Client Outreach in Los Angeles County's Assisted Outpatient Treatment Program: Strategies and Barriers to Engagement

Purpose

Assisted Outpatient Treatment (AOT) programs can compel treatment-refusing individuals to participate in mental health treatment via civil court order. In California's AOT programs, individuals first must be offered 30 days of outreach services and can accept services voluntarily. This study examines the use of outreach strategies in an AOT program with the potential for voluntary or involuntary enrollment.

Methods

Outreach staff completed a survey in which they reported and rated outreach strategies and barriers to treatment for 487 AOT-referred individuals.

Results

Outreach staff reported using a broad array of strategies to persuade and engage clients. Supportive and persuasive strategies were most common. More coercive strategies, including court order, were used when needed. More clients enrolled voluntarily (39.4%) than involuntarily (7.2%).

Conclusions

Outreach, coupled with the strategic used of potential court involvement, can lead to voluntary enrollment of treatment-refusing individuals with many, often severe, barriers to engaging in outpatient treatment.

Integrating Mental Health in Safety-net Primary Care: A Five-year Observational Study on Visits in a County Health System

BACKGROUND

Beginning in 2010, Los Angeles County Departments of Health Services and Mental Health collaborated to increase access to effective mental health care. The Mental Health Integration Program (MHIP) embedded behavioral health specialists in primary care clinics to deliver brief, problem-focused treatments, and psychiatric consultation support for primary care-prescribed psychotropic medications.

OBJECTIVE

The aim was to compare primary care visits associated with psychiatric diagnoses before and after MHIP implementation.

METHODS

This retrospective cohort study (2009-2014) examined 62,945 patients from 8 safety-net clinics that implemented MHIP in a staggered manner in Los Angeles. Patients' primary care visits (n=695,354) were either associated or not with a previously identified or "new" (defined as having no diagnosis within the prior year) psychiatric diagnosis. Multilevel regression models used MHIP implementation to predict odds of visits being associated with psychiatric diagnoses, controlling for time, clinic, and patient characteristics.

RESULTS

9.4% of visits were associated with psychiatric diagnoses (6.4% depression, 3.1% anxiety, <1% alcohol, and substance use disorders). Odds of visits being associated with psychiatric diagnoses were 9% higher [95% confidence interval (CI)=1.05-1.13; P<0.0001], and 10% higher for diagnoses that were new (CI=1.04-1.16; P=0.002), after MHIP implementation than before. This appeared to be fueled by increased visits for depression post-MHIP (odds ratio=1.11; CI=1.06-1.15; P<0.0001).

CONCLUSIONS

MHIP implementation was associated with more psychiatric diagnoses coded in safety-net primary care visits. Scaling up this effort will require greater attention to the notable differences across patient populations and languages, as well as the markedly low coding of alcohol and substance use services in primary care.

Psychosis Without Meaning: Creating Modern Clinical Psychiatry, 1950 to 1980

Over the last fifty years, American psychiatrists have embraced psychotropic drugs as their primary treatment intervention. This has especially been the case in their treatment of patients suffering from psychotic disorders such as schizophrenia. This focus has led to an increasing disregard for patients' subjective lived-experiences, life histories, and social contexts. This transformation of American psychiatry occurred abruptly beginning in the late 1960s and 1970s. My essay looks the ways these major transformations played themselves out in everyday clinical practices of state hospital psychiatrists from 1950 to 1980. Using clinical case records from California state hospitals, I chronicle the ways institutional and ideological forces shaped the clinical care of patients with psychotic disorders. I show there was an abrupt rupture in the late 1960s, where psychiatrists' concerns about the subjective and social were replaced by a clinical vision focused on a narrow set of drug-responsive signs and symptoms. Major political, economic, and ideological shifts occurred in American life and social policy that provided the context for this increasingly pharmacocentric clinical psychiatry, a clinical perspective that has largely blinded psychiatrists to their patients' social and psychological suffering.

Recovery in Context: Thirty Years of Mental Health Policy in California

Over the past quarter century, Recovery has become the hegemonic model guiding mental health policy. Advocates presented Recovery as a radical departure from the past, with the promise of dramatically improved outcomes for those with serious mental illness. This article looks at the implementation of Recovery-based policies in California from the 1990s to the present and interrogates the ways these policies emerged out of and reinforced many of the problems they were intended to solve. Against the backdrop of welfare reform, managed care, and a growing belief in market forces and individual responsibility, California policymakers pivoted from rigorously studied pilot programs that were intended to provide intensive, long-term treatment to Recovery-oriented programs that, while initially intensive, promised to "flow" increasingly independent and self-sufficient patients to less-intensive services. Moreover, these new programs promised to produce cost savings by reducing homelessness, hospitalization, and incarceration. Reported outcomes from these programs have been overwhelmingly positive but are based on flawed evaluations that lean more heavily on belief than on evidence. While proclaiming a comprehensive, patient-centered approach, Recovery's embrace of independence over long-term care and social supports has justified a system of care that systematically fails the sickest patients by abandoning them to the streets and jails.

Reconsidering Systems-Based Practice: Advancing Structural Competency, Health Equity, and Social Responsibility in Graduate Medical Education

Health inequities stem from systematic, pervasive social and structural forces. These forces marginalize populations and create the circumstances that disadvantage these groups, as reflected in differences in outcomes like life expectancy and infant mortality and in inequitable access to and delivery of health care resources. To help eradicate these inequities, physicians must understand racism, sexism, oppression, historical marginalization, power, privilege, and other sociopolitical and economic forces that sustain and create inequities. A new educational paradigm emphasizing the knowledge, skills, and attitudes to achieve health equity is needed.Systems-based practice is the graduate medical education core competency that focuses on complex systems and physicians' roles within them; it includes topics like multidisciplinary team-based care, patient safety, cost containment, end-of-life goals, and quality improvement. This competency, however, is largely health care centric and does not train physicians to engage with the complexities of the social and structural determinants of health or to partner with systems and communities that are outside health care.The authors propose a new core competency centered on health equity, social responsibility, and structural competency to address this gap in graduate medical education. For the development of this new competency, the authors draw on existing, innovative undergraduate and graduate medical pedagogy and public health, health services research, and social medicine frameworks. They describe how this new competency would inform graduate medical education and clinical care and encourage future physicians to engage in the work of health equity.

Community, Public Policy, and Recovery from Mental Illness: Emerging Research and Initiatives

This commentary examines the roles that communities and public policies play in the definition and processes of recovery for adults with mental illness. Policy, clinical, and consumer definitions of recovery are reviewed, which highlight the importance of communities and policies for recovery. This commentary then presents a framework for the relationships between community-level factors, policies, and downstream mental health outcomes, focusing on macroeconomic, housing, and health care policies; adverse exposures such as crime victimization; and neighborhood characteristics such as social capital. Initiatives that address community contexts to improve mental health outcomes are currently under way. Common characteristics of such initiatives and select examples are discussed. This commentary concludes with a discussion of providers', consumers', and other stakeholders' roles in shaping policy reform and community change to facilitate recovery.

History of Psychopharmacology

We live in an age of psychopharmacology. One in six persons currently takes a psychotropic drug. These drugs have profoundly shaped our scientific and cultural understanding of psychiatric disease. By way of a historical review, we try to make sense of psychiatry's dependency on psychiatric drugs in the care of patients. Modern psychopharmacology began in 1950 with the synthesis of chlorpromazine. Over the course of the next 50 years, the psychiatric understanding and treatment of mental illness radically changed. Psychotropic drugs played a major part in these changes as state hospitals closed and psychotherapy gave way to drug prescriptions. Our review suggests that the success of psychopharmacology was not the consequence of increasingly more effective drugs for discrete psychiatric diseases. Instead, a complex mix of political economic realities, pharmaceutical marketing, basic science advances, and changes in the mental health-care system have led to our current infatuation with psychopharmacology.

Using Electronic Health Records to Enhance a Peer Health Navigator Intervention: A Randomized Pilot Test for Individuals with Serious Mental Illness and Housing Instability

Individuals with serious mental illnesses have high rates of comorbid physical health issues and have numerous barriers to addressing their health and health care needs. The present pilot study tested the feasibility of a modified form of the "Bridge" peer-health navigator intervention delivered in a usual care setting by agency personnel. The modifications concerned the use of an electronic personal health record with individuals experiencing with housing instability. Twenty participants were randomized to receive the intervention immediately or after 6 months. Health navigator contacts and use of personal health records were associated with improvements in health care and self-management. This pilot study demonstrated promising evidence for the feasibility of adding personal health record use to a peer-led intervention.

System Transformation Under the California Mental Health Services Act: Implementation of Full-Service Partnerships in L.A. County

OBJECTIVE

The study evaluated the effect of California's Mental Health Services Act (MHSA) on the structure, volume, location, and patient centeredness of Los Angeles County public mental health services.

METHODS

This prospective mixed-methods study (2006-2013) was based in five Los Angeles County public mental health clinics, all with usual care and three with full-service partnerships (FSPs). FSPs are MHSA-funded programs designed to "do whatever it takes" to provide intensive, recovery-oriented, team-based, integrated services for clients with severe mental illness. FSPs were compared with usual care on outpatient services received (claims data) and on organizational climate, recovery orientation, and provider-client working alliance (surveys and semistructured interviews), with regression adjustment for client and provider characteristics.

RESULTS

In the first year after admission, FSP clients (N=174) received significantly more outpatient services than did usual care clients (N=298) (5,238 versus 1,643 minutes, p<.001), and a larger proportion of these services were field based (22% versus 2%, p<.001). Compared with usual care clients, FSP clients reported more recovery-oriented services (p<.001) and a better provider-client working alliance (p=.01). Compared with usual care providers (N=130), FSP providers (N=42) reported more stress (p<.001) and lower morale (p<.001).

CONCLUSIONS

Los Angeles County's public mental health system was able to transform service delivery in response to well-funded policy mandates. For providers, a structure emphasizing accountability and patient centeredness was associated with greater stress, despite smaller caseloads. For clients, service structure and volume created opportunities to build stronger provider-client relationships and address their needs and goals.

Implementation Status of Assisted Outpatient Treatment Programs: A National Survey

OBJECTIVE

The authors' objective was to determine how assisted outpatient treatment (AOT) has been implemented in actual practice in the 45 states with AOT statutes.

METHODS

A national survey of AOT programs was conducted to examine the extent to which AOT programs have been implemented and variations in implementation models.

RESULTS

Although 45 states have current AOT statutes, the most active programs were identified in 20 states. These programs varied considerably in style of implementation, criteria applied, agency responsible, use of a treatment plan, monitoring procedures, and numbers of participants involved. Three implementation models were identified: community gateway, hospital transition, and surveillance (or safety net). Common problems included inadequate resources, lack of enforcement power, inconsistent monitoring, and weakness of interagency collaboration.

CONCLUSIONS

AOT is a widely applied and much-discussed mechanism for providing treatment to individuals with serious mental illnesses nationally. The uneven implementation of AOT programs within and across states highlights the ambivalence in the community, by judicial officials, and by mental health clinicians about the role and scope of AOT and the difficulties of implementation under existing funding constraints and statutory limitations.

Barriers to serving clients with co-occurring disorders in a transformed mental health system

OBJECTIVE

The publication of the President's New Freedom Commission Report in 2003 led to hope and anticipation that system transformation would address barriers that have impeded the delivery of integrated services for clients with co-occurring mental health and substance use disorders. Have problems been resolved? This study analyzed providers' perspectives on serving clients with co-occurring disorders in a large mental health system that has undergone transformation.

METHODS

Six focus groups were conducted with providers at specialty mental health treatment organizations that received funding to transform services. Using content analysis, the authors identified major themes of the focus group discussions.

RESULTS

Participants reported several barriers within the mental health system and challenges associated with collaborating with specialty substance abuse treatment providers that impede the delivery of integrated care.

CONCLUSIONS

In spite of efforts to improve co-occurring disorder service delivery in a transformed mental health system, barriers that have historically impeded integrated treatment persist.

Relationship of community integration of persons with severe mental illness and mental health service intensity

OBJECTIVE

Community integration is integral to recovery for individuals with severe mental illness. This study explored the integration of individuals with severe mental illness into mental health and non-mental health communities and associations with mental health service intensity.

METHODS

Thirty-three ethnically diverse participants with severe mental illness were categorized in high-intensity (N=18) or low-intensity (N=15) mental health service groups. Community integration was assessed with measures of involvement in community activities, social capital resources, social support, social network maps, and subjective integration.

RESULTS

Although participants rated themselves as being more integrated into the mental health community, their social networks and social capital were primarily derived from the non-mental health community. The high-intensity group had a higher proportion of members from the mental health community in their networks and had less overall social capital resources than the low-intensity group.

CONCLUSIONS

The findings suggest opportunities and possible incongruities in the experience of community integration.

Experiencing community: perspectives of individuals diagnosed as having serious mental illness

OBJECTIVE

Community integration is recognized as a crucial component of recovery from serious mental illness. Although the construct of community integration can be measured with structured instruments, little is known about the subjective and experiential meaning of community and community involvement for persons with serious mental illness.

METHODS

In 2010, 30 individuals with serious mental illness treated in two public mental health clinics completed semistructured interviews that elicited the places and people that they associate with the experience of community and the larger meaning of community in their lives.

RESULTS

Participants described four experiences as integral to their concepts of community: receiving help, minimizing risk, avoiding stigma, and giving back. Participants looked for communities that provide reliable support, and they described the need to manage community contact in order to protect themselves and others from their symptoms and from discrimination. Most participants experienced communities centered on mental health treatment or mentally ill peers as providing opportunities for positive engagement.

CONCLUSIONS

The experience of having a serious mental illness shapes preferences for and perceptions of community in pervasive ways. Participants described community involvement not as a means to move away from illness experiences and identities but as a process that is substantially influenced by them. Mental health communities may help individuals with serious mental illness to both manage their illness and recognize and enjoy a sense of community. The findings indicate the need for further research on the relationship between community integration and outcome in serious mental illness.

Generalizability of studies on mental health treatment and outcomes, 1981 to 1996

OBJECTIVE

This study operationalized and measured the external validity, or generalizability, of studies on mental health treatment and outcomes published in four journals between 1981 and 1996.

METHOD

MEDLINE was searched for articles on mental health treatment and outcomes that were published in four leading psychiatry and psychology journals between 1981 and 1996. A 156-item instrument was used to assess generalizability of study findings.

RESULTS

Of more than 9,000 citations, 414 eligible studies were identified. Inclusion of community sites and patients from racial or ethnic minority groups were documented in only 12 and 25 percent of studies, respectively. Random or systematic sampling methods were rare (3 percent), and 75 percent of studies did not explicitly address sample representativeness. Studies with funding from the National Institute of Mental Health (NIMH) were more likely than those without NIMH funding to document the inclusion of patients from minority groups (30 percent compared with 20 percent). Randomized studies were more likely than nonrandomized studies to document the inclusion of patients from minority groups (28 percent compared with 17 percent), include patients with comorbid psychiatric conditions (31 percent compared with 19 percent), and attend to sample representativeness (28 percent compared with 15 percent). Modest improvements were seen over time in inclusion of patients from minority groups, inclusion of patients with psychiatric comorbidities, and attention to sample representativeness.

CONCLUSIONS

Generalizability of studies on treatments and outcomes, whether experimental or observational, remained low and poorly documented over the 16-year period.

The making of contemporary American psychiatry, Part 2: therapeutics and gender before and after World War II

In this article, the 2nd in a 2-part series, the authors use patient records from California's Stockton State Hospital to explore the changing role of gender norms and other cultural values in the care of psychiatric patients. The authors show that cultural values are always imbedded in psychiatric practice and that their role in that practice depends on the patients, treatments, and therapeutic rationales present in a given therapeutic encounter. Because the decade following World War II witnessed dramatic changes in psychiatry's patients, therapeutics, and rationales, Stockton State Hospital's patient records from this time period allow the authors to show not only the extent to which gender norms shape psychiatric practice but also how psychiatry's expansion into the problems of everyday life has led to psychiatry taking a more subtle and yet more active role in enforcing societal norms.

The making of contemporary American psychiatry, part 1: patients, treatments, and therapeutic rationales before and after World War II

This article, the 1st in a 2-part series, uses patient records from California's Stockton State Hospital to unearth the midcentury roots of contemporary American psychiatry. These patient records allow the authors to examine 2 transformations: the post-World War II expansion of psychiatry to include the diagnosis and treatment not only of psychotic patients but also of nonpsychotic patients suffering from problems of everyday living, and the 1950s introduction of the first psychotropic drugs, which cemented the medical status of these new disorders, thus linking a new therapeutic rationale to biological understandings of disease. These transformations laid the groundwork for a contemporary psychiatry characterized by voluntary outpatient care, pharmacological treatment of a wide range of behaviors and distress, and a doctor-patient relationship and cultural acceptance of disease that allow psychiatric patients to identify themselves as consumers.

Improving recognition of depression in primary care: a study of evidence-based quality improvement

BACKGROUND

Depression's high prevalence and large amount of potentially modifiable morbidity make it an excellent candidate for quality improvement (QI) techniques. Yet there is little evidence on how to promote adherence to evidence-based guidelines. A locally run research and QI project that was part of a larger National Institute of Mental Health-funded study to implement depression guidelines was implemented by a primary care team at a Department of Veterans Affairs (VA) ambulatory care center in 1997 and 1998. DEVELOPMENT OF THE QI INTERVENTION: The plan to improve screening and recognition entailed systematically screening all patients attending the primary care clinic; sending computer reminders to clerical staff, nursing assistants, and primary care providers; and auditing team performance with monthly feedback.

RESULTS

Once the intervention was in place, nearly all patients were screened. The primary care provider documented the assessment of whether a patient was depressed for nearly all patients who screened positive. Few resources were needed to maintain the project once it was implemented.

DISCUSSION

An evidence-based QI intervention led to profound and lasting changes in primary care providers' recognition of depression or depressive symptoms. The QI implementation continued for one year after the intervention's end, but a new VA computerized medical record system uses similar computer-generated reminders.

History and evidence-based medicine: lessons from the history of somatic treatments from the 1900s to the 1950s

This paper examines the early history of biological treatments for severe mental illness. Focusing on the period of the 1900s to the 1950s, I assess the everyday use of somatic therapies and the science that justified these practices. My assessment is based upon patient records from state hospitals and the contemporaneous scientific literature. I analyze the following somatic interventions: hydrotherapy, sterilization, malaria fever therapy, shock therapies, and lobotomy. Though these treatments were introduced before the method of randomized controlled trials, they were based upon legitimate contemporary science (two were Nobel Prize-winning interventions). Furthermore, the physicians who used these interventions believed that they effectively treated their psychiatric patients. This history illustrates that what determines acceptable science and clinical practice was and, most likely will, continue to be dependent upon time and place. I conclude with how this history sheds light on present-day, evidence-based medicine.

Effect of therapeutic innovation on perception of disease and the doctor-patient relationship: a history of general paralysis of the insane and malaria fever therapy, 1910-1950

OBJECTIVE

The purpose of this study was to examine the effect of therapeutic innovation on the interpersonal style of physicians by using the historical example of the treatment of general paralysis of the insane by malaria fever therapy.

METHOD

The study employed historical qualitative and descriptive methods to analyze medical and popular literature and medical records. These medical records were from a single institution and contained verbatim transcripts of patient interviews and doctors' conferences. The author examined records of patients diagnosed with neurosyphilis from the periods before (1910-1928) and after (1928-1950) the introduction of malaria fever therapy.

RESULTS

Before the introduction of malaria fever therapy, physicians saw their neurosyphilitic patients as "hopeless," "immoral," and "stupid" paretics--objects to be acted upon, a view consistent with the cultural belief that syphilitic patients were sinful and depraved. After the introduction of malaria fever therapy, doctors wrote more positively and empathically about their neurosyphilitic patients, allowing patients to become active participants in their therapeutic regimens. Patients with neurosyphilis voluntarily sought admission specifically for fever therapy, seeing the asylum as a place of cure rather than as an institution of confinement.

CONCLUSIONS

This history illustrates that biological therapies can powerfully affect physicians' perceptions of patients and need not remove them from patients' subjective experiences. Instead, biological treatments may enhance physicians' ability to empathize with their patients' suffering.

Punishment or therapy. Patients, doctors, and somatic remedies in the early twentieth century

Although it has been argued that psychiatrists entered the modern era with the introduction of shock therapies and lobotomy in the 1930s and antipsychotic drugs in the 1950s, practicing psychiatrists of the 1910s and 1920s did not feel they were in the dark ages of therapeutics. These early twentieth-century psychiatrists had a variety of somatic remedies at their disposal. For example, they had a plethora of sedatives and hypnotic agents from which to choose, although these drugs too often produced troublesome side effects, and, from the point of view of these physicians, too closely resembled physical restraint in their effects on the patient. As we saw, physical restraint had a sullied reputation, psychiatrists believing it, at best, to be a necessary evil and not part of a therapeutic regimen. This did not mean psychiatrists felt helpless in treating insanity for they firmly believed that, unlike drugs and physical restraint, hydrotherapy acted therapeutically. Our examination of every-day treatment practices at Stockton and Patton state hospitals revealed that physicians found hydrotherapy to be a useful remedy on nearly all patients irrespective of diagnosis. The Agnews' investigation allowed us to examine the basic assumptions underpinning early twentieth-century therapeutics, and two major conclusions can be gleaned from this examination. First, how doctors perceive disease is inseparably linked to how they treat disease. In the case of hydrotherapy, physicians believed it effectively controlled their patients' behavior. To assert that it had therapeutic value and to differentiate it from mechanical restraint, however physicians transformed how they saw disease and therapy such that wrapping and bathing the "excited" and "frenzied" patients were therapeutic. Rather than seeing disruptive behavior as simply something in need of physical restraint, hydrotherapy allowed physicians to see these behaviors as the essence of disease and the primary object of their therapeutic ministrations. Second, patients' conceptions of disease and therapy may differ markedly from their physicians, which may be particularly true when disease is defined by visible behavior. At Agnews, patients spoke a different language than their physicians such that restraint differed little from therapy. In contrast to their doctors, patients were unable to see their behavior as necessarily pathologic, and, thus, were unable to recognize and to speak of the difference between mechanical restraint and hydrotherapy; both kinds of technologies simply restricted their bodily movements. With a different therapeutic practice such as malaria fever therapy, doctors and patients saw disease and its treatment in a new light.(ABSTRACT TRUNCATED AT 400 WORDS)