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.

Medical utilization among wellness consumers

This study investigates conventional medicine utilization by wellness-motivated, complementary and alternative medicine (CAM) consumers. While CAM consumers are typically characterized as high health care utilizers, negative correlations have been found between CAM-based wellness programs and the consumption of conventional medical care. We use a nationally representative sample to analyze both illness- and wellness-motivated CAM users, with an interest in whether CAM therapies used for wellness replace conventional medicine, thus potentially offering cost offsets. Results indicate that motivation for CAM use is neither associated with a lower probability nor a lower rate of conventional medicine utilization. Increasingly, individuals, workplaces, and governments incorporate wellness programs involving CAM modalities into health care and policy; as the conventional and unconventional medical spheres begin to integrate and influence one another, understanding our pluralistic medical environment and its consumers will better enable policy makers to balance health and wellness initiatives with economic imperatives.

The Health and Recovery Peer (HARP) Program: a peer-led intervention to improve medical self-management for persons with serious mental illness

OBJECTIVES

Persons with serious mental illnesses (SMI) have elevated rates of comorbid medical conditions, but may also face challenges in effectively managing those conditions.

METHODS

The study team developed and pilot-tested the Health and Recovery Program (HARP), an adaptation of the Chronic Disease Self-Management Program (CDSMP) for mental health consumers. A manualized, six-session intervention, delivered by mental health peer leaders, helps participants become more effective managers of their chronic illnesses. A pilot trial randomized 80 consumers with one or more chronic medical illness to either the HARP program or usual care.

RESULTS

At six month follow-up, participants in the HARP program had a significantly greater improvement in patient activation than those in usual care (7.7% relative improvement vs. 5.7% decline, p=0.03 for group *time interaction), and in rates of having one or more primary care visit (68.4% vs. 51.9% with one or more visit, p=0.046 for group *time interaction). Intervention advantages were observed for physical health related quality of life (HRQOL), physical activity, medication adherence, and, and though not statistically significant, had similar effect sizes as those seen for the CDSMP in general medical populations. Improvements in HRQOL were largest among medically and socially vulnerable subpopulations.

CONCLUSIONS

This peer-led, medical self-management program was feasible and showed promise for improving a range of health outcomes among mental health consumers with chronic medical comorbidities. The HARP intervention may provide a vehicle for the mental health peer workforce to actively engage in efforts to reduce morbidity and mortality among mental health consumers.

Metabolic screening in children receiving antipsychotic drug treatment

OBJECTIVES

To estimate metabolic screening rates, predictors of screening, and incidence of metabolic disturbances in children initiating second-generation antipsychotic (SGA) drug treatment.

DESIGN

A retrospective, new-user cohort study (between July 1, 2004, and June 30, 2006) using Medicaid claims data.

SETTINGS

California, Missouri, and Oregon.

PATIENTS

A total of 5370 children (aged 6-17 years) without diabetes mellitus taking SGA drugs and 15,000 children without diabetes taking albuterol (control individuals) [corrected] but no SGA drugs.

INTERVENTION

Findings 1 year after recommendations from the American Diabetes Association and American Psychiatric Association called for metabolic screening of patients receiving SGA drugs.

OUTCOME MEASURES

Serum glucose and lipid testing, 6-month incidence of diabetes, and dyslipidemia disturbances.

RESULTS

Glucose screening was performed in 1699 (31.6% [95% confidence interval (CI), 30.4%-32.9%]) SGA-treated children vs 1891 (12.6% [12.1%-13.2%]) control individuals. Lipid testing was performed in 720 (13.4% [95% CI, 12.5%-14.4%]) SGA-treated children vs 458 (3.1% [2.8%-3.3%]) controls. In multivariate logistic regression analysis, children with serious and/or multiple psychiatric diagnoses and those who used health care services more intensively were more likely to receive metabolic screening. The case incidence of glucose and lipid disorders was higher in SGA-treated vs albuterol-treated children (8.9 per 1000 children [95% CI, 6.6%-11.8%] vs 4.9 per 1000 children [3.9%-6.2%]; and 9.7 per 1000 children [95% CI, 7.2%-12.7%] vs 4.6 per 1000 children [95% CI, 3.6%-5.8%], respectively).

CONCLUSION

Most children starting treatment with SGA medications in this public sector sample did not receive recommended glucose and lipid screening.

Integrating wellness, recovery, and self-management for mental health consumers

Three distinct, yet interrelated, terms-wellness, recovery, and self-management-have received increasing attention in the research, consumer, and provider communities. This article traces the origins of these terms, seeking to understand how they apply, individually and in conjunction with one another to mental health consumers. Each shares a common perspective that is health-centered rather than disease-centered and that emphasizes the role of consumers as opposed to professional providers as the central determinants of health and well-being. Developing approaches combining elements of each construct may hold promise for improving the overall health and well-being of persons with serious mental disorders.

A randomized trial of medical care management for community mental health settings: the Primary Care Access, Referral, and Evaluation (PCARE) study

OBJECTIVE

Poor quality of healthcare contributes to impaired health and excess mortality in individuals with severe mental disorders. The authors tested a population-based medical care management intervention designed to improve primary medical care in community mental health settings.

METHOD

A total of 407 subjects with severe mental illness at an urban community mental health center were randomly assigned to either the medical care management intervention or usual care. For individuals in the intervention group, care managers provided communication and advocacy with medical providers, health education, and support in overcoming system-level fragmentation and barriers to primary medical care.

RESULTS

At a 12-month follow-up evaluation, the intervention group received an average of 58.7% of recommended preventive services compared with a rate of 21.8% in the usual care group. They also received a significantly higher proportion of evidence-based services for cardiometabolic conditions (34.9% versus 27.7%) and were more likely to have a primary care provider (71.2% versus 51.9%). The intervention group showed significant improvement on the SF-36 mental component summary (8.0% [versus a 1.1% decline in the usual care group]) and a nonsignificant improvement on the SF-36 physical component summary. Among subjects with available laboratory data, scores on the Framingham Cardiovascular Risk Index were significantly better in the intervention group (6.9%) than the usual care group (9.8%).

CONCLUSIONS

Medical care management was associated with significant improvements in the quality and outcomes of primary care. These findings suggest that care management is a promising approach for improving medical care for patients treated in community mental health settings.

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.

Race-ethnicity as a predictor of attitudes toward mental health treatment seeking

OBJECTIVE

Previous research on mental health disparities shows that persons from racial-ethnic minority groups have less access to mental health care, engage in less treatment, and receive poorer-quality treatment than non-Hispanic whites. Attitudes and beliefs about mental health treatment were examined to determine whether they contribute to these disparities.

METHODS

Data from the National Comorbidity Survey Replication (NCS-R) were analyzed to determine attitudes toward treatment-seeking behavior among people of non-Hispanic white, African-American, and Hispanic or Latino race-ethnicity. Additional sociodemographic variables were examined in relation to attitudes and beliefs toward treatment.

RESULTS

African-American race-ethnicity was a significant independent predictor of greater reported willingness to seek treatment and lesser reported embarrassment if others found out about being in treatment. These findings persisted when analyses adjusted for socioeconomic variables. Hispanic or Latino race-ethnicity also was associated with an increased likelihood of willingness to seek professional help and lesser embarrassment if others found out, but these differences did not persist after adjustment for the effects of socioeconomic variables.

CONCLUSIONS

Contrary to the initial hypothesis, African Americans and Hispanics or Latinos may have more positive attitudes toward mental health treatment seeking than non-Hispanic whites. To improve access to mental health services among racial-ethnic minority groups, it is crucial to better understand a broader array of individual-, provider-, and system-level factors that may create barriers to care.

State mental health policy: mending Missouri's safety net: transforming systems of care by integrating primary and behavioral health care

Missouri has begun a three-year pilot program across the state to integrate the primary care services provided by federally qualified health centers (FQHCs) and the behavioral health services provided by community mental health centers (CMHCs). This column describes the integration initiative, in which start-up funds were provided in 2008 to seven FQHC-CMHC partnerships (a total of $700,000 to each pair over 3.5 years). It reviews lessons learned during the first year of the project in bringing these two very different public systems of care together to mend the public health safety net.

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.

Mental disorders, quality of care, and outcomes among older patients hospitalized with heart failure: an analysis of the national heart failure project

OBJECTIVE

To evaluate the effect of a mental illness diagnosis on quality of care and outcomes among patients with heart failure.

DESIGN

Retrospective, national, population-based sample of patients with heart failure hospitalized from April 1, 1998, through March 31, 1999, and July 1, 2000, through June 30, 2001.

SETTING

Nonfederal US acute care hospitals.

PATIENTS

A total of 53 314 Medicare beneficiaries.

MAIN OUTCOME MEASURES

Quality of care measures, including left ventricular ejection fraction (LVEF) assessment, prescription of an angiotensin-converting enzyme (ACE) inhibitor at discharge among patients without treatment contraindications, and 1-year readmission and 1-year mortality.

RESULTS

Of the patients included in the study, 17.0% had a mental illness diagnosis. Compared with patients without mental illness diagnoses, eligible patients with mental illness diagnoses had lower rates of LVEF evaluation (53.0% vs 47.3%; P < .001) but comparable rates of ACE inhibitor prescription (71.3% vs 69.7%; P = .40). Findings were unchanged after multivariate adjustment: patients with mental illness had lower odds of LVEF evaluation (odds ratio [OR], 0.81; 95% confidence interval [CI], 0.76-0.87) but comparable rates of ACE inhibitor prescription (0.96; 0.80-1.14). Patients with mental illness diagnoses had higher crude rates of 1-year all-cause readmission (73.7% vs 68.5%; P < .001), which persisted after multivariate adjustment (OR, 1.30; 95% CI, 1.21-1.39). Crude 1-year mortality was higher among patients with a mental illness diagnosis (41.0% vs 36.2%; P < .001). Presence of a comorbid mental illness diagnosis was associated with 1-year mortality after multivariate adjustment (OR, 1.20; 95% CI, 1.12-1.28).

CONCLUSIONS

Mental illness is commonly diagnosed among elderly patients hospitalized with heart failure. This subgroup receives somewhat poorer care during hospitalization and has a greater risk of death and readmission to the hospital.

Medical services for clients in community mental health centers: results from a national survey

OBJECTIVE

This study provides national data on community mental health centers' (CMHCs') capacity to screen for and address their clients' general medical conditions.

METHODS

A survey was distributed to members of the National Council for Community Behavioral Healthcare, the oldest and largest association of CMHCs.

RESULTS

Among the 181 CMHCs responding to the survey, more than two-thirds reported having protocols or procedures to screen for common medical problems (hypertension, obesity, dyslipidemia, and diabetes). However, only one-half could provide treatment or referral for those conditions, and less than one-third could provide general medical services on site. Barriers to providing general medical services included problems in reimbursement, workforce limitations, physical plant constraints (for example, lack of available space or equipment), and lack of options for referrals to local community medical providers.

CONCLUSIONS

Although most CMHCs had the capacity to screen for common medical conditions, they reported a variety of barriers to providing medical care for those problems either on site or via referral.

Trends in mental health and substance abuse services at the nation's community health centers: 1998-2003

OBJECTIVE

We examined trends in delivery of mental health and substance abuse services at the nation's community health centers.

METHODS

Analyses used data from the Health Resources and Services Administration (HRSA), Bureau of Primary Care's (BPHC) 1998 and 2003 Uniform Data System, merged with county-level data.

RESULTS

Between 1998 and 2003, the number of patients diagnosed with a mental health/substance abuse disorder in community health centers increased from 210,000 to 800,000. There was an increase in the number of patients per specialty mental health/substance abuse treatment provider and a decline in the mean number of patient visits, from 7.3 visits per patient to 3.5 by 2003. Although most community health centers had some on-site mental health/substance abuse services, centers without on-site services were more likely to be located in counties with fewer mental health/substance abuse clinicians, psychiatric emergency rooms, and inpatient hospitals.

CONCLUSIONS

Community health centers are playing an increasingly central role in providing mental health/substance abuse treatment services in the United States. It is critical both to ensure that these centers have adequate resources for providing mental health/substance abuse care and that they develop effective linkages with mental health/substance abuse clinicians in the communities they serve.

Medical services for clients in community mental health centers: results from a national survey

OBJECTIVE

This study provides national data on community mental health centers' (CMHCs') capacity to screen for and address their clients' general medical conditions.

METHODS

A survey was distributed to members of the National Council for Community Behavioral Healthcare, the oldest and largest association of CMHCs.

RESULTS

Among the 181 CMHCs responding to the survey, more than two-thirds reported having protocols or procedures to screen for common medical problems (hypertension, obesity, dyslipidemia, and diabetes). However, only one-half could provide treatment or referral for those conditions, and less than one-third could provide general medical services on site. Barriers to providing general medical services included problems in reimbursement, workforce limitations, physical plant constraints (for example, lack of available space or equipment), and lack of options for referrals to local community medical providers.

CONCLUSIONS

Although most CMHCs had the capacity to screen for common medical conditions, they reported a variety of barriers to providing medical care for those problems either on site or via referral.

Effects of Food and Drug Administration warnings on antidepressant use in a national sample

CONTEXT

In June 2003, the Food and Drug Administration (FDA) recommended that paroxetine hydrochloride not be used to treat young people because of potential increased risk of suicidal behavior, and in October 2004, the FDA issued a black box warning concerning all antidepressants for youth.

OBJECTIVE

To characterize associations between these warnings and antidepressant use.

DESIGN

Interrupted time series analyses of trends in antidepressant use were performed with Medco pharmacy and enrollment data stratified by patient age, sex, antidepressant type, and specialty of the prescribing physician across 3 study periods: prewarning (May 1, 2002 to June 19, 2003), paroxetine warning (June 20, 2003 to October 15, 2004), and black box warning (October 16, 2004 to December 31, 2005).

MAIN OUTCOME MEASURES

The rate of antidepressant use, annualized percentage change in rate of antidepressant use, and difference in trend of antidepressant use between consecutive study periods.

RESULTS

During the prewarning study period, there was a 36.0% per year (P < .001) increase in total youth (aged 6-17 years) antidepressant use, which was followed by decreases of -0.8% per year (P = .85) and -9.6% per year (P = .21) during the paroxetine and black box warning study periods, respectively. The difference in trends between the prewarning and paroxetine warning periods was significant (P < .001). Youth paroxetine use also significantly increased during the prewarning study period (30.0% per year; P < .001) before significantly declining during the paroxetine warning study period (-44.2% per year; P < .001), which was also a significant between-period difference in trends (P < .001). Changes in antidepressant use were less pronounced in adults than in youth. For adults 65 years and older, overall antidepressant use significantly increased (8.1% per year; P < .001) during the black box study period. Changes in the pattern of antidepressant use varied little by patient sex.

CONCLUSIONS

The paroxetine and black box warnings had modest and relatively targeted effects on the intended populations. These changes, which were greatest for youth, were broadly consistent with the FDA warnings and the scientific literature.

Major depression, depression treatment and quality of primary medical care

OBJECTIVE

This study investigated the association between diagnosis of major depression, treatment for major depression and receipt of appropriate primary medical care.

METHOD

As part of the 1999 National Health Interview Survey, a nationally representative sample of 30,801 adults was administered the Composite International Diagnostic Interview - Short Form. Multivariate analyses examined the association between 12-month major depression and each of the four cardinal features of primary care (access, comprehensiveness, coordination and continuity) stratified by whether depressed individuals received care for depression in primary care, specialty mental health care or no treatment.

RESULTS

Overall, persons with depression had statistically significant problems in all four domains of primary care (8/10 indicators in total). However, patterns differed substantially based on depression treatment status. Persons with untreated depression had difficulties in access to (3/3 measures) and comprehensiveness of (5/5 measures) care, but not with coordination (0/1 measure) and continuity (0/1 measure). In contrast, persons with depression who received specialty treatment had more difficulties in coordination (1/1 measure) and continuity (1/1 measure) of primary care. Persons treated for depression in primary care reported the least difficulties in any of the four domains of primary care (0/10 measures).

CONCLUSIONS

Major depression was associated with significant challenges in receipt of primary care; however, these problems varied based on whether and where depression treatment is received.

Improving medical care for persons with serious mental illness: challenges and solutions

A critical step in addressing excess medical morbidity and mortality in persons with serious mental illness is to better understand and seek to improve the medical care that they receive. Medical quality deficits for persons with serious mental illness include problems related to overuse of certain medical services, such as emergency room care; underuse of some evidence-based general medical services; and misuse, or medical error. The origins of poor quality care for persons with mental disorders are rooted in interrelated contributory factors from patients, providers, and the medical and mental health care systems. At a system level, at least 4 types of separation between mental and medical health care may exacerbate the problems for persons with serious mental illnesses: (1) geographic (lack of co-located medical and mental health services), (2) financial (separate funding streams for medical and mental health services), (3) organizational (difficulty in sharing information and expertise across these systems), and (4) cultural (providers' focus on particular symptoms or disorders, rather than on the patients with those problems). Research studies and demonstration programs for improving medical care in this population have spanned a continuum of medical provider involvement from psychiatrist and patient training to on-site consultation by medical staff, multidisciplinary collaborative care approaches, and facilitated linkages between community and mental health and medical providers. Ultimately, it will be important to develop, test, and implement a range of models for improving the medical care of persons with serious mental disorders that are tailored to patients' needs, mental health system capacities, and local community resources.

Understanding mental health treatment in persons without mental diagnoses: results from the National Comorbidity Survey Replication

CONTEXT

Epidemiologic surveys have consistently found that approximately half of respondents who obtained treatment for mental or substance use disorders in the year before interview did not meet the criteria for any of the disorders assessed in the survey. Concerns have been raised that this pattern might represent evidence of misallocation of treatment resources.

OBJECTIVE

To examine patterns and correlates of 12-month treatment of mental health or substance use problems among people who do not have a 12-month DSM-IV disorder.

DESIGN AND SETTING

Data are from the National Comorbidity Survey Replication, a nationally representative face-to-face US household survey performed between February 5, 2001, and April 7, 2003, that assessed DSM-IV disorders using a fully structured diagnostic interview, the World Health Organization Composite International Diagnostic Interview (CIDI).

PARTICIPANTS

A total of 5692 English-speaking respondents 18 years and older.

MAIN OUTCOME MEASURES

Patterns of 12-month service use among respondents without any 12-month DSM-IV CIDI disorders.

RESULTS

Of respondents who used 12-month services, 61.2% had a 12-month DSM-IV CIDI diagnosis, 21.1% had a lifetime but not a 12-month diagnosis, and 9.7% had some other indicator of possible need for treatment (subthreshold 12-month disorder, serious 12-month stressor, or lifetime hospitalization). The remaining 8.0% of service users accounted for only 5.6% of all services and even lower proportions of specialty (1.9%-2.4%) and general medical (3.7%) visits compared with higher proportions of human services (18.9%) and complementary and alternative medicine (7.6%) visits. Only 26.5% of the services provided to the 8.0% of presumably low-need patients were delivered in the mental health specialty or general medical sectors.

CONCLUSIONS

Most services provided for emotional or substance use problems in the United States go to people with a 12-month diagnosis or other indicators of need. Patients who lack these indicators of need receive care largely outside the formal health care system.

Challenges and solutions to integrating mental and physical health care

A critical step in addressing excess medical morbidity and mortality in persons with serious mental illness is to better understand, and seek to improve, the medical care that they receive. Medical quality deficits for persons with serious mental illnesses include problems including overuse of certain medical services such as emergency room care; underuse of some evidence-based general medical services; and misuse, or medical error. The origins of poor quality care for persons with mental disorders are rooted in interrelated contributory factors from patients, providers, and the medical and mental health systems. At a system level, at least 4 types of separation between mental and medical health care may exacerbate the problems for persons with serious mental illnesses: 1) geographic (lack of co-located medical and mental health services), 2) financial (separate funding streams for medical and mental health services), 3) organizational (difficulty in sharing information and expertise across these systems), and 4) cultural (providers' focus on particular symptoms or disorders, rather than on the patients with those problems). Research studies and demonstration programs for improving medical care in this population have spanned a continuum of medical provider involvement from psychiatrist and patient training, to on-site consultation by medical staff, multidisciplinary collaborative care approaches, and facilitated linkages between community and mental health and medical providers. Ultimately, it will be important to develop, test, and implement a range of models for improving the medical care of persons with serious mental disorders tailored to patients' needs, mental health system capacities, and local community resources.