Adding or switching antipsychotic medications in treatment-refractory schizophrenia

OBJECTIVE

This study compared patients with schizophrenia whose antipsychotic medications were switched to manage treatment-resistant positive psychotic symptoms with those for whom another antipsychotic was added. Psychiatrists' characteristics and perceptions of effectiveness of the medication change on clinical outcomes were also reported.

METHODS

Psychiatrists participating in a nationally representative mailed survey (N=209) reported on the clinical features, management, and response to the change in antipsychotic medication (added versus switched) of one adult patient with treatment-refractory schizophrenia under their care for at least one year.

RESULTS

Thirty-three percent of patients were treated with an added antipsychotic medication. Compared with patients whose antipsychotic medications were switched, those with an added antipsychotic medication were more likely to be female, to have received care from the same psychiatrist for more than two years, and to have been recently prescribed an antidepressant. Compared with psychiatrists who switched antipsychotic prescriptions, those who added an antipsychotic reported that the change was less likely to reduce positive symptoms, improve functioning, and prevent hospitalization. Psychiatrists who added rather than switched antipsychotics reported more frequent attendance at educational programs sponsored by a pharmaceutical company.

CONCLUSIONS

Consistent with other lines of research and practice guideline recommendations, psychiatrists perceive antipsychotic polypharmacy to be a generally ineffective strategy for treatment-resistant positive psychotic symptoms. In light of these findings, efforts to identify and implement more effective evidence-based pharmacologic approaches should be undertaken.

Issues in the registration of clinical trials

Public concerns about the perils associated with incomplete or delayed reporting of results from clinical trials has heightened interest in trial registries and results databases. Here we review the current status of trial registration efforts and the challenges in developing a comprehensive system of trial registration and reporting of results. ClinicalTrials.gov, the largest trial registry with 36 249 trials from approximately 140 countries, has procedures in place to help ensure that records are valid and informative. Key challenges include the need to minimize inadvertent duplicate registrations, to ensure that interventions have unambiguous names, and to have a search engine that identifies all trials that meet a user's specifications. Recent policy initiatives have called for the development of a database of trial results. Several issues confound the implementation of such a database, including the lack of an accepted format or process for providing summaries of trial results to the public and concerns about disseminating data in the absence of independent scientific review.

Medication access and continuity: the experiences of dual-eligible psychiatric patients during the first 4 months of the Medicare prescription drug benefit

OBJECTIVE

This study attempted to systematically assess the experiences of Medicare and Medicaid "dual-eligible" psychiatric patients, including evaluating patients' access to medications and the administrative functioning of the program, during the first 4 months of the Medicare Part D prescription drug benefit.

METHOD

Psychiatrists (N=5,833) were randomly selected from the American Medical Association's Physicians Masterfile. After exclusion of those not practicing and with undeliverable addresses, 64% responded; 35% met study eligibility criteria of treating at least one dual-eligible patient during their last typical workweek and reported clinically detailed information on one systematically selected patient.

RESULTS

A total of 53.4% had at least one medication access problem to report between Jan. 1 and April 30, 2006. Although 9.7% experienced improved medication access, 22.3% discontinued or temporarily stopped taking medication because of prescription drug coverage or management issues, and 18.3% were previously stable but were required to switch medications. Among those with medication access problems, 27.3% experienced a significant adverse clinical event; 19.8% had an emergency room visit. Most drug plan features studied, including preferred drug/formulary lists, prior authorization, medication dosing/number limits, "fail-first" protocols, and requirements to switch to generics, were associated with significantly higher rates of medication access problems.

CONCLUSIONS

The findings indicate consequential medication access problems for psychiatric patients during the implementation of Medicare Part D. Although Centers for Medicare and Medicaid Services policies were enacted to ensure access to protected classes of psychopharmacologic medications, the high rates of medication access problems observed indicate further refinement of these policies is needed.

Relationship of comorbid substance and alcohol use disorders to disability among patients in routine psychiatric practice

The primary aim of this study was to present data on the relationship of mental and comorbid substance use disorders to work disability and functioning in routine psychiatric practice in the United States. Data were used from the 1997 and 1999 American Psychiatric Institute for Research and Education's Practice Research Network Study of Psychiatric Patients and Treatments, totaling 754 psychiatrists and 3,088 patients. Results found patients with comorbid substance use disorders had significantly higher rates of work disability. These findings highlight the critical need to address the disturbing lack of substance use treatment and rehabilitation services for this population.

Comorbidity patterns in routine psychiatric practice: is there evidence of underdetection and underdiagnosis?

OBJECTIVE

The purpose of this study is to present data on the rates of diagnosis and patterns of Axis I comorbidity treated by psychiatrists in routine psychiatric practice, ascertained by practicing psychiatrists, and compare them with those ascertained through structured interview in a national sample of individuals treated in the specialty mental health sector for evidence of underdetection or underdiagnosis of comorbid disorders in routine psychiatric practice.

METHODS

Data on 2117 psychiatric patients gathered by 754 psychiatrists participating in the 1997 and 1999 American Psychiatric Institute for Research and Education's Practice Research Network's Study of Psychiatric Patients and Treatments (SPPT) were analyzed, assessing psychiatrist-reported rates of Axis I disorders and comorbidities. SPPT data on patients treated by psychiatrists were compared with a clinical subset of patients in the National Comorbidity Survey who had been treated in the specialty mental health sector (SMA).

RESULTS

Rates of comorbidity were higher in the SMA (53.9%) than in the SPPT (31.5%). The prevalence of schizophrenia diagnoses was more than twice as prevalent in the SPPT as in the SMA sample; anxiety disorders were 2 to 22 times more prevalent in the SMA sample. In the SPPT, 4 of the 10 most prevalent comorbid pairs included schizophrenia or bipolar disorder; only one pair in the SMA sample included either diagnoses. Of the 10 most prevalent comorbidity pairings in the SMA sample, 6 included a phobia diagnosis.

CONCLUSIONS

Results of these analyses suggest greater differences in the patterns and rates of comorbidities than one might expect between these 2 samples. Possible reasons for these disparities, including methodological differences in diagnostic ascertainment and underdiagnosis of anxiety disorders, are discussed.

Determinants of health plan membership among patients in routine U.S. psychiatric practice

This study utilized a large clinical dataset of patients representative of those in routine U.S. psychiatric practice to assess the influence of sociodemographic variables and diagnostic class on health plan membership (public or private). Data on patients with schizophrenia or other psychotic disorders (n=288) and patients with mood or anxiety disorders (n=1304) were obtained from a cross-sectional practice-based survey conducted by the American Psychiatric Institute for Research and Education. The likelihood of health plan membership was lower among males and among those from a minority race/ethnicity. Health plan membership was also affected by educational attainment and employment status. Even after controlling for these sociodemographic determinants of health plan membership, individuals with schizophrenia/other psychotic disorders were significantly less likely to belong to a health plan than those with mood/anxiety disorders.

Patterns of adult psychotherapy in psychiatric practice

OBJECTIVE

Psychotherapy has long been recognized as a key component of psychiatric care. However, concerns have been raised about access to psychotherapy as a result of changes in the financing and management of care. This study examined patterns and predictors of receipt of psychotherapy among patients of psychiatrists.

METHODS

Data were collected for 587 psychiatrists who participated in the American Psychiatric Institute for Research and Education's Practice Research Network 1999 Study of Psychiatric Patients and Treatments, which generated nationally representative data for 1,589 adult patients.

RESULTS

Findings indicate that more than 66 percent of patients of psychiatrists received some form of psychotherapy from the psychiatrist or another provider in the past 30 days--56 percent from their psychiatrist and 10 percent from another clinician. Although 72 percent of patients with depression received psychotherapy, more than half of those with schizophrenia did not.

CONCLUSIONS

A majority of patients of psychiatrists received psychotherapy from their psychiatrist. However, these rates varied by demographic, diagnostic, and health plan characteristics and by practice setting. Further research determining if these observed patterns of psychotherapy are related to differential outcomes is needed.

Treatment compliance in patients with comorbid psychiatric and substance use disorders

This study examines clinical and non-clinical factors associated with treatment compliance problems in 342 patients with substance use disorders (SUD) seen in routine psychiatric practice. Weighted Wald-X(2) and multivariate logistic regression assessed sociodemographic, clinical, treatment, and health plan characteristics associated with treatment compliance problems. Among patients with SUD, 40.5% were reported to currently have treatment compliance problems. Patients with treatment compliance problems were significantly more likely to have personality disorders, lower global assessment of functioning scores, and medication side effects than those without treatment compliance problems. Patients seen by psychiatrists who were reimbursed by discounted rather than undiscounted fee-for-service were five times more likely to be reported to have treatment compliance problems. Both clinical and non-clinical factors appear to be associated with treatment compliance problems. Understanding these factors and targeting treatment interventions may improve treatment compliance and patient outcomes.

Awareness of illness and nonadherence to antipsychotic medications among persons with schizophrenia

OBJECTIVE

The purpose of this study was to assess the effects of patients' awareness of their illness on the clinical presentation, management, and course of nonadherence to antipsychotic medications among patients with schizophrenia.

METHODS

A national survey was conducted of psychiatrists who were treating patients with schizophrenia. The survey was sent to 771 psychiatrists, of whom 534 responded, for a response rate of 69 percent. The psychiatrists were asked to report on presentation, management, and course for one adult patient with schizophrenia who had been under their care for at least one year and who had been nonadherent to oral antipsychotics at some point in the past year. Patients who were aware that they had a mental illness were compared with those who were not aware.

RESULTS

Of the 534 respondent psychiatrists, 310 reported on an eligible patient, and 300 of these patients were classified by illness awareness. Ninety-seven patients, or 32 percent, were not aware that they had a mental illness. These patients who lacked awareness had significantly longer episodes of antipsychotic nonadherence, were more likely to completely cease taking the antipsychotic medication, were more likely to have severe positive symptoms, and were more likely to be psychiatrically hospitalized after nonadherence than those who were aware of their illness. Psychological interventions and several types of family interventions were significantly less effective among patients who lacked awareness.

CONCLUSIONS

A lack of awareness of mental illness is common among patients with schizophrenia who are nonadherent to antipsychotics. Such nonadherence tends to be especially disruptive and unresponsive to simple commonly used psychological interventions.

Prolonged duration of untreated psychosis in nonaffective first-episode psychotic disorders compared to other psychoses

Introduction. While the consequences of the duration of untreated psychosis (DUP) represent an active area of research, less attention has been focused on the determinants of the DUP. This analysis assessed several potential determinants of the DUP from a practice-based survey. Method. Data on selected patients in their first treatment episode for psychotic symptoms were obtained from 104 practicing physicians. Patients with a long DUP (n=31), defined as >4 weeks, were compared to patients with a short DUP (≤4 weeks, n=28). Results. The long-DUP group had a higher percentage of patients with nonaffective psychotic disorders (58%) compared to the short-DUP group (29%). The median DUP among those with nonaffective psychotic disorders was 8 weeks, compared to 3 weeks among those with other psychotic disorders. The long-DUP group had a higher percentage of patients rated as uncertain about or denying a mental illness (55% compared to 25% in the short-DUP group). The presence of negative symptoms approached significance in terms of differentiating between the two groups, with 66% of the long-DUP group having negative symptoms compared to 39% of the short-DUP group. When three variables (nonaffective psychotic disorder versus other psychoses, insight, and negative symptoms) were entered into a logistic regression model, only diagnostic category remained an independently significant predictor. Conclusion. In this practice-based sample, patients with nonaffective psychotic disorders were more likely to have a longer DUP than patients who developed psychotic symptoms in the context of mood disorders, substance use disorders, or other disorders.

The associations between substance use disorders, schizophrenia-spectrum disorders, and Axis IV psychosocial problems

BACKGROUND

Substance abuse among individuals with schizophrenia-spectrum disorders (SSDs) is associated with a range of adverse psychosocial outcomes in the areas of occupational functioning, housing stability, economic independence, access to health care, and involvement with the legal system. The aim of this study was to estimate the effects of substance use disorders (SUDs), SSDS, and dual diagnosis with both disorders on the risk for six important Axis IV psychosocial problems. This was accomplished using a large dataset of patients who are representative of individuals in routine US psychiatric practice.

METHOD

Weighted data from the 1999 Study of Psychiatric Patients and Treatments from a practice-based research network of the American Psychiatric Institute for Research and Education were analyzed. Some 615 US psychiatrists provided detailed clinical, psychosocial, and health services information on 1,843 patients, including 285 patients with one or more SUDs without an SSD, 180 patients with a diagnosis of an SSD without substance abuse comorbidity, and 68 dually diagnosed patients. Logistic regression models were used to determine effect estimates (adjusted odds ratios), and corresponding 95% confidence intervals were calculated.

RESULTS

After adjusting for sociodemographic variables and for SSD diagnosis, SUD diagnosis was independently associated with increased risk for five of the Axis IV psychosocial problems of interest (occupational problems, housing problems, economic problems, problems with access to health care services, and problems related to interaction with the legal system/crime) when compared to all other psychiatric patients (n=1,310). After adjusting for the sociodemographic variables and for SUD diagnosis, SSD diagnosis (compared to all other psychiatric diagnoses) was associated with Axis IV economic problems, but not with the other five psychosocial problems of interest. The presence of both an SUD and an SSD diagnosis (dual diagnosis) was associated with a greater risk for four of the six Axis IV psychosocial problems studied, compared to the risks associated with either diagnosis alone. Limiting the substance of abuse to alcohol resulted in similar findings.

CONCLUSIONS

Although SUDs are associated with increased risk for poor social adjustment, the comorbidity of SUDs and SSDs is associated with greatly compounded psychosocial burdens. These findings, from a large sample of representative US psychiatric patients, demonstrate the ongoing need for improved services and policies for those specially burdened patients with the dual diagnosis of both an SSD and substance abuse or dependence.

Predictors of psychiatrist-reported treatment-compliance problems among patients in routine U.S. psychiatric care

Characteristics associated with psychiatrist-reported treatment-compliance problems were investigated using the 1999 Study of Psychiatric Patients and Treatments from the Practice Research Network of the American Psychiatric Institute for Research and Education (n=1,843). Logistic regression was used to study characteristics associated with compliance problems as perceived by treating psychiatrists. Among the 22 potential predictors of interest, all but three (age, gender, and problems with primary support group) were found to be significantly associated with treatment-compliance problems in bivariate analyses. A predictive model was developed consisting of eight independently significant predictors from diagnostic, clinical, psychosocial, and treatment-history domains. These predictors included substance use disorder diagnosis, medication side effects, moderate to severe psychotic symptoms, personality disorder diagnosis, economic problems, prior hospitalization, current Global Assessment of Functioning scale score, and duration of treatment with current psychiatrist. This predictive model correctly identified the presence or absence of treatment-compliance problems in 91% of patients in a sample randomly drawn from the dataset before model construction. These findings may be useful to clinicians, researchers, and program planners interested in addressing the important issue of treatment-compliance problems in psychiatric care settings.

The geriatric psychiatry workforce in 2002: analysis from the 2002 National Survey of Psychiatric Practice

OBJECTIVE

Using the 2002 National Survey of Psychiatric Practice (NSPP), authors update demographic and professional work activities of a nationally representative sample of the psychiatric workforce who treat geriatric patients.

METHODS

The sampling frame for the 2002 NSPP used the American Medical Association's Masterfile of Physicians. Professional, demographic, and patient data are compared between general and self-reported geriatric psychiatrists. Authors also present detailed analyses comparing high geriatric providers (HGPs; geriatric caseloads >20%), and board-certified geriatric psychiatrists (BCGPs).

RESULTS

The proportion of HGPs in the 2002 NSPP was 26.0% of all respondents and was 28.1% among American Psychiatric Association (APA)-member respondents. Among the APA-member psychiatrists, this reflected a 55% increase from the 1996 NSPP. Of HGPs, 31.0% were certified in geriatric psychiatry. As compared with general psychiatrists, proportionally fewer men and American medical-school graduates were self-reported geriatric psychiatrists. Geriatric psychiatrists saw nearly three times as many geriatric patients and five times as many dementia patients as did their generalist counterparts. Mood-disorder patients were the largest treatment group, however. Investigators observed no significant differences in professional and practice characteristics between HGPs and BCGPs.

CONCLUSIONS

About 1 in 4 psychiatrists in the 2002 survey are HGPs. Geriatric psychiatrists treat proportionally more geriatric patients than do generalists, but they do not have exclusively geriatric practices. The similarities between HGPs and BCGPs raise issues about the incentives for geriatric psychiatry certification, but not the need to train subspecialists to serve as faculty and community resources.

Patterns and quality of treatment for patients with schizophrenia in routine psychiatric practice

OBJECTIVES

This study provided generalizable national data on the treatment of adult patients with schizophrenia in the United States and assessed conformance with the practice guideline treatment recommendations of the Schizophrenia Patient Outcomes Research Team and the American Psychiatric Association.

METHODS

National data from the American Psychiatric Institute for Research and Education's 1999 Practice Research Network study of psychiatric patients and treatments were used to examine treatment patterns for 151 adult patients with schizophrenia. Analyses were performed and adjusted for the weights and sample design to generate nationally representative estimates.

RESULTS

Findings indicated that patients with schizophrenia who were treated by psychiatrists had complex clinical problems and were markedly disabled. Forty-one percent of patients had a comorbid axis I disorder, and 75 percent were currently unemployed. Thirty-five percent were currently experiencing medication side effects, and 37 percent were currently experiencing problems with treatment adherence. Although most patients received guideline-consistent psychopharmacologic treatment, treatment was characterized by significant polypharmacy. Rates of conformance with the guideline recommendations were significantly lower for psychosocial recommendations than for psychopharmacologic recommendations. Although 69 percent of patients received at least some psychosocial treatment, none of the unemployed patients received vocational rehabilitation services in the past 30 days.

CONCLUSIONS

These data suggest unmet need for psychosocial treatment services among individuals with schizophrenia. These findings raise questions about whether currently available antipsychotic medications are being used optimally or whether they offer limited effectiveness for patients with complex clinical problems who are treated in routine psychiatric practice.

Concomitant pharmacotherapy among youths treated in routine psychiatric practice

OBJECTIVES

The aim of this study was to assess rates and correlates of concomitant pharmacotherapy in children and adolescents treated by psychiatrists in a broad range of clinical settings.

METHODS

Cross-sectional data on 392 child and adolescent patients aged 2-17 years from the 1997 and 1999 American Psychiatric Practice Research Network Study of Psychiatric Patients and Treatments were used, and weighted estimates are provided.

RESULTS

Findings indicate that 84% of child and adolescent patients received one or more psychopharmacologic medications; 52% of patients treated with medications received concomitant pharmacotherapy (i.e., two or more medications). Patients who were treated with psychopharmacologic treatments received a median of 2 medications (range, 1-6). Highest rates of concomitant pharmacotherapy were among patients with bipolar disorder (87%). Correlates of concomitant pharmacotherapy included: (1) having a diagnosis of bipolar disorder, (2) having co-occurring Axis I or II disorders or general medical conditions, and (3) currently receiving treatment in an inpatient setting.

CONCLUSIONS

Over 40% of child and adolescent patients of psychiatrists were prescribed two or more psychopharmacologic medications. Patients with chronic and clinically complex conditions were more likely to receive concomitant pharmacotherapy. Most often, efficacy of U.S. Food and Drug Administration (FDA)-approved medications has been examined as monotherapy, and cautions on drug interactions and off-label use derived from multiple sources accompany each product. With high rates of concomitant pharmacotherapy among children and adolescents in psychiatric care, additional research on efficacy and safety of this treatment strategy is necessary.

Challenges to evidence-based medicine: a comparison of patients and treatments in randomized controlled trials with patients and treatments in a practice research network

BACKGROUND

The practice of evidence-based medicine depends on the availability of clinically relevant research, yet questions have been raised about the generalizability of findings from randomized controlled trials (RCTs).

OBJECTIVES

The aim of this study was to quantify differences between RCT patients and treatments and those in day-to-day clinical practice.

RESEARCH DESIGN

Data from published reports of two key RCTs underlying recent treatment advances in psychiatry were compared with data on routine psychiatric practice collected through a Practice Research Network (PRN).

SETTING

Hospital inpatient units (RCT) and the full range of psychiatric practice settings in the United States (PRN).

SUBJECTS

Adults with bipolar I disorder and adults with schizophrenia.

MEASURES

Demographic (age, gender, race), clinical (principal diagnoses, comorbid conditions, psychosocial functioning, and histories of hospitalization), and treatment (medication name and dosage) characteristics.

RESULTS

PRN patients had more comorbid conditions and were more likely to be white, female, and older than RCT patients. In all, 38% of PRN patients with schizophrenia and 55% of PRN patients with bipolar I disorder would have been ineligible for the corresponding RCT. Most PRN patients receiving an RCT study medication were also receiving other medications not allowed by the RCT protocol.

CONCLUSIONS

Findings support the assertion that RCT patients and treatments are not typical of those in clinical practice, and most patients in clinical practice are receiving treatments that do not have direct empirical support. Research is needed to determine the extent to which RCT findings should be used to guide routine clinical decisions.

Quality of care measures for the treatment of bipolar disorder

The staff of the American Psychiatric Association (APA), the American Psychiatric Institute for Research and Education (APIRE), and a national panel of experts in bipolar disorder and practice guideline development have collaborated to generate a set of quality of care indicators for the pharmacologic and psychosocial treatment of bipolar disorder. The indicators were derived from APA's evidence-based Practice Guideline for the Treatment of Patients with Bipolar Disorder, 2002 (1) and the Expert Consensus Guideline Series: Medication Treatment of Bipolar Disorder, 2000 (2) These quality indicators can be used for quality monitoring, benchmarking, and quality improvement efforts across health plans, systems of care, and health care providers to improve quality and outcomes of care for patients with bipolar disorder.

Challenges in increasing access to buprenorphine treatment for opiate addiction

The aims of this study are to assess psychiatrists' comfort using office-based opiate agonist treatment (OBOT) and to identify psychiatrist characteristics associated with OBOT comfort. A random sample of 2,323 AMA Masterfile of Physicians psychiatrists were surveyed through the 2002 APIRE National Survey of Psychiatric Practice (NSSP). Of the 52% responding (N = 1,203), 80.6% (SE = 1.8%) were not comfortable providing OBOT. Males, addiction-certified psychiatrists, and those treating substance abuse patients were more comfortable providing OBOT. These findings highlight significant barriers in providing buprenorphine treatment. Increasing the understanding of specific financing and services delivery barriers that clinicians face is needed to inform the development of effective integrated services models and policies to facilitate OBOT implementation.

Variations in use of second-generation antipsychotic medication by race among adult psychiatric patients

OBJECTIVE

This study examined variations in the use of second-generation antipsychotic medication among African-American and non-Hispanic white patients in a national sample of adults who were treated by psychiatrists.

METHODS

This study used data from studies of psychiatric patients and treatments that were conducted by the American Psychiatric Institute for Research and Education's (APIRE's) Practice Research Network (PRN). Psychiatrists provided detailed clinical data for 126 African-American patients and 574 white patients who were randomly selected and for whom antipsychotic medications were prescribed. The study assessed differences by race in the use of second-generation antipsychotic medication, adjusting for clinical, sociodemographic, and health-system characteristics, including patients' source of payment for treatment.

RESULTS

African-American patients were less likely than white patients to receive second-generation antipsychotic medications (49 percent compared with 66 percent). After the analysis statistically adjusted for clinical, sociodemographic, and health-system characteristics, African-American patients remained less likely than white patients to receive second-generation antipsychotics.

CONCLUSIONS

Because African Americans tended to receive medications that are not first-line recommended treatments and that have a greater risk of producing tardive dyskinesia and extrapyramidal side effects, African Americans could be expected to suffer diminished clinical status. This disparity may also contribute to lower rates of adherence and to more frequent emergency department visits and psychiatric hospitalizations among African Americans

Association of utilization management and treatment plan modifications among practicing U.S. psychiatrists

OBJECTIVE

This study examined the relationship between utilization management techniques and psychiatrists' treatment plan modifications.

METHOD

Nationally representative data on 1,843 patients treated by 615 psychiatrists participating in the American Psychiatric Institute for Research and Education's Practice Research Network were used to examine the demographic and clinical characteristics of patients whose care was subjected to utilization management and to assess the association between utilization management and psychiatrists' treatment plan modifications.

RESULTS

Approximately half of all patients had treatment that was subject to utilization management (52.6%). For the patients whose treatment was not subject to utilization management, 15.5% had their treatment plan changed compared to the 31.5% who were subject to utilization management. Overall, after adjustment for differences in patients, settings, and psychiatrist characteristics, the patients subject to utilization management were 2.6 times more likely to have their treatment changed than the patients who were not subject to utilization management. These patients were 3.7 times more likely to have their type of treatment changed and 2.3 times more likely to have their frequency or number of visits changed. Psychiatrists in individual practice settings and those with nonsalaried income sources were more likely to modify treatment decisions for their patients when subject to utilization management.

CONCLUSIONS

The presence of utilization management is highly associated with changes in psychiatrists' treatment decisions. When compared to evidence-based treatment recommendations, these changes seem likely to result in less than optimal care.