Addressing public stigma and disparities among persons with mental illness: the role of federal policy

Stigma against mental illness is a complex construct with affective, cognitive, and behavioral components. Beyond its symbolic value, federal law can only directly address one component of stigma: discrimination. This article reviews three landmark antidiscrimination laws that expanded protections over time for individuals with mental illness. Despite these legislative advances, protections are still not uniform for all subpopulations with mental illness. Furthermore, multiple components of stigma (e.g., prejudice) are beyond the reach of legislation, as demonstrated by the phenomenon of label avoidance; individuals may not seek protection from discrimination because of fear of the stigma that may ensue after disclosing their mental illness. To yield the greatest improvements, antidiscrimination laws must be coupled with antistigma programs that directly address other components of stigma.

Health services determinants of the duration of untreated psychosis among African-American first-episode patients

OBJECTIVE

The duration of untreated psychosis is associated with poor outcomes in multiple domains in the early course of nonaffective psychotic disorders, although relatively little is known about determinants of this critical period, particularly health services-level determinants. This study examined three hypothesized predictors of duration of untreated psychosis (lack of insurance, financial problems, and broader barriers) among urban, socioeconomically disadvantaged African Americans, while controlling for the effects of three patient-level predictors (mode of onset of psychosis, living with family versus alone or with others before hospitalization, and living above versus below the federally defined poverty level).

METHODS

Analyses included data from 42 patient-family member dyads from a larger sample of 109 patients with a first episode of nonaffective psychosis. The duration of untreated psychosis and all other variables were measured in a rigorous, standardized fashion in a study designed specifically to examine determinants of treatment delay. Survival analyses and Cox regression assessed the effects of the independent predictors on time from onset of psychosis to hospital admission for initial evaluation and treatment.

RESULTS

The median duration of untreated psychosis was 24.5 weeks. When the analyses controlled for the three patient-level covariates, patients without health insurance, with financial problems, or with barriers to seeking help had a significantly longer duration of untreated psychosis.

CONCLUSIONS

Health services-related factors, such as lack of insurance, are predictive of longer treatment delay. Efforts to eliminate uninsurance and underinsurance, as well as minimize barriers to treatment, would be beneficial for improving the prognosis of young patients with emerging nonaffective psychotic disorders.

A Public Health Perspective on Mental and Medical Comorbidity

Association of Mental Disorders With Subsequent Chronic Physical Conditions: World Mental Health Surveys From 17 Countries Kate M. Scott, MA (Clin Psych), PhD; Carmen Lim, MSc; Ali Al-Hamzawi, MD; Jordi Alonso, MD, DrPH; Ronny Bruffaerts, PhD; José Miguel Caldas-de-Almeida, MD, PhD; Silvia Florescu, MD, PhD; Giovannide Girolamo, MD; Chiyi Hu, PhD; Peter de Jonge, PhD; Norito Kawakami, MD, DMSc; Maria Elena Medina-Mora, PhD; Jacek Moskalewicz, PhD; Fernando Navarro-Mateu, MD, PhD; Siobhan O’ Neill, MPsychSc, PhD; Marina Piazza, ScD, MPH; José Posada-Villa, MD; Yolanda Torres, MPH, DraHC; Ronald C. Kessler, PhD

IMPORTANCE

It is clear that mental disorders in treatment settings are associated with a higher incidence of chronic physical conditions, but whether this is true of mental disorders in the community, and how generalized (across a range of physical health outcomes) these associations are, is less clear. This information has important implications for mental health care and the primary prevention of chronic physical disease.

OBJECTIVE

To investigate associations of 16 temporally prior DSM-IV mental disorders with the subsequent onset or diagnosis of 10 chronic physical conditions.

DESIGN, SETTING, AND PARTICIPANTS

Eighteen face-to-face, cross-sectional household surveys of community-dwelling adults were conducted in 17 countries (47 609 individuals; 2 032 942 person-years) from January 1, 2001, to December 31, 2011. The Composite International Diagnostic Interview was used to retrospectively assess the lifetime prevalence and age at onset of DSM-IV–identified mental disorders. Data analysis was performed from January 3, 2012, to September 30, 2015.

MAIN OUTCOMES AND MEASURES

Lifetime history of physical conditions was ascertained via self-report of physician’s diagnosis and year of onset or diagnosis. Survival analyses estimated the associations of temporally prior first onset of mental disorders with subsequent onset or diagnosis of physical conditions.

RESULTS

Most associations between 16 mental disorders and subsequent onset or diagnosis of 10 physical conditions were statistically significant, with odds ratios (ORs) (95% CIs) ranging from 1.2 (1.0–1.5) to 3.6 (2.0–6.6). The associations were attenuated after adjustment for mental disorder comorbidity, but mood, anxiety, substance use, and impulse control disorders remained significantly associated with onset of between 7 and all 10 of the physical conditions (ORs [95% CIs] from 1.2 [1.1–1.3] to 2.0 [1.4–2.8]). An increasing number of mental disorders experienced over the life course was significantly associated with increasing odds of onset or diagnosis of all 10 types of physical conditions, with ORs (95% CIs) for 1 mental disorder ranging from 1.3 (1.1–1.6) to 1.8 (1.4–2.2) and ORs (95% CIs) for 5 or more mental disorders ranging from 1.9 (1.4–2.7) to 4.0 (2.5–6.5). In population-attributable risk estimates, specific mental disorders were associated with 1.5% to 13.3% of physical condition onsets.

CONCLUSIONS AND RELEVANCE

These findings suggest that mental disorders of all kinds are associated with an increased risk of onset of a wide range of chronic physical conditions. Current efforts to improve the physical health of individuals with mental disorders may be too narrowly focused on the small group with the most severe mental disorders. Interventions aimed at the primary prevention of chronic physical diseases should optimally be integrated into treatment of all mental disorders in primary and secondary care from early in the disorder course.

Tracking publication outcomes of National Institutes of Health grants

PURPOSE

The peer-review literature is the primary medium through which the findings of funded research are evaluated by and disseminated to the broader scientific community. This study examines when and how grants funded by the National Institutes of Health (NIH) lead to publications.

METHODS

Data on all investigator-initiated R01 grants funded during 1996 (n = 18211) were extracted from the NIH's Computer Retrieval of Information on Scientific Projects Web site. These data were linked with all MEDLINE articles published during and up through 4 years after completion of each grant using NIH grant numbers reported in the manuscript. Analyses examined the number, timing, and correlates of all linked publications and publications in core journals (179 journals, comprising the top 100 Institute for Scientific Information or 120 Abridged Index Medicus journals).

RESULTS

On average, each grant produced 7.6 MEDLINE manuscripts (95% confidence interval [CI]: 7.47 to 7.69) and 1.61 publications in a core journal (95% CI: 1.56 to 1.65). In multivariable analyses among universities, more manuscripts and publications in core journals were seen for competing renewals versus new grants, for projects reviewed by basic science study sections, for full professors, and for universities with graduate programs ranked in the top 10 by US News and World Report. However, all grant, investigator, and institutional strata produced substantial numbers of publications per grant.

CONCLUSIONS

The findings support the feasibility and potential utility of efforts to study the link between grant funding and research findings, an early step in the process by which funded science leads to improved clinical and public health.

Integrating Health and Mental Health Services: A Past and Future History

The authors trace the modern history, current landscape, and future prospects for integration between mental health and general medical care in the United States. Research and new treatment models developed in the 1980s and early 1990s helped inform federal legislation, including the 2008 Mental Health Parity and Addiction Equity Act and the 2010 Affordable Care Act, which in turn are creating new opportunities to further integrate services. Future efforts should build on this foundation to develop clinical, service-level, and public health approaches that more fully integrate mental, medical, substance use, and social services. [AJP AT 175: Remembering Our Past As We Envision Our Future July 1928: A President Takes Stock Adolf Meyer: "I sometimes feel that Einstein, concerned with the relativity in astronomy, has to deal with very simple facts as compared to the complex and erratic and multicontingent performances of the human microcosmos, the health, happiness and efficiency of which we psychiatrists are concerned with." (Am J Psychiatry 1928; 85(1):1-31 )].

Rethinking funding priorities in mental health research

Mental health research funding priorities in high-income countries must balance longer-term investment in identifying neurobiological mechanisms of disease with shorter-term funding of novel prevention and treatment strategies to alleviate the current burden of mental illness. Prioritising one area of science over others risks reduced returns on the entire scientific portfolio.

At the intersection of chronic disease, disability and health services research: A scoping literature review

BACKGROUND

There is a concerted effort underway to evaluate and reform our nation's approach to the health of people with ongoing or elevated needs for care, particularly persons with chronic conditions and/or disabilities.

OBJECTIVE

This literature review characterizes the current state of knowledge on the measurement of chronic disease and disability in population-based health services research on working age adults (age 18-64).

METHODS

Scoping review methods were used to scan the health services research literature published since the year 2000, including medline, psycINFO and manual searches. The guiding question was: "How are chronic conditions and disability defined and measured in studies of healthcare access, quality, utilization or cost?"

RESULTS

Fifty-five studies met the stated inclusion criteria. Chronic conditions were variously defined by brief lists of conditions, broader criteria-based lists, two or more (multiple) chronic conditions, or other constructs. Disability was generally assessed through ADLs/IADLs, functional limitations, activity limitations or program eligibility. A smaller subset of studies used information from both domains to identify a study population or to stratify it by subgroup.

CONCLUSIONS

There remains a divide in this literature between studies that rely upon diagnostically-oriented measures and studies that instead rely on functional, activity or other constructs of disability to identify the population of interest. This leads to wide ranging differences in population prevalence and outcome estimates. However, there is also a growing effort to develop methods that account for the overlap between chronic disease and disability and to "segment" this heterogeneous population into policy or practice relevant subgroups.

The mental health/primary care interface in the United States: history, structure, and context

This paper, the first in a series commissioned by NIMH for the "Challenges for the 21st Century: Mental Health Services Research Conference," seeks to provide a broad perspective on the primary care/mental health interface in the United States. The manuscript examines both the care of mental disorders in medical settings, and also the medical care of the seriously medically ill. The first section provides a historical overview of the cycling patterns of growth and retrenchment of primary care medicine during the 20th century, and the how those changes have paralleled the care of mental disorders and the mentally ill. The second section examines the four core features of primary care -first contact, longitudinality, comprehensiveness and coordination -and their implications for these issues. An historical and system-level perspective can provide a crucial step towards improving care on the mental health/primary care interface.

Psychiatry's Role in Improving the Physical Health of Patients With Serious Mental Illness: A Report From the American Psychiatric Association

The American Psychiatric Association Integrated Care Workgroup recently convened an expert panel charged with addressing the role of psychiatry in improving the physical health of persons with serious mental illness. The group reviewed the peer-reviewed and gray literature and developed a set of recommendations grounded in this review. This column summarizes the panel's primary findings and recommendations to key stakeholders, including clinicians, health care organizations, researchers, and policy makers.

Associations between mental health shortage areas and county-level suicide rates among adults aged 25 and older in the USA, 2010 to 2018

OBJECTIVE

Suicide is a serious public health concern, but little is known about the relationship between access to mental health care and suicide deaths, and whether suicide rates differ by mental health provider Health Professional Shortage Areas (HPSAs). This study investigated the associations between mental health HPSAs and suicide rates.

METHOD

We used generalized linear mixed models to test the associations between HPSAs and suicide rates from 2010 to 2018. For each county during a 3-year period, the total number of suicides was obtained from Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research (WONDER).

RESULTS

Mental health HPSAs had higher suicide rates (adjusted incidence rate ratio (IRR), 1.06 [95% CI, 1.03-1.09]). The interaction terms of mental health HPSAs and time (adjusted IRR, 1.01 [95% CI, 1.00-1.01]) showed that the association between mental health shortage areas and suicide rates has increased over time.

CONCLUSIONS

Suicide rates are more common in mental health provider shortage areas, and this association has been growing over time. The study's findings suggest that many communities in the US are likely facing simultaneous challenges of limited access to mental health care, social and economic disadvantage, and high burden of suicide.

Mental health care quality under managed care in the United States: a view from the Health Employer Data and Information Set (HEDIS)

OBJECTIVE

This study examined the rates and correlates of mental health care performance measures in the Health Employer Data and Information Set (HEDIS).

METHOD

For all 384 health maintenance organizations (HMOs) participating in the HEDIS program of the National Committee for Quality Assurance during 1999, analyses examined the rates of compliance with five mental health care performance measures and their association with general medical care quality, public reporting, and HMO finances.

RESULTS

The mean rate of mental health care performance was 48.0%, compared with 69.2% for non-mental-health care domains. In multivariate models adjusted for plan characteristics, scores for worse quality of non-mental-health domains, failure to report data publicly, and low medical-loss ratio (proportion of revenues spent on clinical care) all predicted poor mental health care performance.

CONCLUSIONS

Better general medical care, transparency of reporting, and commitment of fiscal resources to clinical care predicted better mental health care performance for U.S. HMOs.

Social Fragmentation and Schizophrenia: A Systematic Review

Objective: Accumulating evidence implicates social context in the etiology of psychosis. One important line of epidemiologic research pointing to a potentially causal role of social context pertains to what is termed social fragmentation. The authors conducted a systematic review of the relationship between area-level social fragmentation and psychosis. Data Sources: Three databases (MEDLINE, PsycINFO, and Web of Science) were searched from inception to May 2, 2021. There were no language restrictions. Search terms were those that identify the area-level orientation, social fragmentation, sample, and outcome. Study Selection: Inclusion criteria were the following: (1) social environment measured at the area level with (2) psychosis outcomes (incidence rates, prevalence of psychosis or schizophrenia, age at onset of psychosis, psychotic symptom severity, and duration of untreated psychosis). In total, 579 research articles were identified, and 19 were eligible to be included in this systematic review. Data Extraction: Two reviewers independently screened, extracted data from, and coded all articles. Results: Evidence from 14 of 19 articles indicates that area-level characteristics reflecting social fragmentation are associated with higher psychosis rates and other outcomes of psychosis even after controlling for other area-level characteristics including deprivation, social capital, race/ethnicity, and urbanicity and individual-level characteristics including age, sex, migrant status, and socioeconomic status. Conclusions: In conclusion, this review finds evidence that measures of area-level social fragmentation are associated with higher psychosis rates. Further research into mechanisms is needed to better characterize this association.

Mind and body reunited: improving care at the behavioral and primary healthcare interface

This paper reviews current models, research, and approaches to improving care on the primary care/behavioral health interface in the USA. We focus on care in the public sector where high rates of comorbidity, regulatory burdens, and lack of resources create particular challenges to collaboration and coordination. To achieve the goals of improved coordination and collaboration, it will be critical to address key financing, workforce, information technology, performance assessment, and research issues. It will also be critical to engage multiple stakeholders including consumers, mental health and health providers, and policymakers and public sector funders.

Receipt of nutrition and exercise counseling among medical outpatients with psychiatric and substance use disorders

OBJECTIVE

Mentally ill persons represent a population that is potentially vulnerable to receiving a poorer quality of medical care. This study examines the relationship between mental disorders and the likelihood of receiving recommended nutrition and exercise counseling.

DESIGN

Cross-sectional study combining chart-review data and administrative database records.

SETTING

One hundred forty-seven Veterans Affairs (VA) medical centers nationwide.

PATIENTS/PARTICIPANTS

The sample included 90,240 patients with obesity and/or hypertension who had >/=3 medical outpatient visits in the previous year.

MEASUREMENTS AND MAIN RESULTS

The outcomes of interest were chart-documented receipt of nutrition counseling and receipt of exercise counseling in the past 2 years. This chart information was merged with VA inpatient and outpatient administrative databases, which were used to identify persons with diagnosed mental disorders. Most patients received nutrition counseling (90.4%), exercise counseling (88.5%), and counseling for both (85.7%) in the past 2 years. The rates of counseling differed significantly but modestly by mental health status. The lowest rates were found among patients dually diagnosed with comorbid psychiatric and substance use disorders; however, the magnitude of the disparities was small, ranging from 2% to 4% across outcomes. These results were unchanged after controlling for demographics, health status, and facility characteristics using multivariable generalized estimating equation modeling.

CONCLUSIONS

Among patients engaged in active medical treatment, rates of nutrition and exercise counseling were high at VA medical centers, and the diagnosis of mental illness was not a substantial barrier to such counseling. More work is needed to determine whether these findings generalize to non-VA settings and to understand the potential role that integrated systems such as the VA can play in reducing disparities for vulnerable populations.

Depression and substance abuse and dependency in relation to current smoking status and frequency of smoking among nondaily and daily smokers

BACKGROUND AND OBJECTIVES

Daily smoking rates are decreasing while intermittent or nondaily smoking rates are increasing. Little is known about the association of depression, alcohol abuse and dependence, and illicit drug abuse and dependence with different patterns of smoking, particularly nondaily smoking. Thus, we examined these relationships among current smokers versus nonsmokers and among those who smoke daily versus less frequently.

METHODS

We conducted a secondary analysis of 37,897 adults who participated in the 2008 National Survey on Drug Use and Health. We developed logistic regression models examining predictors of (i) current smoking and (ii) number of days smoking per month (1-10 days, 11-29 days, and ≥30 days) among current smokers, focusing on past-year major depression, alcohol abuse and dependence, and illicit drug abuse and dependence.

RESULTS

Compared to nonsmokers, current smokers more frequently reported a major depressive episode (p < .001), alcohol dependence (p < .001) and abuse (p < .001), and illicit drug dependence (p < .001) and abuse (p < .001), controlling for sociodemographics. Among current smokers, greater smoking frequency was associated with illicit drug dependence (p = .004), but lower likelihood of alcohol dependence (p = .01), alcohol abuse (p = .01), and illicit drug abuse (p = .01).

CONCLUSIONS

Although depression and substance use were associated with greater likelihood of smoking, most measures were inversely associated with frequency of smoking. Thus, it is important to examine underlying mechanisms contributing to these counterintuitive findings in order to inform intervention approaches.

SCIENTIFIC SIGNIFICANCE

With increased rates of nondaily smoking, developing a greater understanding about the mental health correlates related to this pattern of smoking is critical.

Relationship of total health care charges to selective serotonin reuptake inhibitor utilization patterns including the length of antidepressant therapy--results from a managed care administrative claims database

OBJECTIVE

Administrative claims data analysis performed in the early 1990s found lower total medical costs for patients with depression who remained on antidepressant therapy with selective serotonin reuptake inhibitors (SSRIs) for at least 90 days compared with patients who discontinued therapy prior to 60 days. Over the past decade, many changes in the health care system have occurred that might impact the reproducibility of these findings. The purpose of this study was to investigate the association between SSRI utilization patterns and the use of health care services in the managed care environment.

METHODS

A large managed care claims database was used to identify patients receiving 2 or more SSRI prescriptions between June 2001 and December 2002. In order to ensure that patients were newly started on SSRI therapy, patients were required to have 6 months of enrollment data prior to their index date, without evidence of antidepressant therapy. Continuous enrollment for 12 months following their index prescription was also required. Patients with schizophrenia, bipolar disorder, or who received antipsychotic medications were excluded from this analysis. Patients were placed into 1 of 5 mutually exclusive antidepressant utilization cohorts: (1) <90 days, (2) e 90 days, (3) titration, (4) partial compliance, and (5) therapy change. Total medical costs, with and without pharmacy costs, were then compared between antidepressant utilization cohorts for 12 months of claims data.

RESULTS

There were 65,753 patients included in the study. Medical charges without pharmacy charges were lowest in the e 90-day cohort ($5,143) compared with the partial compliance ($5,909, P<0.05), <90-day ($6,289, P<0.001), titration ($6,375, P<0.001), and therapy change ($7,858, P<0.001) cohorts. Differences in total medical charges without pharmacy charges were primarily influenced by inpatient charges. The addition of pharmacy charges, including the charges for antidepressants, resulted in total medical charges that were not statistically different for the e 90-day cohort compared with the <90-day cohort, $7,454 and $7,829, respectively, P=0.606.

CONCLUSION

Medical charges without pharmacy charges were lower for patients remaining on antidepressant drug therapy for at least 90 continuous days compared with patients who used antidepressants for less than 90 continuous days, but total health care charges, including pharmacy charges, were not different between the 2 groups.

Findings of a U.S. national cardiometabolic screening program among 10,084 psychiatric outpatients

OBJECTIVE

A national cardiometabolic screening program for patients in a variety of public mental health facilities, group practices, and community behavioral health clinics was funded by Pfizer Inc. between 2005 and 2008.

METHODS

A one-day, voluntary metabolic health fair in the United States offered patients attending public mental health clinics free cardiometabolic screening and same-day feedback to physicians from a biometrics testing third party that was compliant with the Health Insurance Portability and Accountability Act.

RESULTS

This analysis included 10,084 patients at 219 sites; 2,739 patients (27%) reported having fasted for over eight hours. Schizophrenia or bipolar disorder was self-reported by 6,233 (62%) study participants. In the overall sample, the mean waist circumference was 41.1 inches for men and 40.4 inches for women; 27% were overweight (body mass index [BMI] 25.0-29.9 kg/m(2)), 52% were obese (BMI >or=30.0 kg/m(2)), 51% had elevated triglycerides (>or=150 mg/dl), and 51% were hypertensive (>or=130/85 mm Hg). In the fasting sample, 52% had metabolic syndrome, 35% had elevated total cholesterol (>or=200 mg/dl), 59% had low levels of high-density lipoprotein cholesterol (<40 mg/dl for men or <50 mg/dl for women), 45% had elevated triglycerides (>or=150 mg/dl), and 33% had elevated fasting glucose (>or=100 mg/dl). Among the 1,359 fasting patients with metabolic syndrome, 60% were not receiving any treatment. Among fasting patients who reported treatment for specific metabolic syndrome components, 33%, 65%, 71%, and 69% continued to have elevated total cholesterol, low levels of high-density lipoprotein, high blood pressure, and elevated glucose levels, respectively.

CONCLUSIONS

The prevalence of metabolic syndrome and cardiometabolic risk factors, such as overweight, hypertension, dyslipidemia, and glucose abnormalities, was substantial and frequently untreated in this U.S. national mental health clinic screening program.

Advancing the adoption, integration and testing of technological advancements within existing care systems

OBJECTIVE

This manuscript reviews the work on uptake and dissemination of health information technologies in mental health populations and settings, with the goal of informing the future research agenda.

METHODS

We reviewed both the formal and "grey" literature describing the rates and correlates of uptake for electronic health records (EHRs) and personal health records (PHRs) for general and specialty mental health settings.

RESULTS

Rates of uptake and use of EHRs and PHRs are low in general medical settings, and the limited evidence suggests even lower rates for specialty mental health settings. Many of the patient, provider and system-level characteristics associated with lower rates of use in general populations would be expected to be exacerbated in mental health settings.

CONCLUSIONS

The findings suggest a need to better understand both the causes and strategies for overcoming barriers to uptake of health information technology (HIT) in mental health settings. Observational studies could help to better elucidate the barriers to adoption of HIT that are unique or disproportionate in mental health populations. Implementation science studies are needed to better identify strategies for addressing these barriers and optimizing uptake of mental health HIT interventions.

Emergency department utilization among Medicaid beneficiaries with schizophrenia and diabetes: the consequences of increasing medical complexity

OBJECTIVE

Individuals with both physical and mental health problems may have elevated levels of emergency department (ED) service utilization either for index conditions or for associated comorbidities. This study examines the use of ED services by Medicaid beneficiaries with comorbid diabetes and schizophrenia, a dyad with particularly high levels of clinical complexity.

METHODS

Retrospective cohort analysis of claims data for Medicaid beneficiaries with both schizophrenia and diabetes from fourteen Southern states was compared with patients with diabetes only, schizophrenia only, and patients with any diagnosis other than schizophrenia and diabetes. Key outcome variables for individuals with comorbid schizophrenia and diabetes were ED visits for diabetes, mental health-related conditions, and other causes.

RESULTS

Medicaid patients with comorbid diabetes and schizophrenia had an average number of 7.5 ED visits per year, compared to the sample Medicaid population with neither diabetes nor schizophrenia (1.9 ED visits per year), diabetes only (4.7 ED visits per year), and schizophrenia only (5.3 ED visits per year). Greater numbers of comorbidities (over and above diabetes and schizophrenia) were associated with substantial increases in diabetes-related, mental health-related and all-cause ED visits. Most ED visits in all patients, but especially in patients with more comorbidities, were for causes other than diabetes or mental health-related conditions.

CONCLUSION

Most ED utilization by individuals with diabetes and schizophrenia is for increasing numbers of comorbidities rather than the index conditions. Improving care in this population will require management of both index conditions as well as comorbid ones.

Metabolic Testing for Adults in a State Medicaid Program Receiving Antipsychotics: Remaining Barriers to Achieving Population Health Prevention Goals

IMPORTANCE

Medicaid quality indicators track diabetes mellitus and cardiovascular disease screening in adults receiving antipsychotics and/or those with serious mental illness.

OBJECTIVE

To inform performance improvement interventions by evaluating the relative importance of patient, prescriber, and practice factors affecting metabolic testing.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was conducted using Missouri Medicaid administrative claims data (January 1, 2010, to December 31, 2012) linked with prescriber market data. The analysis included 9316 adults (age, 18-64 years) who were starting antipsychotic medication. Secondary analysis included the subset of adults (n = 1813) for whom prescriber knowledge, attitudes, and behavior survey data were available. Generalized estimating equations were performed to identify factors associated with failure to receive annual testing during antipsychotic treatment (adjusted odds ratio [OR], <1 favor testing). Data analysis was performed from October 1, 2014, to February 18, 2016.

EXPOSURE

Oral second-generation antipsychotics.

MAIN OUTCOMES AND MEASURES

A medical claim for glucose or lipid testing occurring within 180 days before and after the antipsychotic prescription claim.

RESULTS

The 9317 patients (mean [SD] age, 37.6 [12.0] years) initiated antipsychotic medication in a variety of prescriber specialty-settings: 24.3%, community mental health center (CMHC); 27.6%, non-CMHC behavioral health; 24.3%, primary care practitioners; and 23.8%, other/unknown. Annual testing rates were 79.6% for glucose and 41.2% for lipids. Failure to test glucose and lipids was most strongly associated with patient factors and health care utilization. To illustrate by using findings from glucose modeling (reported as adjusted OR [95% CI]), lower failure to receive testing was associated with older age (40-49 vs 18-29 years; 0.64 [0.55-0.74]), diagnosis of schizophrenia or bipolar disorder (0.55 [0.44-0.67]), cardiometabolic comorbidity (dyslipidemia, 0.28 [0.22-0.37]), hypertension (0.59 [0.50-0.69]), and greater outpatient utilization (>6 encounters vs none; 0.33 [0.28-0.39]). Analysis incorporating prescriber practice information found lower failure to receive glucose testing if the patient received care at a CMHC (0.74 [0.64-0.85]) or if the initiating prescriber was a primary care practitioner (0.81 [0.66-1.00]). However, the initiating prescriber specialty-setting was not associated with lipid testing.

CONCLUSIONS AND RELEVANCE

Compared with prior reports, progress has been made to improve diabetes screening, but lipid screening remains particularly underutilized. Medicaid performance improvement initiatives should target all prescriber settings and not just behavioral health.

Listening to generic Prozac: winners, losers, and sideliners

This study tracks the diffusion of generic fluoxetine after its release in August 2001 within the largest U.S. pharmacy benefit manager (PBM). Within two weeks of the generic's release, prescriptions exceeded those of brand-name Prozac. The main winners proved to be Barr Laboratories, the first entrant to the generic market; large purchasers, who reaped substantial cost savings after Barr's period of exclusivity expired; and the PBM. The major loser was Eli Lilly, the manufacturer of Prozac. Consumers and makers of other antidepressants largely remained on the sidelines, with surprisingly little short-term impact evident from Prozac's patent expiration.

Rising mental health costs: what are we getting for our money?

This synthesis of recent epidemiological and service use data concludes that, in aggregate, rising mental health spending since the early 1990s appear to be purchasing improvements in access to care and to represent a good value for society. However, there is also evidence of continuing waste and quality deficits. Although mental health faces some unique challenges, these patterns are more similar to than different from those seen in all of health care. These parallels suggest the importance of learning from and working with the broader health care system in improving the returns on U.S. mental health spending.

Swept away: use of general medical and mental health services among veterans displaced by Hurricane Katrina

OBJECTIVE

This study examined national patterns of outpatient service use by veterans from regions affected by Hurricane Katrina.

METHODS

Analyses tracked use of general medical and mental/substance use services in September and October through December 2005 in New Orleans and Biloxi-Gulfport compared to a cohort receiving care during the same months in the previous 2 years.

RESULTS

In adjusted models, veterans from New Orleans and Biloxi-Gulfport were, respectively, 73% and 41% less likely in September 2005 to use any outpatient services as were cohorts from 2003-2004. Particularly in New Orleans, the relative decline in service use was substantially greater for specialty mental health and substance use services than for general medical services.

CONCLUSIONS

Although many veterans were able to obtain care after Hurricane Katrina, there was a substantial disruption in delivery of Veterans Administration services, with disproportionate declines in mental health and substance use care.