Emerging trends in mental health policy and practice

Twelve-month diagnosed prevalence of behavioral health disorders among elderly medicare and medicaid members

OBJECTIVES

We examined the 12-month diagnosed prevalence of behavioral health disorders (BHDs) and dementia among elderly Medicare and Medicaid members in Massachusetts by primary payment source group (dual eligible, Medicare only, and Medicaid only) and age group (65-74 years, 75-84 years, and 85 years and older).

DESIGN

A retrospective cross-sectional study.

SETTING

Medicare and Medicaid programs.

PARTICIPANTS

Massachusetts Medicare or Medicaid enrollees age 65 and older as of January 1, 2005, (N = 679,182).

MEASUREMENTS

International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes recorded on Medicare and Medicaid claims were used to identify the BHDs.

RESULTS

The 12-month diagnosed prevalence was 19.4% for any BHD and 11.2% for dementia. The most common BHDs by disease category were major depression (severe mental illness [SMI]), other depression (other mental illness [OMI]), and alcohol abuse or dependence (subtance use disorder [SUD]). Dual eligibles had a considerably higher diagnosed prevalence of any BHD (38.8%), compared with 16.1% in the Medicare only group. The 12-month diagnosed prevalence of SMI, OMI, and dementia was higher in the older-age groups. Co-occurring SUD was higher for younger dual eligibiles. Dementia and mental illness co-occurred at much higher rates for dual eligibles than for either of the single-insurance groups. This combination increased with age in all three groups.

CONCLUSIONS

The 12-month prevalence of BHDs and dementia among elderly dual eligibles was disproportionately higher than other elderly Medicare or Medicaid members. However, access barriers to behavioral health services for this vulnerable population could be significant because Medicare and Medicaid payment limitations resulted in financial disincentives for providing these services.

Trends in behavioral health care service provision by community health centers, 1998-2007

OBJECTIVE

The federal government boosted support for community health centers in medically underserved areas in 2002-2007. This investigation compared trends in behavioral health services provided by community health centers nationwide during the first several years of that initiative with immediately prior trends.

METHODS

Data were extracted from the Health Resources and Services Administration's Uniform Data System on community health centers for 1998-2007 (2007, N=1,067). Regression analyses revealed trends in individual community health centers' likelihood of providing on-site specialty mental health care, crisis services, and substance abuse treatment. Aggregate data were used to show national trends in numbers of behavioral health encounters, patients, and encounters per patient.

RESULTS

The number of federally funded community health centers increased 43% between 2001 and 2007, from 748 to 1,067, over twice the annual growth rate between 1998 and 2001. However, trends in individual community health centers' likelihood of providing different types of behavioral health care were generally consistent across the two time periods. In 2007, 77% of community health centers offered specialty mental health services, 20% offered 24-hour crisis intervention services, and 51% offered substance abuse treatment. The mean number of mental health encounters per mental health patient at community health centers in 2007 was 2.9.

CONCLUSIONS

The behavioral health care safety net has widened through rapid recent growth in the number of community health centers as well as a continuing increase in the proportion offering specialty mental health services.

Trends in behavioral health care service provision by community health centers, 1998-2007

OBJECTIVE

The federal government boosted support for community health centers in medically underserved areas in 2002-2007. This investigation compared trends in behavioral health services provided by community health centers nationwide during the first several years of that initiative with immediately prior trends.

METHODS

Data were extracted from the Health Resources and Services Administration's Uniform Data System on community health centers for 1998-2007 (2007, N=1,067). Regression analyses revealed trends in individual community health centers' likelihood of providing on-site specialty mental health care, crisis services, and substance abuse treatment. Aggregate data were used to show national trends in numbers of behavioral health encounters, patients, and encounters per patient.

RESULTS

The number of federally funded community health centers increased 43% between 2001 and 2007, from 748 to 1,067, over twice the annual growth rate between 1998 and 2001. However, trends in individual community health centers' likelihood of providing different types of behavioral health care were generally consistent across the two time periods. In 2007, 77% of community health centers offered specialty mental health services, 20% offered 24-hour crisis intervention services, and 51% offered substance abuse treatment. The mean number of mental health encounters per mental health patient at community health centers in 2007 was 2.9.

CONCLUSIONS

The behavioral health care safety net has widened through rapid recent growth in the number of community health centers as well as a continuing increase in the proportion offering specialty mental health services.

Behavioral medicine in Russian family medicine

The Russian Federation's recently adopted family medicine as a specialty, but with little or no training in psychosocial and behavioral issues, unlike many training programs in other countries. The purpose of this qualitative study was to explore the perceptions and experiences of Russian primary care physicians regarding the practice of behavioral medicine and psychosocial methods. Semi-structured in-depth interviews were conducted with ten Russian family physicians. Examination of key words, phrases, and concepts used by the physicians revealed five themes that physicians related to their incorporation of psychosocial/behavioral medicine methods: (1) factors limiting the practice of behavioral medicine (inadequate training; cultural barriers); (2) demand for behavioral medicine services; (3) patient-doctor issues related to behavioral medicine (e.g., communication); (4) physician's role strain; and (5) intuition and experience. These findings suggest that Russia's new family physicians would benefit from residency and post-graduate curricula in behavioral sciences, tailored to their unique needs.

Overview Of Publicly Funded Managed Behavioral Health Care

Using MEDLINE and other Internet sources, the authors perform a systematic review of published literature. A total of 109 articles and reports are identified and reviewed that address the development, implementation, outcomes, and trends related to Managed behavioral health care (MBHC). MBHC remains a work in progress. States have implemented their MBHC programs in a number of ways, making interstate comparisons challenging. While managed behavioral health care can lower costs and increase access, ongoing concerns about MBHC include potential incentives to under-treat those with more severe conditions due to the nature of risk-based contracting, the tendency to focus on acute care, difficulties assuring quality and outcomes consistently across regions, and a potential cost-shift to other public agencies or systems. Success factors for MBHC programs appear to include stakeholder involvement in program and policy development, effective contract development and management, and rate adequacy.

DSM-III and the revolution in the classification of mental illness

A revolution occurred within the psychiatric profession in the early 1980s that rapidly transformed the theory and practice of mental health in the United States. In a very short period of time, mental illnesses were transformed from broad, etiologically defined entities that were continuous with normality to symptom-based, categorical diseases. The third edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III) was responsible for this change. The paradigm shift in mental health diagnosis in the DSM-III was neither a product of growing scientific knowledge nor of increasing medicalization. Instead, its symptom-based diagnoses reflect a growing standardization of psychiatric diagnoses. This standardization was the product of many factors, including: (1) professional politics within the mental health community, (2) increased government involvement in mental health research and policymaking, (3) mounting pressure on psychiatrists from health insurers to demonstrate the effectiveness of their practices, and (4) the necessity of pharmaceutical companies to market their products to treat specific diseases. This article endeavors to explain the origins of DSM-III, the political struggles that generated it, and its long-term consequences for clinical diagnosis and treatment of mental disorders in the United States.

Sibling perspectives on severe mental illness: reflections on self and family

Through focus group interviews, participants were asked to describe the impact over time of having a sibling with severe mental illness. Transcript content was then organized into categories and overarching themes using grounded-theory analysis. Respondents' personal and interpersonal experiences are presented, along with suggestions for professional outreach and further research.

Propensity score matching: an illustrative analysis of dose response

BACKGROUND

Health services researchers are often interested in the effect of a treatment or a service in situations in which randomization is difficult or impossible. One useful alternative involves propensity score methods, a means for matching members of different groups based on a range of characteristics. Under certain assumptions, comparisons of the matched groups reveal the impact of the treatment of interest.

OBJECTIVES

This article reviews propensity score methods and illustrates their use in an analysis of dose response, the relationship between the volume of services received, and treatment outcomes. In mental health policy, this question is central to key issues such as parity.

RESEARCH DESIGN

Data for the illustrative analysis are taken from a well-known study of children's mental health services. This analysis estimates the impact of outpatient therapy based on comparisons of individuals receiving different treatment doses. Those comparisons are adjusted for preexisting observed differences among the groups using propensity score methods.

SUBJECTS

The study includes 301 participants aged 5 to 18 years treated at the study sites.

MEASURES

The analyses are based on family characteristics and the mental health status of children and adolescents reported in interviews with parents as well as administrative data on service use.

RESULTS

Analyses using propensity score matching suggest that added services improve treatment outcomes, especially child functioning. However, at least for the services and outcomes considered, the marginal benefits to high levels of treatment are limited.

CONCLUSIONS

These analyses illustrate the potential value of propensity score methods to health services researchers.

Defining recovery: an interactionist analysis of mental health policy development, Wisconsin 1996-1999

The author examines how, as part of a reform of Wisconsin's public mental health system, a workgroup of system stakeholders defined and operationalized the concept of recovery. Based on participant observation, document analysis, and interviews, with an analytic framework drawn from symbolic interactionism, the author finds that although individual members held a range of definitions of recovery, the workgroup was able to reach consensus in its policy recommendations through processual means and by tacitly agreeing on a set of overarching values that were flexible enough to accommodate many definitions.

Interagency and interprofessional collaboration in community care: the interdependence of structures and values

This paper considers the problems of interagency and interprofessional collaboration in community care in Great Britain from the combined perspectives of UK and US researchers. The research team drew on empirical and theoretical literature from both countries to construct a framework for analysing inter- and intra-organisational theories of joint working. This analysis, supplemented and supported by local case studies conducted by the researchers, generates a framework recommendation against which the government's initiatives for partnership working in the NHS plan 2000 and subsequently can be critically reviewed. In particular, at a time when structural integration--via Care Trusts--is being seriously considered, they highlight the vital importance of integrated systems of goal setting, authority and multidisciplinary service delivery rather than a narrow focus on structural integration alone.

Diffusion of new generation antidepressant treatment among elderly diagnosed with depression

RESEARCH OBJECTIVE

This study analyzes the prevalence of new generation antidepressant treatment including selective serotonin reuptake inhibitor (SSRI) use from 1992 to 1997 among the elderly diagnosed with depression, using a large, nationally representative survey of Medicare beneficiaries. Relationships between use of new generation antidepressant treatment and socioeconomic characteristics, physical comorbidity, insurance coverage, and care sector (mental health specialty vs. general health services) are explored.

RESEARCH DESIGN

Merged survey data, Medicare claims, and detailed self-reports from the Medicare Current Beneficiary Survey were used to explore use of new generation antidepressant treatment.SUBJECTS Medicare beneficiaries aged 65 and older living in the community, enrolled in fee-for-service Medicare throughout the year and diagnosed with depression.

RESULTS

In 1997, among an estimated 1.1 million community dwelling older adults with diagnosis of depression in health care claims, nearly two thirds received antidepressant treatments. Among those diagnosed with depression and treated with antidepressants, the use of new generation antidepressants increased from 35% in 1992 to 77% in 1997. The rates of use increased among all subgroups examined. In the early years after the introduction of these new antidepressant medications (1992-1994), there were socioeconomic disparities in use of these medications, with less use by less educated and poor patients. However, these differences abated over time.

CONCLUSIONS

An increasing proportion of elderly treated for depression with antidepressants received the new generation antidepressants. The diffusion of these new medications lagged for those with low socioeconomic status defined by education and income. This diffusion process conforms to a general model of diffusion in which during the initial years following introduction of a new treatment, especially one which is costly, early adopters of the treatment are likely to disproportionately represent those of higher socioeconomic status.

The integration of psychiatric rehabilitation services in behavioral health care structures: a state example

This article describes a model for integrating psychiatric rehabilitation services in a managed behavioral health care structure. Psychiatric rehabilitation and managed care are two distinct developments in the provision of mental health services that have proceeded independently though they can have compatible methods and outcomes. Descriptive detail is provided about a state initiative in Iowa to provide psychiatric rehabilitation services to those with serious mental illness through the state-contracted managed behavioral health care corporation. The article describes factors leading to the program's implementation, service delivery structures, reimbursements, personnel requirements, and performance indicators. Evidence for supporting this innovation is provided through a case-controlled outcomes study of mental health service units used and their costs for participants and matched controls.

Problems in Community Living Identified by People with Schizophrenia

1. Problems in community living were identified by a group of people with schizophrenia who received a telephone nursing intervention after discharge from a state psychiatric facility. 2. The most frequently reported problems were medication side effects, financial concerns, and anxiety. 3. A telephone nursing intervention has the potential to reduce the negative effects of stressors on people with schizophrenia living in the community.

Full parity: steps toward treatment equity for mental and addictive disorders

The 1996 Mental Health Parity Act requiring equal annual and lifetime dollar limits for mental health benefits is to sunset 30 September 2001. This paper reviews the impact and limitations of both this law and existing state provisions and describes recent research on the actual and projected costs associated with such laws. We contend that full parity provided within the context of managed care not only is possible, but represents a "sequential" rather than a final step toward the broader goal of achieving equity in the treatment of persons with mental and addictive disorders.

Are Fortune 100 companies responsive to chronically ill workers?

We conducted a survey of Fortune 100 companies to determine their response to the growing number of employees with chronic conditions. We found that although all companies cover some services that are particularly beneficial to persons with chronic conditions, gaps in coverage remain. We also found large variations in cost-sharing mechanisms, number of covered visits, and lifetime maximum benefit provisions, which are especially important to persons with chronic conditions. In general, for persons with chronic conditions the benefits offered by these Fortune 100 companies are superior to those offered by Medicare.

Community analysis for health planning with vulnerable populations

This article describes how advanced practice nurses used a theory-based community health analysis process to examine the healthcare services most needed and used by an adult public housing community and to examine the satisfaction of the community with those services. The goal of the project was to determine if the identified needs would be amenable to an alternative healthcare delivery model, such as an academic nursing clinic. Data were collected using the Health Needs and Health Status Survey, Center for Epidemiological Studies-Depression scale, interactive participant interviews, key informant interviews and observations. Community residents (N = 242) were typically unmarried, middle-aged, and low income and had multiple chronic physical illnesses, serious and persistent mental illnesses, and/or disabilities. Despite the high identified service need, use of preventative or routine healthcare services was low, with residents using emergency services inappropriately or delaying care until requiring more expensive intensive healthcare services.

Depression, service need, and use in vulnerable populations

Health care reform has created opportunities for mental health nurses to develop innovative health care delivery models to provide integrated behavioral health and primary health care. A community health analysis is one method to ensure appropriate services are planned. This study examined the health care services most needed and those used by depressed and nondepressed participants (N = 231), and their satisfaction with these services. Individual and system characteristics were examined using a framework developed by Anderson and Aday. Significant differences were found between the 2 groups for predisposing characteristics, enabling characteristics, need for care, service use, and satisfaction with services.

Cognitive behavioral psychotherapy for schizophrenia: a review of recent empirical studies

A set of cognitive behavioral psychotherapies (CBT) has been developed for schizophrenia. These interventions have been used for the treatment of both recent onset patients and those with treatment-refractory symptoms. This article reviews clinical trials of CBT for schizophrenia since 1990. The CBT interventions appear to be beneficial in reducing overall symptom levels, especially the severity of delusions. The relative efficacy of CBT is more evident when CBT is compared with routine care than when it is compared with other therapies matched for therapist attention. Further studies are needed to objectively determine the active ingredients of CBT and to better identify the interactions of CBT with concurrent psychosocial and medication treatments.

Comparing provider perceptions of access and utilization management in full-risk and no-risk Medicaid programs for adults with serious mental illness

This article compares provider perceptions of access to services and utilization management (UM) procedures in two Medicaid programs in the same state: a full-risk capitated managed care (MC) program and a no-risk, fee-for-service (FFS) program. Survey data were obtained from 198 mental health clinicians and administrators. The only difference found between respondents in the FFS and MC sites was that outpatient providers in the MC site reported significantly lower levels of access to high-intensity services than did providers in the FFS site (p < .001). Respondents in the two sites reported similar attitudes toward UM procedures, including a strong preference for internal over external UM procedures. These findings support the conclusion that through diffusion of UM procedures, all care in the Medicaid program for persons with a serious mental illness is managed, regardless of risk arrangement. Implications for mental health services and further research are discussed.