The Hierarchical Taxonomy of Psychopathology (HiTOP) in psychiatric practice and research

The Hierarchical Taxonomy of Psychopathology (HiTOP) has emerged out of the quantitative approach to psychiatric nosology. This approach identifies psychopathology constructs based on patterns of co-variation among signs and symptoms. The initial HiTOP model, which was published in 2017, is based on a large literature that spans decades of research. HiTOP is a living model that undergoes revision as new data become available. Here we discuss advantages and practical considerations of using this system in psychiatric practice and research. We especially highlight limitations of HiTOP and ongoing efforts to address them. We describe differences and similarities between HiTOP and existing diagnostic systems. Next, we review the types of evidence that informed development of HiTOP, including populations in which it has been studied and data on its validity. The paper also describes how HiTOP can facilitate research on genetic and environmental causes of psychopathology as well as the search for neurobiologic mechanisms and novel treatments. Furthermore, we consider implications for public health programs and prevention of mental disorders. We also review data on clinical utility and illustrate clinical application of HiTOP. Importantly, the model is based on measures and practices that are already used widely in clinical settings. HiTOP offers a way to organize and formalize these techniques. This model already can contribute to progress in psychiatry and complement traditional nosologies. Moreover, HiTOP seeks to facilitate research on linkages between phenotypes and biological processes, which may enable construction of a system that encompasses both biomarkers and precise clinical description.

Whole genome and transcriptome analysis enhances precision cancer treatment options

BACKGROUND

Recent advances are enabling delivery of precision genomic medicine to cancer clinics. While the majority of approaches profile panels of selected genes or hotspot regions, comprehensive data provided by whole genome and transcriptome sequencing and analysis (WGTA) presents an opportunity to align a much larger proportion of patients to therapies.

PATIENTS AND METHODS

Samples from 570 patients with advanced or metastatic cancer of diverse types enrolled in the Personalized OncoGenomics (POG) program underwent WGTA. DNA-based data, including mutations, copy number, and mutation signatures, were combined with RNA-based data, including gene expression and fusions, to generate comprehensive WGTA profiles. A multidisciplinary molecular tumour board used WGTA profiles to identify and prioritize clinically actionable alterations and inform therapy. Patient responses to WGTA-informed therapies were collected.

RESULTS

Clinically actionable targets were identified for 83% of patients, 37% of whom received WGTA-informed treatments. RNA expression data were particularly informative, contributing to 67% of WGTA-informed treatments; 25% of treatments were informed by RNA expression alone. Of a total 248 WGTA-informed treatments, 46% resulted in clinical benefit. RNA expression data were comparable to DNA-based mutation and copy number data in aligning to clinically beneficial treatments. Genome signatures also guided therapeutics including platinum, PARP inhibitors, and immunotherapies. Patients accessed WGTA-informed treatments through clinical trials (19%), off-label use (35%), and as standard therapies (46%) including those which would not otherwise have been the next choice of therapy, demonstrating the utility of genomic information to direct use of chemotherapies as well as targeted therapies.

CONCLUSIONS

Integrating RNA expression and genome data illuminated treatment options that resulted in 46% of treated patients experiencing positive clinical benefit, supporting the use of comprehensive WGTA profiling in clinical cancer care.

CLINICAL TRIAL NUMBER

NCT02155621.

A Crosswalk Study of DSM-IV and DSM-5 Criteria for PTSD from the DSM-5 Field Trials

Objective: Posttraumatic stress disorder (PTSD) is prevalent and sometimes severely disabling. Providing effective treatment for PTSD and addressing its social consequences require accurate diagnosis. PTSD criteria have changed in all editions of the American Diagnostic Criteria since introduction of the diagnosis in DSM-III in 1980. The DSM-5 Field Trials demonstrated very good inter-rater reliability for PTSD, but a crosswalk study comparing DSM-IV and DSM-5 criteria has potential to identify diagnostic differences generated by changed criteria. Methods: A DSM-IV to DSM-5 PTSD crosswalk study was conducted in real-world adult clinical treatment settings in two DSM-5 Field Trials sites, the Dallas (N = 93) and Houston (N = 48) Veterans Affairs medical centers. The crosswalk assessment was conducted by trained clinicians who interviewed the patients and rated both sets of criteria on a combined checklist. Results: PTSD prevalence differed insubstantially between criteria sets (42% vs. 45% and 55% vs. 52% in the Dallas and Houston sites, respectively), with moderate to excellent diagnostic agreement (reliability indicated, respectively, by κ = .53 and .93); however, substantial proportions of individuals diagnosed in one criteria set did not meet criteria in the other. Differences in cross-criteria diagnostic reliability were largely a function of differing definitions of criterion A trauma. Conclusions: Reliability across the two criteria sets was generally good to excellent, and diagnostic discrepancy predominantly reflected the elimination of criterion A2 in DSM-5 with a smaller contribution from changes to the avoidance and numbing criteria.

Les progrès dans la réalisation de la classification quantitative de la psychopathologie☆

Shortcomings of approaches to classifying psychopathology based on expert consensus have given rise to contemporary efforts to classify psychopathology quantitatively. In this paper, we review progress in achieving a quantitative and empirical classification of psychopathology. A substantial empirical literature indicates that psychopathology is generally more dimensional than categorical. When the discreteness versus continuity of psychopathology is treated as a research question, as opposed to being decided as a matter of tradition, the evidence clearly supports the hypothesis of continuity. In addition, a related body of literature shows how psychopathology dimensions can be arranged in a hierarchy, ranging from very broad "spectrum level" dimensions, to specific and narrow clusters of symptoms. In this way, a quantitative approach solves the "problem of comorbidity" by explicitly modeling patterns of co-occurrence among signs and symptoms within a detailed and variegated hierarchy of dimensional concepts with direct clinical utility. Indeed, extensive evidence pertaining to the dimensional and hierarchical structure of psychopathology has led to the formation of the Hierarchical Taxonomy of Psychopathology (HiTOP) Consortium. This is a group of 70 investigators working together to study empirical classification of psychopathology. In this paper, we describe the aims and current foci of the HiTOP Consortium. These aims pertain to continued research on the empirical organization of psychopathology; the connection between personality and psychopathology; the utility of empirically based psychopathology constructs in both research and the clinic; and the development of novel and comprehensive models and corresponding assessment instruments for psychopathology constructs derived from an empirical approach.

Cost-effectiveness of brentuximab vedotin in advanced stage Hodgkin's lymphoma: a probabilistic analysis

BACKGROUND

Treatment with ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) is a well-established therapy for advanced Hodgkin's lymphoma (HL). However, the recently completed ECHELON-1 trial showed potential net clinical benefit for brentuximab vedotin (BREN+AVD) compared to ABVD as frontline therapy in patients with advanced Hodgkin's lymphoma. The objective of this analysis is to determine whether, on current evidence, BREN+AVD is cost-effective relative to ABVD as frontline therapy in patients with advanced HL.

METHODS

We constructed a probabilistic Markov model with two arms and six mutually exclusive health states, using six-month cycle lengths, and a 15-year time horizon. Time-dependent transition probabilities were calculated from 'real-world' data collected by the BC Cancer's Centre for Lymphoid Cancer database or from the literature for ABVD. Time-dependent transition probabilities for BREN+AVD were taken from the ECHELON-1 trial. We estimated the incremental cost and effects per patient of each therapy and calculated the incremental cost-effectiveness ratio (ICER). Costs were measured in 2018 Canadian dollars and effects measured in quality-adjusted life years (QALYs). A probabilistic analysis was used to generate a cost-effectiveness acceptability curve (CEAC).

RESULTS

The incremental cost between standard therapy with ABVD and therapy with BREN+AVD was estimated to be $192,336. The regimen of BREN+AVD resulted in a small benefit in terms of QALYs (0.46 QALYs). The estimated ICER was $418,122 per QALY gained. The probabilistic analysis suggests very few (8%) simulations fall below $100,000 per QALY. Even at a threshold of $200,000 per QALY gained, there was only a 24% chance that BREN+AVD would be considered cost-effective. Sensitivity analyses evaluating price reductions for brentuximab showed that these reductions needed to be in excess of 70% for this regimen to be cost-effective at a threshold of $100,000 per QALY.

CONCLUSIONS

There may be a clinical benefit associated with BREN+AVD, but on current evidence the benefit is not adequately substantive compared to ABVD therapy given the cost of brentuximab vedotin. Agencies responsible for making decisions about BREN+AVD as frontline therapy for patients with advanced HL should consider whether they are willing to implement this treatment given the current uncertainty and cost-benefit profile, or negotiate substantial price-reductions from the manufacturer should they choose to reimburse.

Integrating the Hierarchical Taxonomy of Psychopathology (HiTOP) into clinical practice

OBJECTIVE

Diagnosis is a cornerstone of clinical practice for mental health care providers, yet traditional diagnostic systems have well-known shortcomings, including inadequate reliability, high comorbidity, and marked within-diagnosis heterogeneity. The Hierarchical Taxonomy of Psychopathology (HiTOP) is a data-driven, hierarchically based alternative to traditional classifications that conceptualizes psychopathology as a set of dimensions organized into increasingly broad, transdiagnostic spectra. Prior work has shown that using a dimensional approach improves reliability and validity, but translating a model like HiTOP into a workable system that is useful for health care providers remains a major challenge.

METHOD

The present work outlines the HiTOP model and describes the core principles to guide its integration into clinical practice.

RESULTS

Potential advantages and limitations of the HiTOP model for clinical utility are reviewed, including with respect to case conceptualization and treatment planning. A HiTOP approach to practice is illustrated and contrasted with an approach based on traditional nosology. Common barriers to using HiTOP in real-world health care settings and solutions to these barriers are discussed.

CONCLUSIONS

HiTOP represents a viable alternative to classifying mental illness that can be integrated into practice today, although research is needed to further establish its utility. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Real-world costing analysis for diffuse large B-cell lymphoma in British Columbia

Introduction

Diffuse large B-cell lymphoma (dlbcl) accounts for 30%-40% of all non-Hodgkin lymphomas. Approximately 60% of patients are cured with standard treatment. Targeted treatments are being investigated and might improve disease outcomes; however, their effect on cancer drug budgets will be significant. For the present study, we conducted an analysis of real-world costs for dlbcl patients treated in British Columbia, useful for health care system planning.

Methods

Patient records from a retrospective cohort of patients diagnosed with dlbcl in British Columbia during 2004-2013 were anonymously linked across multiple administrative data sources: systemic therapy, radiotherapy, hospitalizations, oncologist services, outpatient medications, and fee-for-service physician services. Using generalized linear modelling regression, time-dependent costs (in 2015 Canadian dollars) were estimated in 6-month intervals over a 5-year period. The inverse probability weighting method was applied to account for censored observations. Nonparametric bootstrapping was used to estimate standard errors for the mean cost at each time interval.

Results

The cohort consisted of 678 patients (5-year overall survival: 67%). Mean age at diagnosis was 64 ± 14 years; median follow-up was 3.2 years. Mean total cost of care was highest in the first 6 months after diagnosis ($29,120; 95% confidence interval: $28,986 to $29,170) and after disease progression ($18,480; 95% confidence interval: $15,187 to $24,772). Systemic therapy and hospitalization costs were the largest cost drivers. At each time interval, costs were observed to be positively skewed.

Conclusions

Our results depict real-world costs for the treatment of dlbcl patients with standard chop-r therapy. Cost-model parameters are also provided for economic modelling of dlbcl interventions.

Progress in achieving quantitative classification of psychopathology

Shortcomings of approaches to classifying psychopathology based on expert consensus have given rise to contemporary efforts to classify psychopathology quantitatively. In this paper, we review progress in achieving a quantitative and empirical classification of psychopathology. A substantial empirical literature indicates that psychopathology is generally more dimensional than categorical. When the discreteness versus continuity of psychopathology is treated as a research question, as opposed to being decided as a matter of tradition, the evidence clearly supports the hypothesis of continuity. In addition, a related body of literature shows how psychopathology dimensions can be arranged in a hierarchy, ranging from very broad "spectrum level" dimensions, to specific and narrow clusters of symptoms. In this way, a quantitative approach solves the "problem of comorbidity" by explicitly modeling patterns of co-occurrence among signs and symptoms within a detailed and variegated hierarchy of dimensional concepts with direct clinical utility. Indeed, extensive evidence pertaining to the dimensional and hierarchical structure of psychopathology has led to the formation of the Hierarchical Taxonomy of Psychopathology (HiTOP) Consortium. This is a group of 70 investigators working together to study empirical classification of psychopathology. In this paper, we describe the aims and current foci of the HiTOP Consortium. These aims pertain to continued research on the empirical organization of psychopathology; the connection between personality and psychopathology; the utility of empirically based psychopathology constructs in both research and the clinic; and the development of novel and comprehensive models and corresponding assessment instruments for psychopathology constructs derived from an empirical approach.

A time-and-motion approach to micro-costing of high-throughput genomic assays

BACKGROUND

Genomic technologies are increasingly used to guide clinical decision-making in cancer control. Economic evidence about the cost-effectiveness of genomic technologies is limited, in part because of a lack of published comprehensive cost estimates. In the present micro-costing study, we used a time-and-motion approach to derive cost estimates for 3 genomic assays and processes-digital gene expression profiling (gep), fluorescence in situ hybridization (fish), and targeted capture sequencing, including bioinformatics analysis-in the context of lymphoma patient management.

METHODS

The setting for the study was the Department of Lymphoid Cancer Research laboratory at the BC Cancer Agency in Vancouver, British Columbia. Mean per-case hands-on time and resource measurements were determined from a series of direct observations of each assay. Per-case cost estimates were calculated using a bottom-up costing approach, with labour, capital and equipment, supplies and reagents, and overhead costs included.

RESULTS

The most labour-intensive assay was found to be fish at 258.2 minutes per case, followed by targeted capture sequencing (124.1 minutes per case) and digital gep (14.9 minutes per case). Based on a historical case throughput of 180 cases annually, the mean per-case cost (2014 Canadian dollars) was estimated to be $1,029.16 for targeted capture sequencing and bioinformatics analysis, $596.60 for fish, and $898.35 for digital gep with an 807-gene code set.

CONCLUSIONS

With the growing emphasis on personalized approaches to cancer management, the need for economic evaluations of high-throughput genomic assays is increasing. Through economic modelling and budget-impact analyses, the cost estimates presented here can be used to inform priority-setting decisions about the implementation of such assays in clinical practice.

Mental Health, Disabilities, and Women

Ongoing development and reform of health care systems worldwide are directing the attention of policymakers to the significance of mental disorders and ensuing disabilities. While this awareness has encouraged empirical work and scientific literature on disabilities associated with mental disorders, insufficient attention has been paid to issues of gender in the context of mental disorder and disability. This paper draws on four data sets-the 1994-96 Disability Survey; the 1992 National Health Interview Survey (NHIS); Social Security Disability Programs; and the recent international measure of Disability-Adjusted Life Years-to explore relationships among gender, mental disorders, and disability in the United States and to consider the special needs presented by women disabled by mental disorders for service development and service configuration. Generally younger than women disabled by physical disorders, women with mental disorders tend to be in their prime child-bearing years. While in the United States private sector managed care programs increasingly are perceived as the most reasonable way to provide health services in a fiscally responsible way, there appears to exist an implicit notion that managed care is intended exclusively for provision of acute care and preventive services. There is little discussion or exploration of the use of managed care systems for rehabilitation generally, or of the particular rehabilitation needs of young women. The implications for the additional “burden” of disabilities along with the potential risk factor of traditional female roles require serious consideration and enlightened policies. Mental

Feasibility and acceptability of the DSM-5 Field Trial procedures in the Johns Hopkins Community Psychiatry Programs

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) contains criteria for psychiatric diagnoses that reflect advances in the science and conceptualization of mental disorders and address the needs of clinicians. DSM-5 also recommends research on dimensional measures of cross-cutting symptoms and diagnostic severity, which are expected to better capture patients' experiences with mental disorders. Prior to its May 2013 release, the American Psychiatric Association (APA) conducted field trials to examine the feasibility, clinical utility, reliability, and where possible, the validity of proposed DSM-5 diagnostic criteria and dimensional measures. The methods and measures proposed for the DSM-5 field trials were pilot tested in adult and child/adolescent clinical samples, with the goal to identify and correct design and procedural problems with the proposed methods before resources were expended for the larger DSM-5 Field Trials. Results allowed for the refinement of the protocols, procedures, and measures, which facilitated recruitment, implementation, and completion of the DSM-5 Field Trials. These results highlight the benefits of pilot studies in planning large multisite studies.

APIRE Practice Research Network: accomplishments, challenges, and lessons learned

The Practice Research Network (PRN) was established in 1993 to bridge the gap between the science base and the clinical practice of psychiatry by expanding the generalizability of findings and involving clinicians in the development and conduct of research. It began as a nationwide network of psychiatrists and has evolved to conduct large-scale, clinical and policy research studies using randomly selected samples of psychiatrists from the AMA Physician Masterfile. This paper provides an overview of major PRN initiatives and the impact of these studies. It describes the benefits to clinicians of participating in PRN research, as well as strategies developed to address key challenges.

Testing DSM-5 in routine clinical practice settings: feasibility and clinical utility

OBJECTIVE

This article describes the clinical utility and feasibility of proposed DSM-5 criteria and measures as tested in the DSM-5 Field Trials in Routine Clinical Practice Settings (RCP). METHODS RCP data were collected online for six months (October 2011 to March 2012). Participants included psychiatrists, licensed clinical psychologists, clinical social workers, advanced practice psychiatric-mental health nurses, licensed counselors, and licensed marriage and family therapists. Clinicians received staged, online training and enrolled at least one patient. Patients completed self-assessments of cross-cutting symptom domains, disability measures, and an evaluation of these measures. Clinicians conducted diagnostic interviews and completed DSM-5 and related assessments and a clinical utility questionnaire.

RESULTS

A total of 621 clinicians provided data for 1,269 patients. Large proportions of clinicians reported that the DSM-5 approach was generally very or extremely easy for assessment of both pediatric (51%) and adult (46%) patients and very or extremely useful in routine clinical practice for pediatric (48%) and adult (46%) patients. Clinicians considered the DSM-5 approach to be better (57%) or much better (18%) than that of DSM-IV. Patients, including children age 11 to 17 (47%), parents of children age six to ten (64%), parents of adolescents age 11 to 17 (72%), and adult patients (52%), reported that the cross-cutting measures would help their clinicians better understand their symptoms. Similar patterns in evaluations of feasibility and clinical utility were observed among clinicians from various disciplines.

CONCLUSIONS

The DSM-5 approach was feasible and clinically useful in a wide range of routine practice settings and favorably received by both clinicians and patients.

Sustaining practice change one year after completion of the national depression management leadership initiative

OBJECTIVE

This report describes the sustainability of quality improvement interventions for depression care in psychiatric practice one year after the completion of the National Depression Management Leadership Initiative (NDMLI) in 2006. The main intervention involved continued use of the nine-item depression scale of the Patient Health Questionnaire (PHQ-9) for routine care of patients with depressive disorders.

METHODS

One year after project completion, lead psychiatrists from the 17 participating practices were surveyed about the sustainability of key practice interventions and dissemination of the interventions.

RESULTS

All 14 practices that provided baseline and follow-up data reported sustained use of the PHQ-9 for screening, diagnosis, or monitoring purposes. Moreover, practices reported dissemination of this approach to clinicians within and outside their practices.

CONCLUSIONS

Psychiatrists reported sustainability and dissemination of PHQ-9 use one year after the conclusion of the NDMLI. The model has potential as a depression care improvement strategy and is worthy of additional study.

The DSM-5: Classification and criteria changes

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) marks the first significant revision of the publication since the DSM-IV in 1994. Changes to the DSM were largely informed by advancements in neuroscience, clinical and public health need, and identified problems with the classification system and criteria put forth in the DSM-IV. Much of the decision-making was also driven by a desire to ensure better alignment with the International Classification of Diseases and its upcoming 11th edition (ICD-11). In this paper, we describe select revisions in the DSM-5, with an emphasis on changes projected to have the greatest clinical impact and those that demonstrate efforts to enhance international compatibility, including integration of cultural context with diagnostic criteria and changes that facilitate DSM-ICD harmonization. It is anticipated that this collaborative spirit between the American Psychiatric Association (APA) and the World Health Organization (WHO) will continue as the DSM-5 is updated further, bringing the field of psychiatry even closer to a singular, cohesive nosology.

DSM-5 field trials in the United States and Canada, Part I: study design, sampling strategy, implementation, and analytic approaches

OBJECTIVE

This article discusses the design,sampling strategy, implementation,and data analytic processes of the DSM-5 Field Trials.

METHOD

The DSM-5 Field Trials were conducted by using a test-retest reliability design with a stratified sampling approach across six adult and four pediatric sites in the United States and one adult site in Canada. A stratified random sampling approach was used to enhance precision in the estimation of the reliability coefficients. A web-based research electronic data capture system was used for simultaneous data collection from patients and clinicians across sites and for centralized data management.Weighted descriptive analyses, intraclass kappa and intraclass correlation coefficients for stratified samples, and receiver operating curves were computed. The DSM-5 Field Trials capitalized on advances since DSM-III and DSM-IV in statistical measures of reliability (i.e., intraclass kappa for stratified samples) and other recently developed measures to determine confidence intervals around kappa estimates.

RESULTS

Diagnostic interviews using DSM-5 criteria were conducted by 279 clinicians of varied disciplines who received training comparable to what would be available to any clinician after publication of DSM-5.Overall, 2,246 patients with various diagnoses and levels of comorbidity were enrolled,of which over 86% were seen for two diagnostic interviews. A range of reliability coefficients were observed for the categorical diagnoses and dimensional measures.

CONCLUSIONS

Multisite field trials and training comparable to what would be available to any clinician after publication of DSM-5 provided “real-world” testing of DSM-5 proposed diagnoses.

DSM-5 field trials in the United States and Canada, Part II: test-retest reliability of selected categorical diagnoses

OBJECTIVE

The DSM-5 Field Trials were designed to obtain precise (standard error,0.1) estimates of the intraclass kappa asa measure of the degree to which two clinicians could independently agree on the presence or absence of selected DSM-5 diagnoses when the same patient was interviewed on separate occasions, in clinical settings, and evaluated with usual clinical interview methods.

METHOD

Eleven academic centers in the United States and Canada were selected,and each was assigned several target diagnoses frequently treated in that setting.Consecutive patients visiting a site during the study were screened and stratified on the basis of DSM-IV diagnoses or symptomatic presentations. Patients were randomly assigned to two clinicians for a diagnostic interview; clinicians were blind to any previous diagnosis. All data were entered directly via an Internet-based software system to a secure central server. Detailed research design and statistical methods are presented in an accompanying article.

RESULTS

There were a total of 15 adult and eight child/adolescent diagnoses for which adequate sample sizes were obtained to report adequately precise estimates of the intraclass kappa. Overall, five diagnoses were in the very good range(kappa=0.60–0.79), nine in the good range(kappa=0.40–0.59), six in the questionable range (kappa = 0.20–0.39), and three in the unacceptable range (kappa values,0.20). Eight diagnoses had insufficient sample sizes to generate precise kappa estimates at any site.

CONCLUSIONS

Most diagnoses adequately tested had good to very good reliability with these representative clinical populations assessed with usual clinical interview methods. Some diagnoses that were revised to encompass a broader spectrum of symptom expression or had a more dimensional approach tested in the good to very good range.

DSM-5 field trials in the United States and Canada, Part III: development and reliability testing of a cross-cutting symptom assessment for DSM-5

OBJECTIVE

The authors sought to document, in adult and pediatric patient populations, the development, descriptive statistics,and test-retest reliability of cross-cutting symptom measures proposed for inclusion in DSM-5.

METHOD

Data were collected as part of the multisite DSM-5 Field Trials in large academic settings. There were seven sites focusing on adult patients and four sites focusing on child and adolescent patients.Cross-cutting symptom measures were self-completed by the patient or an informant before the test and the retest interviews, which were conducted from 4 hours to 2 weeks apart. Clinician-report measures were completed during or after the clinical diagnostic interviews. Informants included adult patients, child patients age 11 and older, parents of all child patients age 6 and older, and legal guardians for adult patients unable to self-complete the measures. Study patients were sampled in a stratified design,and sampling weights were used in data analyses. The mean scores and standard deviations were computed and pooled across adult and child sites. Reliabilities were reported as pooled intraclass correlation coefficients (ICCs) with 95% confidence intervals.

RESULTS

In adults, test-retest reliabilities of the cross-cutting symptom items generally were good to excellent. At the child and adolescent sites, parents were also reliablereporters of their children’s symptoms,with few exceptions. Reliabilities were not as uniformly good for child respondents, and ICCs for several items fell into the questionable range in this age group. Clinicians rated psychosis with good reliability in adult patients but were less reliable in assessing clinical domains related to psychosis in children and to suicide in all age groups.

CONCLUSIONS

These results show promising test-retest reliability results for this group of assessments, many of which are newly developed or have not been previously tested in psychiatric populations

Depression outcomes in psychiatric clinical practice: using a self-rated measure of depression severity

OBJECTIVES

This study determined rates of response and remission at 12 and 24 weeks among patients being treated by psychiatrists for depression on the basis of Patient Health Questionnaire-9 (PHQ-9) scores and identified factors associated with response and remission.

METHODS

Adult patients at 17 psychiatric practices participating in the National Depression Management Leadership Initiative completed the PHQ-9 at every office visit for one year irrespective of severity or chronicity of symptoms or adherence to treatment. Treating psychiatrists recorded the date when formal self-management goals were documented. Patients with a diagnosis of depression and a PHQ-9 score ≥10 were included in the response and remission analysis. Results are based on "last observation carried forward" analysis.

RESULTS

Of the 1,763 patients with a depressive disorder, 960 had PHQ-9 scores ≥10 (mean±SD of 16.4±4.6) on their first study visit, indicating moderate to severe depression. At 12 weeks, 41% of the 792 who returned for follow-up had responded to treatment, and by 24 weeks 45% had responded. Response was defined as a PHQ-9 score <10. Symptoms were in remission for 13% and 18% of patients at 12 and 24 weeks, respectively. Severity of initial PHQ-9 score, weeks to first follow-up, and documented self-management were the three factors that predicted remission.

CONCLUSIONS

Administering the PHQ-9 at each visit allowed psychiatrists to determine rates of response and remission among patients, but as anticipated, the rates were lower than those reported in trials of efficacy and effectiveness of psychiatric treatment of depression.

Research planning for the future of psychiatric diagnosis

More than 10 years prior to the anticipated 2013 publication of DSM-5, processes were set in motion to assess the research and clinical issues that would best inform future diagnostic classification of mental disorders. These efforts intended to identify the clinical and research needs within various populations, examine the current state of the science to determine the empirical evidence for improving criteria within and across disorders, and stimulate research in areas that could potentially provide evidence for change. In the second phase of the revision process, the American Psychiatric Institute for Research and Education (APIRE) recently completed the 5-year international series of 13 diagnostic conferences convened by APA/APIRE in collaboration with the World Health Organization and the National Institutes of Health (NIH), under a cooperative grant funded by the NIH. From these conferences, the DSM-5 Task Force and Work Groups have developed plans for potential revisions for DSM-5, including the incorporation of dimensional approaches within and across diagnostic groups to clarify heterogeneity, improve diagnostic validity, and enhance clinical case conceptualization. Use of dimensions for measurement-based care has been shown to be feasible in psychiatric and primary care settings and may inform monitoring of disorder threshold, severity, and treatment outcomes. The integration of dimensions with diagnostic categories represents an exciting and potentially transformative approach for DSM-5 to simultaneously address DSM-IV's clinical short-comings and create novel pathways for research in neurobiology, genetics, and psychiatric epidemiology.

Suicidality is associated with medication access problems in publicly insured psychiatric patients

BACKGROUND

Beginning January 1, 2006, the Medicare Part D prescription drug benefit shifted drug coverage from Medicaid to the new Medicare Part D program for patients who were eligible for both Medicare and Medicaid benefits ("dual-eligibles"). These patients were randomly assigned to a private Part D plan and came under specific formulary and utilization management procedures of the plan in which they were enrolled.

OBJECTIVE

To examine the relationship between physician-reported medication switches, discontinuations, and other access problems and suicidal ideation or behavior among "dual-eligible" psychiatric patients.

METHOD

Data were collected in 3 cross-sectional cycles in 2006 (January-April, May-August, and September-December) as part of the National Study of Medicaid and Medicare Psychopharmacologic Treatment Access and Continuity using through-the-mail, practice-based survey research methods. Data from the third cycle, representing all events since January 1, 2006, were used for these analyses. A national sample of psychiatrists randomly selected from the AMA Masterfile provided clinically detailed data on 1 systematically selected, dual-eligible psychiatric patient (N = 908). Propensity score analyses adjusted for patient sociodemographics, treatment setting, diagnoses, and psychiatric symptom severity.

RESULTS

Patients who experienced medication switches, discontinuations, and other access problems had 3 times the rate of suicidal ideation or behavior compared with patients with no access problems (22.0% vs 7.4%, P < .0001). Mean odds ratios and excess probabilities were highest for patients who were clinically stable but were required to switch medications (31.8%; mean OR = 4.87, mean P = 8.92(-5), excess probability = 0.21). Patients who experienced discontinuations (26.4%; mean OR = 2.13, mean P = 2.12(-2), excess probability = 0.12), other access problems (18.7%; mean OR = 3.01, mean P = 1.03(-5), excess probability = 0.15), and multiple access problems (22.3%; mean OR = 2.88, mean P = 4.10(-5), excess probability = 0.14) also had significantly increased suicidal ideation or behavior.

CONCLUSION

Increased occurrences of suicidal ideation or behavior appear to be associated with disruptions in patient medication access and continuity. Clinicians need to be aware of the possibility of increased suicidality when, for administrative reasons, a clinically stable patient's medication regimen is altered. Dual-eligible psychiatric patients represent a highly vulnerable group with a substantial burden of illness; these findings underscore the need to provide special protections for this population.

Medicaid medication access problems and increased psychiatric hospital and emergency care

OBJECTIVES

To quantify the extent to which Medicaid programs may incur increased psychiatric emergency department and hospital use associated with clinically unintended medication discontinuations, gaps, switches and other access problems attributed to prescription drug coverage and management.

METHOD

This study uses clinically detailed, physician-reported data. A total of 4866 psychiatrists in 10 states were randomly selected from the AMA Masterfile; 62% responded and 32% treated Medicaid patients and reported on 1625 systematically selected Medicaid patients. Propensity score multivariate models assessed predicted probabilities and mean number of emergency department visits and hospital days.

RESULTS

Many patients (46.0%, S.E.=1.3%) had medication access problems reported during the past year, including discontinuing or switching medications or inability to obtain clinically indicated prescriptions because of drug coverage or management. The expected number of emergency department visits was estimated to be 73.8% higher among patients with medication access problems reported compared to matched patients without access problems reported. Among acute stay inpatients, the expected number of hospital days was 71.7% higher for patients with medication access problems reported.

CONCLUSIONS

Medication access problems may have significant implications for Medicaid programs. The potential indirect costs of these policies in psychiatric and social services utilization should be considered in addition to direct pharmacy costs.

First-year Medicare Part D prescription drug benefits: medication access and continuity among dual eligible psychiatric patients

OBJECTIVE

This study provides national data on medication access and continuity problems experienced during the first year of the Medicare Part D prescription drug program, which was implemented on January 1, 2006, among a national sample of Medicare and Medicaid "dual eligible" psychiatric patients.

METHOD

Practice-based research methods were used to collect clinician-reported data across the full range of public and private psychiatric treatment settings. A random sample of psychiatrists was selected from the American Medical Association Physician Masterfile. Among these physicians, 1,490 provided clinically detailed data on a systematically selected sample of 2,941 dual eligible psychiatric patients.

RESULTS

Overall, 43.3% of patients were reported to be unable to obtain clinically indicated medication refills or new prescriptions in 2006 because they were not covered or approved; 28.9% discontinued or temporarily stopped their medication(s) as a result of prescription drug coverage or management issues; and 27.7% were reported to be previously stable on their medications but were required to switch medications. Adjusting for case mix to control for sociodemographic and clinical confounders, the predicted probability of an adverse event among patients with medication access problems was 0.64 compared to 0.36 for those without access problems (P < .0001). All prescription drug utilization management features studied were associated with increased medication access problems (P < .0001). Adjusting for patient case mix, patients with "step therapy" (P < .0001), limits on medication number/dosing (P < .0001), or prior authorization (P < .0001) had 2.4 to 3.4 times the increased likelihood of an adverse event.

CONCLUSIONS

More effective Part D policies and management practices are needed to promote clinically safer and appropriate pharmacotherapy for psychiatric patients to enhance treatment outcomes.

Part D and dually eligible patients with mental illness: medication access problems and use of intensive services

OBJECTIVE

This study examined the occurrence of medication access problems and use of intensive mental health services after the transition in January 2006 from Medicaid drug coverage to Medicare Part D for persons dually eligible for Medicaid and Medicare benefits.

METHODS

Psychiatrists randomly selected from the American Medical Association's Physicians Masterfile reported on experiences of one systematically selected dually eligible patient (N=908) in the nine to 12 months after Part D implementation. Propensity score matching was used to compare use of psychiatric emergency department care and inpatient care between individuals who experienced a problem accessing a psychiatric medication after Part D and those who did not.

RESULTS

Approximately 44% of dually eligible patients were reported to have experienced a problem accessing medications. The likelihood of visiting an emergency department was significantly higher for those who experienced an access problem than for those who did not (mean odds ratio=1.75, mean p=.003). There was no difference in number of emergency department visits or hospitalizations for those who had at least one.

CONCLUSIONS

Many dually eligible patients had difficulty accessing psychiatric medications after implementation of Part D. These patients were significantly more likely to visit psychiatric emergency departments than patients who did not experience difficulties. These findings raise concerns about possible negative effects on quality of care. Additional study is needed to understand the full effects of Part D on outcomes and functioning as well as treatment costs for this population.

Obsessive-compulsive behavior spectrum: refining the research agenda for DSM-V

The American Psychiatric Association, in collaboration with the World Health Organization and the National Institutes of Health, has undertaken a 5-year international research planning effort in preparation for the formal revision of the Diagnostic and Statistical Manual of Mental Disorders. One element of the project was a conference titled "Obsessive-Compulsive Behavior Spectrum," in which participants reviewed an array of disorders that cross current diagnostic categories. Questions raised challenge those responsible for the DSM-V revision to assess the pros and cons of changing definitions, boundaries, or linkages among diverse conditions characterized by obsessive-compulsive behaviors in the revised classification.

Valuing the benefit of diagnostic testing for genetic causes of idiopathic developmental disability: willingness to pay from families of affected children

Idiopathic developmental disability (DD) has been found to put significant psychological distress on families of children with DD. The cause of the disability, however, is unknown for up to one-half of the affected children. Chromosomal abnormalities identified by cytogenetic analysis are the most frequently recognized cause of DD, although they account for less than 10% of cases. Array genomic hybridization (AGH) is a new diagnostic tool that provides a much higher detection rate for chromosomal imbalance than conventional cytogenetic analysis. This increase in diagnostic capability comes at greater monetary costs, which provides an impetus for understanding how individuals value genetic testing for DD. This study estimated the willingness to pay (WTP) for diagnostic testing to find a genetic cause of DD from families of children with DD. A discrete choice experiment was used to obtain WTP values. When it was assumed that AGH resulted in twice as many diagnoses and a 1-week reduction in waiting time compared with conventional cytogenetic analysis, this study found that families were willing to pay up to CDN$1118 (95% confidence interval, $498-1788) for the expected benefit. These results support the conclusion that the introduction of AGH into the Canadian health care system may increase the perceived welfare of society, but future studies should examine the cost-benefit of AGH vs cytogenetic testing.

Part D and dually eligible patients with mental illness: medication access problems and use of intensive services

OBJECTIVE

This study examined the occurrence of medication access problems and use of intensive mental health services after the transition in January 2006 from Medicaid drug coverage to Medicare Part D for persons dually eligible for Medicaid and Medicare benefits.

METHODS

Psychiatrists randomly selected from the American Medical Association's Physicians Masterfile reported on experiences of one systematically selected dually eligible patient (N=908) in the nine to 12 months after Part D implementation. Propensity score matching was used to compare use of psychiatric emergency department care and inpatient care between individuals who experienced a problem accessing a psychiatric medication after Part D and those who did not.

RESULTS

Approximately 44% of dually eligible patients were reported to have experienced a problem accessing medications. The likelihood of visiting an emergency department was significantly higher for those who experienced an access problem than for those who did not (mean odds ratio=1.75, mean p=.003). There was no difference in number of emergency department visits or hospitalizations for those who had at least one.

CONCLUSIONS

Many dually eligible patients had difficulty accessing psychiatric medications after implementation of Part D. These patients were significantly more likely to visit psychiatric emergency departments than patients who did not experience difficulties. These findings raise concerns about possible negative effects on quality of care. Additional study is needed to understand the full effects of Part D on outcomes and functioning as well as treatment costs for this population.

Medicaid prescription drug policies and medication access and continuity: findings from ten states

OBJECTIVES

The aims of this study were to compare medication access problems among psychiatric patients in ten state Medicaid programs, assess adverse events associated with medication access problems, and determine whether prescription drug utilization management is associated with access problems and adverse events.

METHODS

Psychiatrists from the American Medical Association's Masterfile were randomly selected (N=4,866). Sixty-two percent responded; 32% treated Medicaid patients and were randomly assigned a start day and time to report on two Medicaid patients (N=1,625 patients).

RESULTS

A medication access problem in the past year was reported for a mean+/-SE of 48.3%+/-2.0% of the patients, with a 37.6% absolute difference between states with the lowest and highest rates (p<.001). The most common access problems were not being able to access clinically indicated medication refills or new prescriptions because Medicaid would not cover or approve them (34.0%+/-1.9%), prescribing a medication not clinically preferred because clinically indicated or preferred medications were not covered or approved (29.4%+/-1.8%), and discontinuing medications as a result of prescription drug coverage or management issues (25.8%+/-1.6%). With patient case mix adjusted to control for sociodemographic and clinical confounders, patients with medication access problems had 3.6 times greater likelihood of adverse events (p<.001), including emergency visits, hospitalizations, homelessness, suicidal ideation or behavior, or incarceration. Also, all prescription drug management features were significantly associated with increased medication access problems and adverse events (p<.001). States with more access problems had significantly higher adverse event rates (p<.001).

CONCLUSIONS

These associations indicate that more effective Medicaid prescription drug management and financing practices are needed to promote medication continuity and improve treatment outcomes.

Systematic use of patient-rated depression severity monitoring: is it helpful and feasible in clinical psychiatry?

OBJECTIVE

The gap between evidence-based treatments and routine care has been well established. Findings from the Sequenced Treatments Alternatives to Relieve Depression (STAR*D) emphasized the importance of measurement-based care for the treatment of depression as a key ingredient for achieving response and remission; yet measurement-based care approaches are not commonly used in clinical practice.

METHODS

The Nine-Item Patient Health Questionnaire (PHQ-9) for monitoring depression severity was introduced in 19 diverse psychiatric practices. During the one-year course of the project the helpfulness and feasibility of implementation of PHQ-9 in these psychiatric practices were studied. The project was modeled after the Institute for Healthcare Improvement Breakthrough Series. Two of the 19 practices dropped out during the course of the project.

RESULTS

By the conclusion of the study, all remaining 17 practices had adopted PHQ-9 as a routine part of depression care in their practice. On the basis of responses from 17 psychiatrists from those practices, PHQ-9 scores influenced clinical decision making for 93% of 6,096 patient contacts. With the additional information gained from the PHQ-9 score, one or more treatment changes occurred during 40% of these clinical contacts. Changing the dosage of antidepressant medication and adding another medication were the most common treatment changes recorded by psychiatrists, followed by starting or increasing psychotherapy and by switching or initiating antidepressants. In 3% of the patient contacts, using the PHQ-9 led to additional suicide risk assessment.

CONCLUSIONS

The study findings suggest that adopting measurement-based care, such as using the PHQ-9, is achievable, even in practices with limited resources.

Systematic use of patient-rated depression severity monitoring: is it helpful and feasible in clinical psychiatry?

OBJECTIVE

The gap between evidence-based treatments and routine care has been well established. Findings from the Sequenced Treatments Alternatives to Relieve Depression (STAR*D) emphasized the importance of measurement-based care for the treatment of depression as a key ingredient for achieving response and remission; yet measurement-based care approaches are not commonly used in clinical practice.

METHODS

The Nine-Item Patient Health Questionnaire (PHQ-9) for monitoring depression severity was introduced in 19 diverse psychiatric practices. During the one-year course of the project the helpfulness and feasibility of implementation of PHQ-9 in these psychiatric practices were studied. The project was modeled after the Institute for Healthcare Improvement Breakthrough Series. Two of the 19 practices dropped out during the course of the project.

RESULTS

By the conclusion of the study, all remaining 17 practices had adopted PHQ-9 as a routine part of depression care in their practice. On the basis of responses from 17 psychiatrists from those practices, PHQ-9 scores influenced clinical decision making for 93% of 6,096 patient contacts. With the additional information gained from the PHQ-9 score, one or more treatment changes occurred during 40% of these clinical contacts. Changing the dosage of antidepressant medication and adding another medication were the most common treatment changes recorded by psychiatrists, followed by starting or increasing psychotherapy and by switching or initiating antidepressants. In 3% of the patient contacts, using the PHQ-9 led to additional suicide risk assessment.

CONCLUSIONS

The study findings suggest that adopting measurement-based care, such as using the PHQ-9, is achievable, even in practices with limited resources.