hazard ratio, 0.71 [95% CI, 0.53-0.96]). The CBP program's overall significant effect was driven by a lower incidence of depressive episodes during the first 9 months after enrollment. The CBP program's benefit was seen in youths whose index parent was not depressed at enrollment, on depression incidence (hazard ratio, 0.54 [95% CI, 0.36-0.81]), depression-free days (d = 0.34, P = .01), and developmental competence (d = 0.36, P = .04); these effects on developmental competence were mediated via the CBP program's effect on depression-free days. CONCLUSIONS AND RELEVANCE The effect of CBP on new onsets of depression was strongest early and was maintained throughout the follow-up period; developmental competence was positively affected 6 years later. The effectiveness of CBP may be enhanced by additional booster sessions and concomitant treatment of parental depression. TRIAL REGISTRATION clinicaltrials.gov Identifier:NCT00073671.
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Owen-Smith AA, Bent S, Lynch FL, Coleman KJ, Yau VM, Pearson KA, Massolo ML, Quinn V, Croen LA. Prevalence and Predictors of Complementary and Alternative Medicine Use in a Large Insured Sample of Children with Autism Spectrum Disorders. RESEARCH IN AUTISM SPECTRUM DISORDERS 2015; 17:40-51. [PMID: 26366192 PMCID: PMC4562462 DOI: 10.1016/j.rasd.2015.05.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
PURPOSE The purpose of the present study was to examine the prevalence and predictors of complementary and alternative medicine (CAM) use as well as parental perceptions of CAM efficacy in a large, geographically diverse sample of children with Autism Spectrum Disorders (ASD). METHODOLOGY Data were obtained from a web-based survey administered to parents of children with ASD at four sites participating in the Mental Health Research Network (MHRN). The web survey obtained information about services and treatments received by children with ASD as well as the caregivers' experiences with having a child with ASD. RESULTS Approximately 88% of the sample had either used CAM in the past or had recently used some type of CAM. The following characteristics were associated with CAM use: greater parental education, younger child age, a mix of regular and special classroom settings and prescription drug use in the past three months. CONCLUSIONS The use of CAM was very prevalent in this large, geographically diverse sample of children with ASD. It is critical that providers be prepared to discuss the advantages and potential side effects with families to help them make well-informed health care decisions and prevent possible CAM-drug interactions.
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Coleman KJ, Lutsky MA, Yau V, Qian Y, Pomichowski ME, Crawford PM, Lynch FL, Madden JM, Owen-Smith A, Pearson JA, Pearson KA, Rusinak D, Quinn VP, Croen LA. Validation of Autism Spectrum Disorder Diagnoses in Large Healthcare Systems with Electronic Medical Records. J Autism Dev Disord 2015; 45:1989-96. [PMID: 25641003 PMCID: PMC4474741 DOI: 10.1007/s10803-015-2358-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
To identify factors associated with valid Autism Spectrum Disorder (ASD) diagnoses from electronic sources in large healthcare systems. We examined 1,272 charts from ASD diagnosed youth <18 years old. Expert reviewers classified diagnoses as confirmed, probable, possible, ruled out, or not enough information. A total of 845 were classified with 81% as a confirmed, probable, or possible ASD diagnosis. The predictors of valid ASD diagnoses were >2 diagnoses in the medical record (OR 2.94; 95% CI 2.03-4.25; p < 0.001) and being male (OR 1.51; 95% CI 1.05-2.17; p = 0.03). In large integrated healthcare settings, at least two diagnoses can be used to identify ASD patients for population-based research.
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Lynch FL, Clarke G, Schneider J, Firemark AJ, Scheminske MM. The Role of Cost Information in Health System Decisions to Adopt New Services. J Patient Cent Res Rev 2015. [DOI: 10.17294/2330-0698.1124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Ahmedani BK, Solberg LI, Copeland LA, Fang-Hollingsworth Y, Stewart C, Hu J, Nerenz DR, Williams LK, Cassidy-Bushrow AE, Waxmonsky J, Lu CY, Waitzfelder BE, Owen-Smith AA, Coleman KJ, Lynch FL, Ahmed AT, Beck A, Rossom RC, Simon GE. Psychiatric comorbidity and 30-day readmissions after hospitalization for heart failure, AMI, and pneumonia. Psychiatr Serv 2015; 66:134-40. [PMID: 25642610 PMCID: PMC4315504 DOI: 10.1176/appi.ps.201300518] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE In 2012, the Centers for Medicare and Medicaid Services implemented a policy that penalizes hospitals for "excessive" all-cause hospital readmissions within 30 days after discharge from an index hospitalization for heart failure (HF), acute myocardial infarction (AMI), and pneumonia. The aim of this study was to investigate the influence of psychiatric comorbidities on 30-day all-cause readmissions following hospitalizations for HF, AMI, and pneumonia. METHODS Data from 2009-2011 were derived from the HMO Research Network Virtual Data Warehouse of 11 health systems affiliated with the Mental Health Research Network. All index inpatient hospitalizations for HF, AMI, and pneumonia were captured (N=160,169). Psychiatric diagnoses for the year prior to admission were measured. All-cause readmissions within 30 days of discharge were the outcome variable. RESULTS Approximately 18% of all individuals with index inpatient hospitalizations for HF, AMI, and pneumonia were readmitted within 30 days. The rate of readmission was 5% greater for individuals with a psychiatric comorbidity compared with those without a psychiatric comorbidity (21.7% and 16.5%, respectively, p<.001). Depression, anxiety, and dementia were associated with more readmissions of persons with index hospitalizations for each general medical condition and for all the conditions combined (p<.05). Substance use and bipolar disorders were linked with higher readmissions for those with initial hospitalizations for HF and pneumonia (p<.05). Readmission rates declined overall from 2009 to 2011. CONCLUSIONS Individuals with HF, AMI, and pneumonia experience high rates of readmission, but psychiatric comorbidities appear to increase that risk. Future interventions to reduce readmission should consider adding mental health components.
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Lynch FL. Population health outcome models in suicide prevention policy. Am J Prev Med 2014; 47:S137-43. [PMID: 25145731 DOI: 10.1016/j.amepre.2014.05.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 05/16/2014] [Accepted: 05/23/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Suicide is a leading cause of death in the U.S. and results in immense suffering and significant cost. Effective suicide prevention interventions could reduce this burden, but policy makers need estimates of health outcomes achieved by alternative interventions to focus implementation efforts. PURPOSE To illustrate the utility of health outcome models to help in achieving goals defined by the National Action Alliance for Suicide Prevention's Research Prioritization Task Force. The approach is illustrated specifically with psychotherapeutic interventions to prevent suicide reattempt in emergency department settings. METHODS A health outcome model using decision analysis with secondary data was applied to estimate suicide attempts and deaths averted from evidence-based interventions. RESULTS Under optimal conditions, the model estimated that over 1 year, implementing evidence-based psychotherapeutic interventions in emergency departments could decrease the number of suicide attempts by 18,737, and if offered over 5 years, it could avert 109,306 attempts. Over 1 year, the model estimated 2,498 fewer deaths from suicide, and over 5 years, about 13,928 fewer suicide deaths. CONCLUSIONS Health outcome models could aid in suicide prevention policy by helping focus implementation efforts. Further research developing more sophisticated models of the impact of suicide prevention interventions that include a more complex understanding of suicidal behavior, longer time frames, and inclusion of additional outcomes that capture the full benefits and costs of interventions would be helpful next steps.
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Lynch FL, McCarty D, Mertens J, Perrin NA, Green CA, Parthasarathy S, Dickerson JF, Anderson BM, Pating D. Costs of care for persons with opioid dependence in commercial integrated health systems. Addict Sci Clin Pract 2014; 9:16. [PMID: 25123823 PMCID: PMC4142137 DOI: 10.1186/1940-0640-9-16] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 06/24/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND When used in general medical practices, buprenorphine is an effective treatment for opioid dependence, yet little is known about how use of buprenorphine affects the utilization and cost of health care in commercial health systems. METHODS The objective of this retrospective cohort study was to examine how buprenorphine affects patterns of medical care, addiction medicine services, and costs from the health system perspective. Individuals with two or more opioid-dependence diagnoses per year, in two large health systems (System A: n = 1836; System B: n = 4204) over the time span 2007-2008 were included. Propensity scores were used to help adjust for group differences. RESULTS Patients receiving buprenorphine plus addiction counseling had significantly lower total health care costs than patients with little or no addiction treatment (mean health care costs with buprenorphine treatment = $13,578; vs. mean health care costs with no addiction treatment = $31,055; p < .0001), while those receiving buprenorphine plus addiction counseling and those with addiction counseling only did not differ significantly in total health care costs (mean costs with counseling only: $17,017; p = .5897). In comparison to patients receiving buprenorphine plus counseling, those with little or no addiction treatment had significantly greater use of primary care (p < .001), other medical visits (p = .001), and emergency services (p = .020). Patients with counseling only (compared to patients with buprenorphine plus counseling) used less inpatient detoxification (p < .001), and had significantly more PC visits (p = .001), other medical visits (p = .005), and mental health visits (p = .002). CONCLUSIONS Buprenorphine is a viable alternative to other treatment approaches for opioid dependence in commercial integrated health systems, with total costs of health care similar to abstinence-based counseling. Patients with buprenorphine plus counseling had reduced use of general medical services compared to the alternatives.
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Lynch FL, Dickerson JF, Saldana L, Fisher PA. Incremental Net Benefit of Early Intervention for Preschool-Aged Children with Emotional and Behavioral Problems in Foster Care. CHILDREN AND YOUTH SERVICES REVIEW 2014; 36:213-219. [PMID: 29097828 PMCID: PMC5663296 DOI: 10.1016/j.childyouth.2013.11.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Of 1 million cases of child maltreatment identified every year in the United States, one-fifth result in foster care. Many of these children suffer from significant emotional and behavioral conditions. Decision-makers must allocate highly constrained budgets to serve these children. Recent evidence suggests that Multidimensional Treatment Foster Care for Preschoolers can reduce negative outcomes for these children, but the relative benefits and costs of the program have not been evaluated. The objective of this study was to assess net benefit, over 24 months, of Multidimensional Treatment Foster Care for Preschoolers compared to regular foster care. Data were from a randomized controlled trial of 117 young children entering a new foster placement. A subsample exhibited placement instability (n = 52). Intervention services including parent training, lasted 9-12 months. Multidimensional Treatment Foster Care for Preschoolers significantly increased permanent placements for the placement instability sample. Average total cost for the new intervention sample was significantly less than for regular foster care (full sample: $27,204 vs. $30,090; P = .004; placement instability sample: $29,595 vs. $36,061; P = .045). Incremental average net benefit was positive at all levels of willingness to pay of zero or greater, indicating that the value of benefits exceeded costs. Multidimensional Treatment Foster Care for Preschoolers has significant benefit for preschool children in foster care with emotional and behavioral disorders compared to regular foster care services. At even modest levels of willingness to pay, benefits exceed costs indicating a strong likeliness that this program is an efficient choice for improving outcomes for young children with emotional and behavioral disorders in foster care.
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Penfold RB, Stewart C, Hunkeler EM, Madden JM, Cummings J, Owen-Smith AA, Rossom RC, Lu C, Lynch FL, Waitzfelder BE, Coleman KA, Ahmedani BK, Beck AL, Zeber JE, Simon GE, Simon GE. Use of antipsychotic medications in pediatric populations: what do the data say? Curr Psychiatry Rep 2013; 15:426. [PMID: 24258527 PMCID: PMC4167011 DOI: 10.1007/s11920-013-0426-8] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Recent reports of antipsychotic medication use in pediatric populations describe large increases in rates of use. Much interest in the increasing use has focused on potentially inappropriate prescribing for non-Food and Drug Administration-approved uses and use amongst youth with no mental health diagnosis. Different studies of antipsychotic use have used different time periods, geographic and insurance populations of youth, and aggregations of diagnoses. We review recent estimates of use and comment on the similarities and dissimilarities in rates of use. We also report new data obtained on 11 health maintenance organizations that are members of the Mental Health Research Network in order to update and extend the knowledge base on use by diagnostic indication. Results indicate that most use in pediatric populations is for disruptive behaviors and not psychotic disorders. Differences in estimates are likely a function of differences in methodology; however, there is remarkable consistency in estimates of use by diagnosis.
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Beardslee WR, Brent DA, Weersing VR, Clarke GN, Porta G, Hollon SD, Gladstone TR, Gallop R, Lynch FL, Iyengar S, DeBar L, Garber J. Prevention of depression in at-risk adolescents: longer-term effects. JAMA Psychiatry 2013; 70:1161-70. [PMID: 24005242 PMCID: PMC3978119 DOI: 10.1001/jamapsychiatry.2013.295] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Adolescent offspring of depressed parents are at high risk for experiencing depressive disorders themselves. OBJECTIVE To determine whether the positive effects of a group cognitive-behavioral prevention (CBP) program extended to longer-term (multiyear) follow-up. DESIGN A 4-site randomized clinical trial with 33 months of follow-up was conducted. Recruitment of participants was from August 2003 through February 2006. SETTING The study settings included a health maintenance organization, university medical centers, and a community mental health center. PARTICIPANTS Three hundred sixteen adolescent (aged 13-17 years) offspring of parents with current and/or prior depressive disorders; adolescents had histories of depression, current elevated depressive symptoms, or both but did not currently meet criteria for a depressive disorder. INTERVENTIONS The CBP program consisted of 8 weekly 90-minute group sessions followed by 6 monthly continuation sessions. Adolescents were randomly assigned to either the CBP program or usual care (UC). MAIN OUTCOMES AND MEASURES The primary outcome was a probable or definite episode of depression (Depression Symptom Rating score ≥4) for at least 2 weeks through the month 33 follow-up evaluation. RESULTS Over the 33-month follow-up period, youths in the CBP condition had significantly fewer onsets of depressive episodes compared with those in UC. Parental depression at baseline significantly moderated the intervention effect. When parents were not depressed at intake, CBP was superior to UC (number needed to treat, 6), whereas when parents were actively depressed at baseline, average onset rates between CBP and UC were not significantly different. A 3-way interaction among intervention, baseline parental depression, and site indicated that the impact of parental depression on intervention effectiveness varied across sites. CONCLUSIONS AND RELEVANCE The CBP program showed significant sustained effects compared with UC in preventing the onset of depressive episodes in at-risk youth over a nearly 3-year period. Important next steps will be to strengthen the CBP intervention to further enhance its preventive effects, improve intervention outcomes when parents are currently depressed, and conduct larger implementation trials to test the broader public health impact of the CBP program for preventing depression in youth. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00073671.
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Green CA, McCarty D, Mertens J, Lynch FL, Hilde A, Firemark A, Weisner CM, Pating D, Anderson BM. A qualitative study of the adoption of buprenorphine for opioid addiction treatment. J Subst Abuse Treat 2013; 46:390-401. [PMID: 24268947 DOI: 10.1016/j.jsat.2013.09.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 08/13/2013] [Accepted: 09/03/2013] [Indexed: 11/17/2022]
Abstract
Qualified physicians may prescribe buprenorphine to treat opioid dependence, but medication use remains controversial. We examined adoption of buprenorphine in two not-for-profit integrated health plans, over time, completing 101 semi-structured interviews with clinicians and clinician-administrators from primary and specialty care. Transcripts were reviewed, coded, and analyzed. A strong leader championing the new treatment was critical for adoption in both health plans. Once clinicians began using buprenorphine, patients' and other clinicians' experiences affected decisions more than did the champion. With experience, protocols developed to manage unsuccessful patients and changed to support maintenance rather than detoxification. Diffusion outside addiction and mental health settings was nonexistent; primary care clinicians cited scope-of-practice issues and referred patients to specialty care. With greater diffusion came questions about long-term use and safety. Recognizing how implementation processes develop may suggest where, when, and how to best expend resources to increase adoption of such treatments.
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McMakin DL, Olino TM, Porta G, Dietz LJ, Emslie G, Clarke G, Wagner KD, Asarnow JR, Ryan ND, Birmaher B, Shamseddeen W, Mayes T, Kennard B, Spirito A, Keller M, Lynch FL, Dickerson JF, Brent DA. Anhedonia predicts poorer recovery among youth with selective serotonin reuptake inhibitor treatment-resistant depression. J Am Acad Child Adolesc Psychiatry 2012; 51:404-11. [PMID: 22449646 PMCID: PMC3536476 DOI: 10.1016/j.jaac.2012.01.011] [Citation(s) in RCA: 218] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Revised: 01/13/2012] [Accepted: 01/27/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To identify symptom dimensions of depression that predict recovery among selective serotonin reuptake inhibitor (SSRI) treatment-resistant adolescents undergoing second-step treatment. METHOD The Treatment of Resistant Depression in Adolescents (TORDIA) trial included 334 SSRI treatment-resistant youth randomized to a medication switch, or a medication switch plus CBT. This study examined five established symptom dimensions (Child Depression Rating Scale-Revised) at baseline as they predicted recovery over 24 weeks of acute and continuation treatment. The two indices of recovery that were evaluated were time to remission and number of depression-free days. RESULTS Multivariate analyses examining all five depression symptom dimensions simultaneously indicated that anhedonia was the only dimension to predict a longer time to remission, and also the only dimension to predict fewer depression-free days. In addition, when anhedonia and CDRS-total score were evaluated simultaneously, anhedonia continued to uniquely predict longer time to remission and fewer depression-free days. CONCLUSIONS Anhedonia may represent an important negative prognostic indicator among treatment-resistant depressed adolescents. Further research is needed to elucidate neurobehavioral underpinnings of anhedonia, and to test treatments that target anhedonia in the context of overall treatment of depression.
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Lynch FL, Dickerson JF, Clarke G, Vitiello B, Porta G, Wagner KD, Emslie G, Asarnow JR, Keller MB, Birmaher B, Ryan ND, Kennard B, Mayes T, DeBar L, McCracken JT, Strober M, Suddath RL, Spirito A, Onorato M, Zelazny J, Iyengar S, Brent D. Incremental cost-effectiveness of combined therapy vs medication only for youth with selective serotonin reuptake inhibitor-resistant depression: treatment of SSRI-resistant depression in adolescents trial findings. ACTA ACUST UNITED AC 2011; 68:253-62. [PMID: 21383263 DOI: 10.1001/archgenpsychiatry.2011.9] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Many youth with depression do not respond to initial treatment with selective serotonin reuptake inhibitors (SSRIs), and this is associated with higher costs. More effective treatment for these youth may be cost-effective. OBJECTIVE To evaluate the incremental cost-effectiveness over 24 weeks of combined cognitive behavior therapy plus switch to a different antidepressant medication vs medication switch only in adolescents who continued to have depression despite adequate initial treatment with an SSRI. DESIGN Randomized controlled trial. SETTING Six US academic and community clinics. PATIENTS Three hundred thirty-four patients aged 12 to 18 years with SSRI-resistant depression. INTERVENTION Participants were randomly assigned to (1) switch to a different medication only or (2) switch to a different medication plus cognitive behavior therapy. MAIN OUTCOME MEASURES Clinical outcomes were depression-free days (DFDs), depression-improvement days (DIDs), and quality-adjusted life-years based on DFDs (DFD-QALYs). Costs of intervention, nonprotocol services, and families were included. RESULTS Combined treatment achieved 8.3 additional DFDs (P = .03), 0.020 more DFD-QALYs (P = .03), and 11.0 more DIDs (P = .04). Combined therapy cost $1633 more (P = .01). Cost per DFD was $188 (incremental cost-effectiveness ratio [ICER] = $188; 95% confidence interval [CI], -$22 to $1613), $142 per DID (ICER = $142; 95% CI, -$14 to $2529), and $78,948 per DFD-QALY (ICER = $78,948; 95% CI, -$9261 to $677,448). Cost-effectiveness acceptability curve analyses suggest a 61% probability that combined treatment is more cost-effective at a willingness to pay $100,000 per QALY. Combined treatment had a higher net benefit for subgroups of youth without a history of abuse, with lower levels of hopelessness, and with comorbid conditions. CONCLUSIONS For youth with SSRI-resistant depression, combined treatment decreases the number of days with depression and is more costly. Depending on a decision maker's willingness to pay, combined therapy may be cost-effective, particularly for some subgroups. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00018902.
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Lynch FL, Striegel-Moore RH, Dickerson JF, Perrin N, Debar L, Wilson GT, Kraemer HC. Cost-effectiveness of guided self-help treatment for recurrent binge eating. J Consult Clin Psychol 2010; 78:322-33. [PMID: 20515208 PMCID: PMC2880825 DOI: 10.1037/a0018982] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Adoption of effective treatments for recurrent binge-eating disorders depends on the balance of costs and benefits. Using data from a recent randomized controlled trial, we conducted an incremental cost-effectiveness analysis (CEA) of a cognitive-behavioral therapy guided self-help intervention (CBT-GSH) to treat recurrent binge eating compared to treatment as usual (TAU). METHOD Participants were 123 adult members of an HMO (mean age = 37.2 years, 91.9% female, 96.7% non-Hispanic White) who met criteria for eating disorders involving binge eating as measured by the Eating Disorder Examination (C. G. Fairburn & Z. Cooper, 1993). Participants were randomized either to treatment as usual (TAU) or to TAU plus CBT-GSH. The clinical outcomes were binge-free days and quality-adjusted life years (QALYs); total societal cost was estimated using costs to patients and the health plan and related costs. RESULTS Compared to those receiving TAU only, those who received TAU plus CBT-GSH experienced 25.2 more binge-free days and had lower total societal costs of $427 over 12 months following the intervention (incremental CEA ratio of -$20.23 per binge-free day or -$26,847 per QALY). Lower costs in the TAU plus CBT-GSH group were due to reduced use of TAU services in that group, resulting in lower net costs for the TAU plus CBT group despite the additional cost of CBT-GSH. CONCLUSIONS Findings support CBT-GSH dissemination for recurrent binge-eating treatment.
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Garber J, Clarke GN, Weersing VR, Beardslee WR, Brent DA, Gladstone TRG, DeBar LL, Lynch FL, D'Angelo E, Hollon SD, Shamseddeen W, Iyengar S. Prevention of depression in at-risk adolescents: a randomized controlled trial. JAMA 2009; 301:2215-24. [PMID: 19491183 PMCID: PMC2737625 DOI: 10.1001/jama.2009.788] [Citation(s) in RCA: 325] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Adolescent offspring of depressed parents are at markedly increased risk of developing depressive disorders. Although some smaller targeted prevention trials have found that depression risk can be reduced, these results have yet to be replicated and extended to large-scale, at-risk populations in different settings. OBJECTIVE To determine the effects of a group cognitive behavioral (CB) prevention program compared with usual care in preventing the onset of depression. DESIGN, SETTING, AND PARTICIPANTS A multicenter randomized controlled trial conducted in 4 US cities in which 316 adolescent (aged 13-17 years) offspring of parents with current or prior depressive disorders were recruited from August 2003 through February 2006. Adolescents had a past history of depression, current elevated but subdiagnostic depressive symptoms, or both. Assessments were conducted at baseline, after the 8-week intervention, and after the 6-month continuation phase. INTERVENTION Adolescents were randomly assigned to the CB prevention program consisting of 8 weekly, 90-minute group sessions followed by 6 monthly continuation sessions or assigned to receive usual care alone. MAIN OUTCOME MEASURE Rate and hazard ratio (HR) of a probable or definite depressive episode (ie, depressive symptom rating score of > or = 4) for at least 2 weeks as diagnosed by clinical interviewers. RESULTS Through the postcontinuation session follow-up, the rate and HR of incident depressive episodes were lower for those in the CB prevention program than for those in usual care (21.4% vs 32.7%; HR, 0.63; 95% confidence interval [CI], 0.40-0.98). Adolescents in the CB prevention program also showed significantly greater improvement in self-reported depressive symptoms than those in usual care (coefficient, -1.1; z = -2.2; P = .03). Current parental depression at baseline moderated intervention effects (HR, 5.98; 95% CI, 2.29-15.58; P = .001). Among adolescents whose parents were not depressed at baseline, the CB prevention program was more effective in preventing onset of depression than usual care (11.7% vs 40.5%; HR, 0.24; 95% CI, 0.11-0.50), whereas for adolescents with a currently depressed parent, the CB prevention program was not more effective than usual care in preventing incident depression (31.2% vs 24.3%; HR, 1.43; 95% CI, 0.76-2.67). CONCLUSION The CB prevention program had a significant prevention effect through the 9-month follow-up period based on both clinical diagnoses and self-reported depressive symptoms, but this effect was not evident for adolescents with a currently depressed parent. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00073671.
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Lynch FL, Clarke GN. Estimating the economic burden of depression in children and adolescents. Am J Prev Med 2006; 31:S143-51. [PMID: 17175409 DOI: 10.1016/j.amepre.2006.07.001] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2005] [Revised: 06/29/2006] [Accepted: 07/12/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Depression in childhood and adolescence creates significant burden to individuals, families, and societies by increasing morbidity, increasing mortality, and negatively affecting quality of life during times of significantly depressed mood. Several studies have estimated the cost of depression in the United States and elsewhere, but none have included the costs associated with depression in children or younger adolescents. This paper reviews data currently available on the cost of depression in childhood and the cost effectiveness of interventions to treat and prevent depression in this population. METHODS A systematic review was conducted of published literature related to the cost of depression in children and adolescents and of economic evaluations of interventions to treat or prevent depression in this population. RESULTS Five articles were identified that included any type of data related to the cost of depression in childhood; four articles were identified that conducted economic evaluations of interventions to treat or prevent depression in children or adolescents. CONCLUSIONS Little information on the economic burden of depression in childhood is currently available. Future research in this area needs to include a broad range of costs; long-term outcomes; and costs relevant to decision makers in public and private agencies, such as implementation costs and costs of sustaining intervention fidelity over time.
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Polen MR, Freeborn DK, Lynch FL, Mullooly JP, Dickinson DM. Medical cost-offset following treatment referral for alcohol and other drug use disorders in a group model HMO. J Behav Health Serv Res 2006; 33:335-46. [PMID: 16752110 DOI: 10.1007/s11414-006-9020-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to determine whether specialty alcohol and other drug (AOD) treatment is associated with reduced subsequent medical care costs. AOD treatment costs and medical costs in a group model health maintenance organization (HMO) were collected for up to 6 years on 1,472 HMO members who were recommended for specialty AOD treatment, and on 738 members without AOD diagnoses or treatment. Addiction Severity Index measures were also obtained from a sample of 293 of those recommended for treatment. Changes in medical costs did not differ between treatment and comparison groups. Nor did individuals with improved treatment outcomes have greater reductions in medical costs. AOD treatment costs were not inversely related to subsequent medical costs, except for a subgroup with recent AOD treatment. In the interviewed sample, better treatment outcomes did not predict lower subsequent medical costs. Multiple treatment episodes may hold promise for producing cost-offsets.
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McFarland BH, Lynch FL, Freeborn DK, Green CA, Polen MR, Deck DD, Dickinson DM. Substance Abuse Treatment Duration for Medicaid Versus Commercial Clients in a Health Maintenance Organization. Med Care 2006; 44:601-6. [PMID: 16708010 DOI: 10.1097/01.mlr.0000215814.01127.ce] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND As Medicaid clients have come to be enrolled in managed care, concerns have arisen about the ability of private sector systems to meet the needs of enrollees with substance abuse problems. OBJECTIVES This project describes treatment initiation and duration for Medicaid and commercial substance abuse treatment clients in a large health maintenance organization (HMO). RESEARCH DESIGN This study was a prospective secondary analysis of information from HMO databases. Subjects were 641 adult Medicaid clients who contacted the HMO's addiction medicine department in 1996 or 1997 and commercial HMO addiction medicine patients (n=447). First contact with addiction medicine during the study period was the index event. MEASURES Chief dependent variables were initiation and duration of substance abuse treatment after the index event. RESULTS Logistic regression showed that longer HMO enrollment predicted treatment initiation after substance abuse assessment, but Medicaid status was not a significant predictor. A competing risks analysis using Cox proportional hazards models indicated that once subjects had initiated, Medicaid was not significantly related to exit from substance abuse treatment. Analysis of health plan disenrollment by Medicaid clients indicated that the most common reason was loss of Medicaid eligibility. CONCLUSIONS These results raise the possibility that state Medicaid policies may make it difficult for clients to obtain suitable chemical dependency treatment services.
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Meenan RT, Smith DH, Hornbrook MC, Fellows J, Lynch FL, Helfand MC. The state of cost-effectiveness analysis in American managed care. Expert Rev Pharmacoecon Outcomes Res 2006; 6:229-37. [PMID: 20528558 DOI: 10.1586/14737167.6.2.229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In 1996, the US Panel on Cost-Effectiveness in Health and Medicine published detailed recommendations for the conduct and use of cost-effectiveness analyses (CEA) of medical technologies. These recommendations were expected to promote the use of CEA to inform the resource allocation decisions of a diverse audience including, among others, American managed care organizations. Yet, nearly 10 years later, the limited explicit use of CEA in the USA remains a prominent discussion topic, with few signs of resolution. Its limited use within managed care is especially striking given the industry's stated interest in efficient healthcare and historically unstable finances in the face of continually rising healthcare costs.
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Lynch FL, Hornbrook M, Clarke GN, Perrin N, Polen MR, O'Connor E, Dickerson J. Cost-effectiveness of an Intervention to Prevent Depression in At-Risk Teens. ACTA ACUST UNITED AC 2005; 62:1241-8. [PMID: 16275811 DOI: 10.1001/archpsyc.62.11.1241] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTACT Depression is common in adolescent offspring of depressed parents and can be prevented, but adoption of prevention programs is dependent on the balance of their incremental costs and benefits. OBJECTIVE To examine the incremental cost-effectiveness of a group cognitive behavioral intervention to prevent depression in adolescent offspring of depressed parents. DESIGN Cost-effectiveness analysis of a recent randomized controlled trial. SETTING Kaiser Permanente Northwest, a large health maintenance organization. PARTICIPANTS Teens 13 to 18 years old at risk for depression. INTERVENTIONS Usual care (n = 49) or usual care plus a 15-session group cognitive therapy prevention program (n = 45). MAIN OUTCOME MEASURES Clinical outcomes were converted to depression-free days and quality-adjusted life-years. Total health maintenance organization costs, costs of services received in other sectors, and family costs were combined with clinical outcomes in a cost-effectiveness analysis comparing the intervention with usual care for 1 year after the intervention. RESULTS Average cost of the intervention was $1632, and total direct and indirect costs increased by $610 in the intervention group. However, the result was not statistically significant, suggesting a possible cost offset. Estimated incremental cost per depression-free day in the base-case analysis was $10 (95% confidence interval, -$13 to $52) or $9275 per quality-adjusted life-year (95% confidence interval, -$12 148 to $45 641). CONCLUSIONS Societal cost-effectiveness of a brief prevention program to reduce the risk of depression in offspring of depressed parents is comparable to that of accepted depression treatments, and the program is cost-effective compared with other health interventions commonly covered in insurance contracts.
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Green CA, Polen MR, Perrin NA, Leo M, Lynch FL, Rush DP. Gender-based structural models of health care costs: alcohol use, physical health, mental health, and functioning. THE JOURNAL OF MENTAL HEALTH POLICY AND ECONOMICS 2004; 7:107-25. [PMID: 15478990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 12/15/2003] [Accepted: 06/10/2004] [Indexed: 04/30/2023]
Abstract
BACKGROUND Most models of health services use or costs include gender as a covariate, combining data for men and women in analyses. This strategy may obscure differences in underlying processes producing differential health care use by men and women, particularly in examinations of factors that affect health care use and differ by gender (e.g. alcohol consumption and depression). AIMS To examine gender differences in the relationships between alcohol consumption, physical and mental health and functioning, and costs of health care. METHODS The setting was Kaiser Permanente Northwest, a large non-profit group practice model HMO serving northwest Oregon and southwest Washington in the northwest United States. Primary (survey) and secondary (health plan records of service use; diagnoses from medical chart review) data were collected for random samples of health plan members in the period 1989-1993 (n = 5,669). Health plan administrative records of service use were used to estimate health care costs. Gender-specific latent structure models predicting health care costs were created using self-reported mental health, physical health, functioning, alcohol consumption, and prior-year health plan record-based diagnoses of depression and alcohol problems. RESULTS Alcohol consumption and prior alcohol problems were directly related to health care costs, although in opposite directions, for both men and women. Alcohol consumption was negatively associated with costs, while prior alcohol problems predicted higher costs. Gender differences existed in the relationship between physical health and health care costs indirectly via drinking status. Prior depression had direct effects on increased health care costs, and this relationship was stronger for men than for women. The roles played by mental health symptoms were similar for men and women. Better mental health at the time of the survey was associated with reduced alcohol consumption or likelihood of consuming alcohol, but had no direct effects on later costs. Indirect effects of mental health were found via alcohol consumption. CONCLUSIONS Gender plays an important role in the factors underlying total costs of health care, and gender differences in these relationships appear more common among those who consume alcohol. For both genders, alcohol use predicts lower health care costs in this light-to-moderate drinking population, although prior diagnoses of alcohol problems predict higher costs. The direct relationship between depression diagnosis and higher health care costs is stronger among men.
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DeBar LL, Lynch FL, Boles M. Healthcare use by children with attention deficit/hyperactivity disorder with and without psychiatric comorbidities. J Behav Health Serv Res 2004; 31:312-23. [PMID: 15263869 DOI: 10.1007/bf02287293] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study examined healthcare services used by children with attention-deficit/hyperactivity disorder (ADHD), with and without psychiatric comorbidities. The study was conducted in a large health maintenance organization in the Pacific Northwest on all continuously enrolled children aged 5 to 12 from January 1997 through July 1998. The study measured all outpatient medical care, specialty mental health care services, and prescription drug dispensings from computer records. Children with ADHD, with and without other psychiatric comorbidities, use more general medical services than do other groups of children, including outpatient visits, acute care (emergency room [ER] urgent care) visits. ADHD and other psychiatric comorbidities lead to higher use of specialty mental health services and greater use of psychotropic medications.
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Green CA, Polen MR, Lynch FL, Dickinson DM, Bennett MD. Gender differences in outcomes in an HMO-based substance abuse treatment program. J Addict Dis 2004; 23:47-70. [PMID: 15132342 DOI: 10.1300/j069v23n02_04] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This study examined gender differences in treatment outcomes and outcomes predictors among 155 men and 81 women attending a gender-sensitive substance abuse treatment program. Bivariate analyses indicated women improved more than men in social/family and daily functioning domains, but differences disappeared after controlling for baseline characteristics. Multivariate models predicting treatment outcomes revealed that, across Addiction Severity Index domains, outcomes for men were predicted primarily by mental health and medical conditions, severity of the substance abuse problem, and treatment com- pletion. For women, in addition to treatment completion, outcomes were more likely to be predicted by social, socio-demographic, and life-history characteristics. For abstinence outcomes, women who completed treatment were 9 times as likely to be abstinent at 7-month follow-up as other women; men who completed were 3 times more likely to be abstinent than other men. Women with more severe psychiatric status and those who felt their life was out of control were less likely to be abstinent, as were men who lived alone. Clinicians targeting such factors differentially for men and women may enhance the effectiveness of treatment.
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Lynch FL, Whitlock EP, Valanis BG, Smith SK. Cost-effectiveness of a tailored intervention to increase screening in HMO women overdue for Pap test and mammography services. Prev Med 2004; 38:403-11. [PMID: 15020173 DOI: 10.1016/j.ypmed.2003.11.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Research has established the societal cost-effectiveness of providing breast and cervical cancer screening to women. Less is known about the cost of motivating women significantly overdue for services to receive screening. METHODS In this intent-to-treat study, a total of 254 women, aged 52-69, who were overdue for both Pap test and mammography, were randomized to two groups, a tailored, motivational outreach or usual care. For effectiveness, we calculated the percent of women who received both services within 14 months of randomization. We used a comprehensive cost model to estimate total cost, per-participant cost, and the incremental cost-effectiveness of delivering the outreach intervention from the health plan perspective. We also conducted sensitivity analyses around two key parameters, target population size and level of effectiveness. RESULTS Compared with usual care, outreach (P = 0.006) screened significantly more women. The intervention cost US dollars 167.62 (2000 U.S. dollars) for each woman randomized to outreach, and incremental cost-effectiveness of outreach over usual care was US dollars 818 per additional woman screened. Sensitivity analyses estimated incremental cost-effectiveness between Us dollars 19 and US dollars 90 per additional woman screened. CONCLUSIONS Larger health plans can likely increase Pap test and mammography services in this population for a relatively low cost using this outreach intervention.
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Green CA, Lynch FL, Polen MR, McFarland BH, Dickinson DM, Freeborn DK. Talk About Costs: Health Care Professionals' Views About Expenses Related to Substance Abuse Treatment. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2003; 31:483-94. [PMID: 15478877 DOI: 10.1023/b:apih.0000036415.93415.54] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Green CA, Polen MR, Dickinson DM, Lynch FL, Bennett MD. Gender differences in predictors of initiation, retention, and completion in an HMO-based substance abuse treatment program. J Subst Abuse Treat 2002; 23:285-95. [PMID: 12495790 DOI: 10.1016/s0740-5472(02)00278-7] [Citation(s) in RCA: 145] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
We studied gender differences in treatment process indicators among 293 HMO members recommended for substance abuse treatment. Treatment initiation, completion, and time spent in treatment did not differ by gender, but factors predicting these outcomes differed markedly. Initiation was predicted in women by alcohol diagnoses; in men, by being employed or married. Failure to initiate treatment was predicted in women by mental health diagnoses; in men, by less education. Treatment completion was predicted in women by higher income and legal/agency referral; in men, by older age. Failure to complete was predicted in women by more dependence diagnoses and higher Addiction Severity Index Employment scores; in men, by worse psychiatric status, receiving Medicaid, and motivation for entering treatment. More time spent in treatment was predicted, in women, by alcohol or opiate diagnoses and legal/agency referral; in men, by fewer mental health diagnoses, higher education, domestic violence victim status, and prior 12-step attendance. Clinical implications of results are discussed.
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Boles M, Lynch FL, DeBar LL. Variations in pharmacotherapy for attention deficit hyperactivity disorder in managed care. J Child Adolesc Psychopharmacol 2001; 11:43-52. [PMID: 11322744 DOI: 10.1089/104454601750143429] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The purpose of this study was to identify the patterns of pharmacotherapy in the treatment of children diagnosed with attention deficit hyperactivity disorder (ADHD) in a large, non-profit, group-model managed care organization from January 1997 through July 1998. We sought to determine whether children with uncomplicated ADHD use different drug therapies when compared to children with ADHD and psychiatric comorbidity. We also examined the relationships between the use of specialty mental health services and the use of various psychotropic medications for treatment of ADHD. We found that children with ADHD and psychiatric comorbidity were less likely to use psychostimulants (odds ratio [OR] = 0.71, 95% confidence interval [CI] = 0.55-0.93, p = 0.01) but more likely to use antidepressants (OR = 2.74, 95% CI = 1.95-3.86, p < 0.01), alpha adrenergic agonists (OR = 2.63, 95% CI = 1.93-3.57, p < 0.01), and other psychotropic medications (OR = 2.40, 95% CI = 1.27-4.50, p < 0.01) than children with uncomplicated ADHD (who were more likely to use stimulants only). Additionally, children with psychiatric comorbidity were more likely to use multiple psychotropic drugs (p < 0.01). The results of this study indicate that children with potentially more complex mental health needs are being treated with more varied drug therapy and/or specialty mental health care services.
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Penner NR, Lynch FL. Integrating mental health into the Oregon Health Plan. NEW DIRECTIONS FOR MENTAL HEALTH SERVICES 2000:49-56. [PMID: 10758719 DOI: 10.1002/yd.23320008508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Public mental health has long struggled to be accepted as a part of health care. Its interface with social services and its broad spectrum of professionals make a clear definition of public mental health's boundaries difficult, fueling policymakers' skepticism about such acceptance. The Oregon Health Plan was the result of a process that explicitly included mental health but recognized that the tools for doing so need to be carefully developed.
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Lynch FL. Quantitative results. NEW DIRECTIONS FOR MENTAL HEALTH SERVICES 2000:73-81. [PMID: 10758722 DOI: 10.1002/yd.23320008511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Detailed analysis of information obtained is still under way, but initial trends appear to show stable enrollment, maintenance of minimum service levels, and lower hospital utilization.
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Frank RG, Jackson CA, Lynch FL. The structure of economic incentives in the Robert Wood Johnson/HUD Program on Chronic Mental Illness 1988. JOURNAL OF MENTAL HEALTH ADMINISTRATION 1999; 20:20-31. [PMID: 10125383 DOI: 10.1007/bf02521400] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This paper describes the financial arrangements put into place by cities participating in the Robert Wood Johnson Foundation's Program on Chronic Mental Illness. Descriptive information is given on the level of expenditure, the mix of revenues, and the terms under which local, federal, and Medicaid dollars are allocated to local programs. Data are presented on the use of state hospitals and the number of severely mentally ill individuals in treatment. These data are used to make observations on the initial stages of the demonstration.
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Lynch FL. The effects of state intergovernmental transfers on local public mental health services. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 1997; 24:279-99. [PMID: 9217329 DOI: 10.1007/bf02042515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The provision of public mental health services is shifting increasingly from states to local areas. Yet state governments continue to bear financial responsibility for the majority of these services. One implication of this trend is that the success of state policies become dependent on a state's ability to influence the behavior of local areas. This paper discusses the different options states have in designing intergovernmental grant contracts with local areas, and describes likely impacts of the different strategies. These propositions are then tested using data from the Ohio state mental health system from 1989-1993. This study finds that the design of grants affects public expenditures, local revenue generation, and the mix of services provided at the local level.
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