JBHSR Recent Issues

The Table of Contents and abstracts for recent issues of the JBHS&R are listed below.

Volume 29, 2002

Number 1 / January 2002

REGULAR ARTICLES
Medicaid Patients in a Private Health Maintenance Organization: Patterns of Chemical Dependency Treatment… 1-14
Lawrence J. Walter, MA, Sujaya Parthasarathy, PhD, Steven Allen, PhD, and Lynn Ackerson, PhD
 Abstract: Although many Medicaid beneficiaries receive health care through commercial health maintenance organizations (HMOs), the impact of private managed care on low-income individuals seeking treatment for substance abuse has rarely been studied. This study examined treatment patterns of 234 Medicaid recipients who presented for care at an HMO between 1995 and 1997. After adjustment for demographic factors and duration of health plan membership, the Medicaid patients returned to start treatment after intake less often (odds ratio = 0.60) and dropped out of treatment sooner (median = 14 versus 28 days) than non-Medicaid patients. While many Medicaid patients received significant amounts of substance abuse treatment, further research is needed to explain the observed treatment gap and to identify areas where HMOs can improve services for some of their most vulnerable members.

Access to New Medications to Treat Schizophrenia…15-29
Tami L. Mark, PhD, MBA, Riad Dirani, PhD, Patricia Russo, PhD, MSW, RN and Eric Slade, PhD
Abstract: Between 1989 and 1997, the Food and Drug Administration approved four new-generation antipsychotic medications for use in the treatment of schizophrenia. This article examines factors associated with the use of new antipsychotic medications as compared with traditional antipsychotic medications from patient interviews, medical records, and a physician survey administered at schizophrenia treatment sites around the country as part of the Schizophrenia Care and Assessment Program. The following variables were significantly associated with a higher probability of receiving an atypical antipsychotic medication in multiple regression analysis at p < .05: female, younger age, younger age of onset, non-African American, having a higher Positive and Negative Syndrome Scale-Negative Syndrome subscale score. Some physician characteristics were statistically significant in the bivariate results but not in the multivariate analyses. Access to new atypical antipsychotic medications is dependent on more than clinical characteristics. In particular, barriers to access may exist for African Americans. Physician access to information about advances in drug therapies also may play a substantial role in the rate of diffusion of new medications.

Prevalence of Alcohol and Drug Use in a Highly Educated Workforce…30-44
Robert A. Matano, PhD, Stanley F. Wanat, PhD, Darrah Westrup, PhD, Cheryl Koopman, PhD, and Shelly D. Whitsell, BA
Abstract: This study examined alcohol and licit and illicit drug use in a highly educated workforce. A comprehensive health survey of a 10% random sample of a workforce (n = 8,567) yielded a 60 response rate (n = 504) after accounting for 15 undeliverable surveys. Many respondents reported past-year use of alcohol (87%). Thirteen percent of respondents consumed three or more drinks daily; 15% were binge drinkers. Twelve percent of the workforce was assessed as having a high likelihood of lifetime alcohol dependence; 5% of respondents met criteria for current problem drinking. Overall, 42% reported using mood-altering prescription drugs (analgesics, antidepressants, sedatives, or tranquilizers). Eleven percent reported using illicit drugs (cocaine, hallucinogens, heroin, or marijuana) in the past year. Significant relationships were found between gender, age, ethnicity, and occupation with some measures of alcohol consumption and use of mood-altering drugs. These results indicate prevention and early intervention programs need to address use of mood-altering substances (including alcohol) in highly educated workforces.

Referral Sources, Diagnoses, and Service Types of Youth in Public Outpatient Mental Health Care: A Focus on Ethnic Minorities…45-60
May Yeh, PhD, Kristen McCabe, PhD, Michael Hurlburt, PhD, Richard Hough, PhD, Andrea Hazen, PhD, Shirley Culver, LCSW, Ann Garland, PhD, and John Landsverk, PhD
Abstract: Racial/ethnic variations in clinical and service delivery characteristics among youth in public outpatient mental health services were examined using data from San Diego County mental health service programs for fiscal year 1996 to 1997 (N = 3,962). Differences in referral sources, primary diagnoses, and service types were investigated for three racial/ethnic groups (African Americans, Asian/Pacific Islander Americans, and Latinos) compared to non-Hispanic whites. Controlling for age, gender, functional impairment, and prior service use, significant differences by race/ethnicity were found for all three variables studied. Possible explanations for these variations and future directions for research are discussed.

Utilization and Cost of Behavioral Health Services: Employee Characteristics and Workplace Health Promotion…61-74
James V. Trudeau, PhD, Diane K. Deitz, PhD, and Royer F. Cook, PhD
Abstract: The study sought to (1) model demographic and employment-related influences on behavioral health care utilization and cost; (2) model behavioral health care utilization and cost influences on general health care cost, job performance, and earnings; and (3) assess workplace-based health promotion's impact on these factors. Behavioral health care utilization was more common in employees who were female, over age 30, with below-median earnings, or with above-median general (non-behavioral) health care costs. Among employees utilizing behavioral health care, related costs were higher for employees with below-median earnings. Employees utilizing behavioral health care had higher general health care costs and received lower performance ratings than other employees. Health promotion participants were compared with a nonparticipant random sample matched on gender, age, and pre-intervention behavioral health care utilization. Among employees without pre-intervention behavioral health care, participants and nonparticipants did not differ in post-intervention utilization. Among employees utilizing behavioral health care adjusting for pre-intervention costs, participants had higher short-term post-intervention behavioral health care costs than nonparticipants.

BRIEF REPORTS
Use of Measurement Audit in Outcomes Management…75-80
John S. Lyons, PhD, Purva Rawal, BA, Irene Yeh, MD, Scott C. Leon, BA, and Peter Tracy, MA
Abstract: With the growing emphasis on accountability in mental health services, outcomes management strategies are gaining popularity. However, for these techniques to be credible, it is necessary to ensure the reliability of clinical data. In other words, outcomes measures must accurately reflect the actual status of service recipients. This article presents the use of the measurement audit as one means of monitoring and improving the reliability of outcomes measurements. The methods and findings from an audit of crisis assessment workers for children in state custody are presented. Clinical assessments completed at the time of service were compared with assessments using the same measure completed via retrospective file review. Findings suggest generally good reliability, 0.72 overall, with some variation by provider and type of information.

Issues Related to Combining Risk Factor Reduction and Clinical Treatment for Eating Disorders in Defined Populations…81-90
C. Barr Taylor, MD, Rebecca P. Cameron, PhD, Michelle G. Newman, PhD, and Juliane Junge, Dipl.-Psych
Abstract: Population-based psychotherapy considers the provision of services to a population at risk for or already affected with a disease or disorder. Using existing data on prevalence, incidence, risk factors, and interventions (both preventive and clinical) for eating disorders (anorexia excluded), this article examines issues related to integrating and providing risk reduction and treatment to a population of female college students. Population-based psychotherapy models have important implications for the provision of services and for future directions in research on eating and other types of mental health disorders, but the assumptions need to be carefully examined. Studies that provide data combining population-based risk factor reduction and clinical treatment are needed to advance this field.

Mental Health Service Use and Cost of Care for Older Adults In Assisted Living Facilities: Implications for Public Policy…91-98
Marion Becker, RN, PhD, Paul Stiles, JD, PhD, and Lawrence Schonfeld, PhD
Abstract: With changing demographics prompting greater demand for assisted living facility (ALF) care, indigent older adults with mental health needs face underfunded residential care options and mental health systems currently unpre pared to meet their service requirements. In particular, overreliance on inpatient mental health services for older individuals with mental illness and inadequate reimbursement of ALF facilities potentially increase costs and threaten availability of ALF care. This article analyzes Florida's administrative data and presents findings on mental health service use and cost of care for poor older persons. Using Florida as an example, the authors recommend policy changes to ensure the quality and availability of residential care for low-income adults with mental health needs.

The Effect of Technical Support on Clinician Attitudes Toward an Outcome Assessment Instrument…99-108
Jennifer L. Close-Goedjen, MS, and Stephen M. Saunders, PhD
Abstract: This study evaluated the impact of technical support on mental health clinicians' attitudes and use of an outcome assessment (OA) instrument. Technical support involved providing clinicians with the scored and profiled results of an OA instrument administered to their patients. It was predicted that temporary exposure to the instrument's uses would improve clinicians' attitudes toward the instrument and that improved attitudes would lead to greater use. The results indicated that subsequent to support clinicians' attitudes toward the instrument were generally more positive, as they had generally more favorable opinions, saw it as more relevant, and reported that it was relatively easy to use. Contrary to expectations, however, clinicians did not use the OA instrument more frequently or regularly after support. The implications for clinics seeking to implement OA protocols are discussed.

Number 2 / April 2002

SPECIAL SECTION: Health Services Research in Substance Abuse

Special Section Editor: Brenda M. Booth, PhD

SPECIAL SECTION: Introduction...113-114
Brenda M. Booth, PhD

Predicting Closure of Private Substance Abuse Treatment Facilities…115-125
J. Aaron Johnson, PhD, and Paul M. Roman, PhD
Abstract: Researchers in organizational ecology have long been interested in identifying the factors associated with organizations’ closing their doors or “organizational death.” Though the predictors of closure have been examined across many different types of organizations, private substance abuse treatment centers, often characterized as being unstable and having high closure rates, have not been subject to empirically based study of closure. Data for this study are derived from a nationally representative longitudinal study of 450 private substance abuse treatment centers. This study, begun in 1994, includes two waves of on-site interviews with both center administrators and clinical directors conducted in 1995-96 and 1997-98 and five waves of telephone follow-ups conducted at six month intervals in the interim between on-site data collections and following the second on-site visit. Using discrete time event history analysis, the authors examined predictors of closure. Contrary to most previous research on organizational death where the “liability of newness” predicted closure, center age was not a significant predictor of closure among private substance abuse treatment centers. Significant predictors of closure included being a freestanding facility, center capacity, the percentage of clients covered by Medicaid, and the ratio of patients to FTEs.

A Prospective Study of the Factors Influencing Entry to Alcohol and Drug Treatment….126-137
Constance Weisner, DrPH, and Helen Matzger, MPH
Abstract: A great deal is known about the factors related to entering alcohol and drug treatment, but most of the research has been cross-sectional “snapshots” in time. What is not known is whether the reasons for entering treatment remain the same when a sample of problem drinkers is studied over time. Drawing on utilization models from the medical literature, this paper contrasts characteristics predicting treatment entry in a cross-sectional analysis at baseline with a longitudinal perspective at one and three year follow-up interviews. Socio-demographic characteristics were less important in the longitudinal than the cross-sectional analysis. In contrast to the community social policy interventions and social consequences important at the baseline interview, physiological symptoms of alcohol dependence and interventions by medical professionals were prominent at later interview points. The influence of legal and workplace interventions decreased. Treatment history was an important predictor at each interview point. The findings have implications for interventions by health professionals, both for the development of early interventions targeting individuals to treatment, and for a chronic condition, continuing care service model.

Depressive Symptomatology and Early Attrition from Intensive Outpatient Substance Abuse Treatment…138-143
Geoffrey M. Curran, PhD, JoAnn E. Kirchner, MD, Mark Worley, MD, Craig Rookey, PhD, and Brenda M. Booth, PhD
Abstract: This study examined the relationship between depressive symptoms and attrition from outpatient treatment in a Mid-Southern Veterans Healthcare System that had recently moved to intensive outpatient-only treatment for substance abuse. This reports focuses on 126 consecutively admitted patients who were enrolled on their last day of a 3-4 day outpatient detoxification. Results indicate that severe depressive symptomatology presenting at treatment entry is a significant risk factor for early attrition from intensive outpatient substance use treatment but not later attrition. These data indicate that retention efforts should be directed towards the assessment and management of depressive symptoms early in the treatment process, with interventions targeted to those who report severe symptomatology. The results also indicate that future research should focus on potential distinguishing characteristics between early and later attrition.

Mental Health, Drug Use, and the Transition from Welfare to Work…144-156
Isaac D. Montoya, PhD, CMC, CLS, David C. Bell, PhD, John S. Atkinson, MA, MS, Carl W. Nagy, MA, and Donna Whitsett, BA
ABSTRACT: This study examines the effects of drug use and work requirements on psychological distress and employment among chronic drug using and non-drug using welfare recipients. Using a natural history design, 442 female Temporary Assistance for Needy Families (TANF) recipients (including 251 with chronic drug use problems) were interviewed every four months in order to assess changes in psychological functioning, employment status, and wages. Data from the first year (4 waves) indicate that employment and wages increased substantially, though less so for drug users than non-users. Psychological distress decreased only slightly over the study period. Growth curve analyses show that drug use had no direct effect on wages, however drug use did significantly increase psychological distress. Both the work mandate and psychological distress contributed to wages. The authors consider the implications of these trends for the mental health service needs of drug using TANF recipients.

The Impact of Drinking and Drinking Consequences on Short-Term Employment Outcomes in At-Risk Drinkers in Six Southern States…157-166
Brenda M. Booth, PhD, and Weiwei Feng, PhD
Abstract: Social cost studies report that alcohol use and misuse impose a great economic burden on society, with over half of the total costs estimated to be due to the loss of work productivity. However, research on labor productivity and alcohol abuse has been limited by methodological differences, making conclusions equivocal. This study was based on two waves of data (six months apart) from a community probability sample of 658 at-risk drinkers in six Southern U.S. states. This paper analyzed the prospective impact of several measures of drinking and drinking consequences on the six-month follow-up probability of: 1) not being employed; and 2) fewer weeks of employment if employed. The authors found that drinking seven drinks or more on an average drinking day significantly increased the likelihood of not working and for those who were working, reduced weeks of employment, after controlling for employment status in the previous year. This implies potential productivity benefits from developing effective treatments for at-risk drinkers and in particular from interventions to reduce the level of drinking.

A Descriptive Profile of Health Problems, Health Services Utilization and HIV Serostatus among Incarcerated Male Drug Abusers…167-175
Carl Leukefeld, DSW, Michele Staton, MSW, Matthew L. Hiller, PhD, TK Logan, PhD, Barbara Warner, PhD, Keena Shaw, BA, and Richard T. Purvis, PsyD
Abstract: The number of incarcerated offenders is increasing and many have physical and mental health problems. Drug-involved prisoners exhibit more health problems and greater rates of chronic health problems than prisoners who have not used drugs. Furthermore, HIV prevalence rates are generally high in prisons. The primary purpose of this descriptive study, therefore, is to profile health problems (including HIV) and health services utilization in a sample of drug-involved prisoners from a rural state. Analysis focused on a group of prisoners who tested HIV positive and a group who tested HIV negative. Although 2.3% of all male prisoners in the United States tested positive for HIV, the HIV seropositivity rate in this study was higher at 3.8%. Overall, seropositivity appeared to be unrelated to drug use, except for marijuana. That is, longer use of marijuana was associated with being HIV positive. The only health problem that was found to be significantly associated with HIV serostatus was liver problems. Having a history of mental health treatment was also related to greater likelihood of being HIV positive. Not surprising, HIV status was most clearly associated with sexual risk behaviors. These preliminary findings suggest that prisons represent an important opportunity for providing targeted behavioral health interventions focused on HIV-risk reduction.

Met and Unmet Need for Dental Services Among Active Drug Users in Miami, Florida…176-188
Lisa R. Metsch, PhD, Lee Crandall, PhD, Brad Wohler-Torres, MS, Christine C. Miles, MA, Dale D. Chitwood, PhD, and Clyde B. McCoy, PhD
Abstract: In May, 2000, David Satcher, Surgeon General, released the first ever report on oral health in the United States, a report which emphasizes the inextricable link between oral health and general health and identifies existing disparities in oral health. Within this context, the purpose of this study is to consider both met and unmet need for dental services among chronic users of opiates and/or cocaine in Miami, Florida and to compare them to non-users who were recruited from the same neighborhoods (N=1,479). Three primary findings emerge from this study: (1) dental problems were among the most frequently reported health problems, (2) drug use was independently associated with need for dental services, and (3) injection drug use was independently associated with increased odds of unmet need for dental services. These findings suggest that health care providers, managed care organizations, and policymakers should consider policies that promote increased access to dental services for drug users and other disadvantaged groups. These services could be integrated into existing behavioral health programs already targeting active drug users such as drug treatment, methadone maintenance, and risk reduction programs.

Satisfaction with Access to Health Care Among Injection Drug Users, Other Drug Users and Non-Users…189-197
Dale D. Chitwood, PhD, Mary Comerford, MSPH, and H. Virginia McCoy, PhD
Abstract: This paper examines the satisfaction of users of cocaine and/or opiates and non-drug users with their access to the health care system. Data were obtained from a sample of 1,477 injection drug users, non-injection drug users and non-drug users who were recruited from neighborhoods with high drug use. Multiple regression was used to examine the relationship between satisfaction with access to health care and demographic, health status and health care utilization, ability to pay, and alcohol and drug use variables. Age, ethnicity, health status, having received health care in the last 12 months, not having received health care when needed, having received preventative health care, health insurance and drug use were independently associated with satisfaction. Injection drug users and non-injection drug users were less satisfied with access to health care than were their non-drug user counterparts. Strategies to improve health care delivery to drug users are discussed.

REGULAR ARTICLE
Service Penetration by Persons with Severe Mental Illness: How Should it be Measured?…198-207
Paul Stiles, JD, PhD, Roger Boothroyd, PhD, Kristen Snyder, PhD, and Xiang Zong, MSPH
Abstract: As performance indicators and outcomes measures have become almost an essential part of doing business for providers of mental health services, a number of access measures have been developed and used. One access measure that is being used with increasing frequency is service penetration. However, the lack of standard methods for calculating and reporting service penetration have made the comparison of penetration rates across studies difficult. This paper provides a discussion of the conceptualization and operationalization of service penetration. In addition, the article presents an exploratory study of service penetration using data from the same persons using very different data sources collected during an evaluation of a Medicaid managed care system in Florida. Finally, recommendations are offered for the use and reporting of service penetration rates.

BRIEF REPORT
Standardization of the Behavioral and Emotional Rating Scale: Factor Structure, Reliability and Criterion Validity…208-216
Michael H. Epstein, EdD, Gail Ryser, PhD, and Nils Pearson, PhD
Abstract: The purpose of the present study was to report on the standardization of the Behavioral and Emotional Rating Scale and to examine the scale's factor structure, reliability and criterion validity. Data on a national sample of children without disabilities (N = 2,176) (NEBD) and children with emotional and behavioral disorders (N = 861) (EBD) were collected. Analysis of the data from the NEBD sample identified five factors: interpersonal strengths, family involvement, intrapersonal strength, school functioning, and affective development. The factors appeared to be highly stable and reliable (.79 to .99). No statistically significant age or gender differences were noted with the NEBD sample, although females were rated higher on each factor and the overall score. The EBD sample was rated significantly lower than the NEBD sample across the factors and total scores. Future research issues and practical implications are discussed.

COMMENTARY
Administrative, Clinical and Ethical Issues Surrounding the Use of Waiting Lists in the Delivery of Mental Health Services…217-228
Seth A. Brown, PhD, Jefferson D. Parker, PhD, and Phillip R. Godding, PhD
Abstract: The utilization of waiting lists is a common practice in the delivery of mental health services. Despite their prevalence, the design and management of waiting lists are generally not standardized, but rather take place on an ad hoc basis as a response to undesirable circumstances. The formulation and management of a waiting list initially appears to be a simple, straightforward, and benign process. However, upon close examination, waiting lists are complicated and their implementation has pervasive costs and benefits. The purpose of this paper is to delineate a variety of the costs and benefits involving the use of waiting lists. This paper outlines administrative, clinical, and ethical issues intrinsic in the use of waiting lists and provides recommendations aimed to assist in the design and management of waiting lists. While recommendations encompassing the range of possible unique situations are impractical, guidelines for consideration of important variables are provided.

Number 3 / July 2002

REGULAR ARTICLES
Preventive Mental Health and Substance Abuse Programs and Services in Managed Care…233-258
Sharon L. Dorfman, ScM, CHES and Shelagh A. Smith, MPH, CHES
Abstract: If effective preventive behavioral health services were available to the millions of Americans enrolled in managed care organizations, the public health impact could be significant. This project was undertaken to summarize published research-based information about effective preventive interventions for mental health and substance use (tobacco, alcohol and other drugs) shown or likely to have no negative cost impact. Fifty-four studies found satisfied seven screening criteria. Their findings demonstrated that preventive behavioral health interventions appropriate for managed care settings have been evaluated and shown to be effective. Some produced cost savings or offset costs. Six preventive behavioral health interventions are therefore recommended for managed care. Findings can inform decisions about preventive behavioral health interventions in managed care.

Assessing the effectiveness of care for youth with severe emotional disturbances: Is there agreement between popular outcome measures? … 259-273
Abram Rosenblatt, Ph.D. and Jennifer A. Rosenblatt, Ph.D.
Abstract: Limited information exists regarding how some of the most popular measures for assessing the effectiveness of services to children with severe emotional disturbance interrelate when used as part of ongoing outcome accountability systems. This article examines the interrelationships, at intake and over time, between the Child Behavior Checklist (CBCL), the Youth Self Report (YSR), the Child and Adolescent Functional Assessment Scale (CAFAS) and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) clinical diagnoses across six California care systems. At intake, there are mild to moderate relationships between the clinical diagnosis, the CAFAS, the CBCL, and the YSR. These relationships are not as strong as those found in other studies conducted in more controlled research environments. There was limited agreement among the CAFAS, the CBCL, and the YSR regarding the outcomes of the youths served. These findings raise questions regarding translating measures from research settings to clinical environments and reconciling differences between outcome measures.

Clinicians As Advocates: An Exploratory Study of Responses to Managed Care by Mental Health Professionals... 274-287
Nancy Wolff, Ph.D. and Mark Schlesinger, Ph.D.
Abstract: Utilization review and other managed care techniques require that health care professionals assume new responsibilities as patient advocates. This article explores the extent to which characteristics of providers or their experiences with managed care practices predict the nature and extent of advocacy behavior. Interviews of 142 mental health providers revealed experiences of harmful utilization review and norms of professionalism significantly predicted advocacy behavior. However, providers who were concerned about disaffiliation were less likely to challenge the plan directly but more likely to alter their presentation of the case to reviewers. Providers who believe that manage care plans retaliate against advocacy behavior by deselection appear to substitute covert advocacy for direct advocacy. These results are preliminary but suggest that providers condition their advocacy behavior in response to their experiences with and perceptions of managed care plans.

A Brief Telephone Intervention Targeting Treatment Engagement from a Substance Abuse Program Wait List…288-303
Jefferson D. Parker, Ph.D., Cynthia L. Turk, Ph.D., and Lisa D. Busby, M.C.P.
ABSTRACT: This study compared three brief participant-initiated telephone interventions aimed at enhancing treatment engagement from an inpatient VAMC substance abuse treatment wait list. Policies requiring that wait list members call at least every other week in order to remain eligible for treatment remained in place for the standard and enhanced conditions but not the voluntary condition. The standard condition was a minimal intervention, providing information about the policies and structure of the treatment program. The enhanced condition focused on client motivation for treatment and recovery. The Voluntary condition required no contact with the clinic in order to remain on the wait list. If individuals in the voluntary condition called, they were provided information about current wait list number and approximate remaining wait time. The rate of treatment engagement was not different between treatment conditions. The best predictor of engagement was the number of calls placed to the program while waiting. Treatment condition was a positive predictor of call frequency; presence of a comorbid psychiatric diagnosis was a negative predictor. This article discusses future directions.

State Mental Hospitals and Their Host Communities: The Origins of Hostile Public Reactions…304-317
Nancy Wolff, Ph.D. and Jennifer Stuber, M.Phil.
Abstract: This article examines the hostile public reactions of a community that, through a state policy to consolidate all long-term behavioral health services, was to become the site of a state’s only mental hospital. A telephone survey conducted in the host community (N=800) and a matched community (N=800) was used to test whether the origins of hostility towards consolidation are related to the public’s negative attitudes towards mental illness and homelessness or to the beliefs about the discharge and supervisory behavior of the hospital. The host community was not found to have more negative views of mental illness, although it did have significantly more negative views about the homeless. Disapproval of consolidation was unrelated to negative views of mental illness or homelessness but was strongly related to the expected “bad” behavior of the hospital. These results suggest that the best way to improve relations between hospitals and their host communities is for hospitals to behave like “good” neighbors.

BRIEF REPORTS
Theoretical Basis and Program Design of a School Based Mental Health Intervention for Traumatized Immigrant Children: A Collaborative Research Partnership…318-326
Bradley D. Stein, M.D., M.P.H., Sheryl Kataoka, M.D., Lisa H. Jaycox, Ph.D., Marleen Wong, MSW, Arlene Fink, Ph.D., Pia Escudero, MSW, and Catalina Zaragoza, MSW
Abstract: This article describes a collaborative research model for school-based mental health services that targets recently immigrated children with violence-related mental health symptoms. The model describes a conceptual framework used in the establishment of an academic-community partnership in the development, evaluation, and implementation of the Mental Health for Immigrants Program (MHIP); a school-based mental health intervention. The article discusses challenges that occurred and provides specific examples of how a participatory research partnership may work together through all program phases -- from design through implementation and program evaluation-- to meet a specific community’s needs and produce generalizable knowledge. The challenges and limitations of collaborative research approaches also are discussed, with particular emphasis on the role of participatory research in the development and evaluation of school-based mental health programs.

Clients with Substance Abuse and Mental Health Concerns: A Guide for Conducting Intake Interviews…327-334
Christiane Brems, Ph.D., ABPP, Mark E. Johnson, Ph.D., and Lorraine L. Namyniuk, M.S.
Abstract: Although comorbidity (co-occurrence of a psychiatric and substance use disorder) is a common phenomenon at both mental health and substance abuse treatment agencies, rarely do such agencies thoroughly assess for both types of diagnoses during their standard intake interview. This article describes the development of an intake form designed to guide a comprehensive assessment of both mental health and substance abuse concerns. The form guides intake interviewers toward documenting administrative and demographic information, substance use and mental health concerns, and variables needed for compliance with grant funding sources. Use of the protocol can provide a clinical foundation for treatment planning and continuity of care for clients, while also providing error-free agency data that can be used for administrative, program planning, outcome assessment, and research purposes.

The Mental Healthcare Context and Patient Characteristics: Implications for Provider Job Satisfaction…335-344
C. Raymond Bingham, Ph.D., Marcia Valenstein, M.D., Frederic C. Blow, Ph.D. and, Jeffrey A. Alexander, Ph.D.
Abstract: This research examines job satisfaction among 282 staff providing mental healthcare to 574 patients with serious mental illness. The mental health staff worked in 18 Department of Veterans Affairs inpatient and outpatient mental healthcare units at 12 VA Medical Centers located across the contiguous 48 States. The purpose of this research was to identify (1) aspects of the healthcare context that were associated with provider job satisfaction, and (2) administrative and organizational procedures/interventions that might sustain or improve provider job satisfaction. The association of provider job satisfaction with patient’s functional status and symptom severity were tested in multi-level statistical models that accounted for provider and unit characteristics. Provider job satisfaction was found to be greater on smaller units and units with higher patient functioning and lower illness severity. Implications of these results are discussed.

The Relationship between Problem Severity and Ancillary Treatment Services: Is Substance Abuse Treatment Responsive To Client Need? …345-355
Stephen E. Asche, M.A. and Patricia A. Harrison, Ph.D.
Abstract: This study examines whether a greater self-reported problem severity at intake is associated with a greater likelihood of receiving related ancillary treatment services. The sample of 3,625 adult substance abuse treatment completers represents 162 outpatient and 41 short-term inpatient/residential programs located throughout the state of Minnesota. Problem severity and receipt of ancillary services were assessed in medical, psychological, family/social, employment, financial, and legal domains. Across treatment setting and client gender, individuals with higher problem severity were significantly more likely to receive related ancillary services in the areas of medical services, psychotropic medication, family/relationship counseling, financial services, and legal services. For other services examined, the positive association between problem severity and receipt of related ancillary services held for some but not all groups defined by treatment setting or gender. Despite consistent relationships between service need and receipt, large gaps remain with respect to programs’ responsiveness to client needs.

Number 4 / October 2002

REGULAR ARTICLES
The Prevalence and Management of Trauma in the Public Domain: An Agency and Clinician Perspective…365-380
Theresa Cea Hanson, PA-C, MSW, Mischie Hesselbrock, Ph.D., Sophie H. Tworkowski, MPH,LCSW and Suzanne Swan, Ph.D.
Abstract: This descriptive study surveyed the ways in which the needs of survivors of trauma have been addressed within the public mental health system in one sector of Connecticut. information was obtained about the prevalence of traumatic history among consumers, the existence of policy related to trauma, trauma screening and cross-referral mechanisms, and trauma-related supervision and education. The study maps current service system functioning related to the provision of trauma-specific services on both the agency and the clinician level. The study data indicate a need for service enhancement and increased service system collaboration and integration that will permit consumers to access a full range of trauma interventions. The data also indicate a need for increased clinician education and supervision specific to trauma both across agencies and among individual clinicians.

The Integration of Psychiatric Rehabilitation Services in Behavioral Health Care Structures: A State Example…381-393
Marsha Langer Ellison, Ph.D., William A. Anthony, Ph.D., John L. Sheets, M.S.W., M.P.H., William Dodds, M.S.E., William J. Barker, L.I.C.S.W., Joseph Massaro, Ph.D. and Nancy J. Wewiorski, Ph.D.
Abstract: 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.

Evaluating Mental Health Outcomes in an Inpatient Setting: Convergent and Divergent Validity of the OQ-45 and BASIS-32…394-404
Leonard A. Doerfler, Ph.D., Michael E. Addis, Ph.D. and Peter W. Moran, Ph.D.
Abstract: The evolution of managed behavioral health care has led to an increased emphasis on reliable and valid assessment of outcomes in clinical practice. The present study evaluated the convergent, divergent, and concurrent validity, and sensitivity to change of two widely used measures: the Behavior and Symptom Indetification Scale (BASIS-32) and Outcome Questionnaire (OQ-45). Comparisons of the two measures revealed that both were sensitive to change over a relatively short inpatient stay. Both measures also showed evidence of convergent and divergent validity of specific subscales, although the total scores of each measure were also highly correlated. Evidence of concurrent validity was suggested by differences between diagnostic groups on specific subscale scores. Together with previous research, these results suggest that the BASIS-32 and OQ-45 can be useful measures for tracking patient functioning over a range of treatment contexts.

Cohesion of the Primary Social Network and Sustained Service Use before the First Psychiatric Hospitalization…404-418
Normand Carpentier, Ph.D. and Deena White, Ph.D.
Abstract: This study analyzed the relationship between social network dynamics and initial help-seeking behaviors. The primary social network was reconstructed for the period beginning with the initial observation of unusual behaviors and ending with the first psychiatric hospitalization. The social network’s influence was analyzed based on the concept of social network cohesion, considering both structure and content of social ties. The results demonstrate that networks succeed more easily in referring the family member to services and in maintaining a clinical follow-up to the degree that they are cohesive. When a network lacks cohesiveness, the onset and development of problem behaviors are less easily recognized. These findings confirm the importance of social and interactional contexts in decision-making processes leading to utilization of psychiatric services and specify the roles they play.

The Resident Assessment Instrument-Mental Health (RAI-MH ): Inter-Rater Reliability and Convergent Validity…419-432
John P. Hirdes, Ph.D., Trevor F. Smith, Ph.D., Terry Rabinowitz, M.D., Keita Yamauchi, M.D., Edgardo Pérez M.D., Nancy Curtin Telegdi, R.N. M.A, Peter Prendergast, M.D., John N. Morris, Ph.D., Naoki Ikegami, M.D. Ph.D., Charles Phillips, Ph.D., and Brant E. Fries, Ph.D.
Abstract: An important challenge facing the rapidly changing sectors involved in behavioral health services is the lack of good quality, clinically relevant data at the individual level. The article describes a multinational research effort to develop a comprehensive, multidisciplinary mental health assessment system for use with adults in facilities providing acute, long-stay, forensic and geriatric services. The Resident Assessment Instrument-Mental Health (RAI-MH) comprehensively assesses psychiatric, social, environment and medical issues at intake, emphasizing patient functioning. Data from the RAI-MH are intended to support care-planning, quality improvement, outcome measurement and case-mix-based payment systems. The article provides the first set of evidence on the reliability and validity of the RAI-MH.

Linking Mental Health and Addiction Services: A Continuity-of-Care Team Model…433-444
Michael T. Lambert, M.D.
Abstract: Reorganization of mental health care delivery services at a Department of Veterans Affairs medical center addressed problems with the coordination of addiction treatment and mental health programming for patients with significant psychiatric and addiction comorbidity. Clinical services were organized into interdisciplinary continuity-of-care teams that follow their patients across different levels of care. The teams provide addiction treatment to dual diagnosis patients through “universally available” resources such as a partial hospital addiction rehabilitation module. Continuity of care remains within the team structure as clinicians follow patients throughout their rehabilitation course. Patient and staff satisfaction focus on improved accessibility of addiction services and continuity of care providers across time and levels of care. Overall inpatient utilization and recidivism decreased after model implementation.

Improving Access to Primary Health Care for Chronic Drug Users: An Innovative Systemic Intervention for Providers…445-457
H. Virginia McCoy, Ph.D., Sarah E. Messiah, MPH, and Wei Zhao, MD, MS
Abstract: An intervention was designed to improve access to primary care for chronic drug users (CDUs) by enhancing health care providers’ knowledge and skills. Using a case study method, three study sites were systematically selected for intervention implementation: a primary care clinic (PC), an emergency department (ED) and a drug treatment (DT) facility. Participants completed pre- and post-intervention tests of knowledge, skills and intentions to practice. Compared with pre-test scores, participants had significantly higher post-test scores concerning knowledge of CDU’s healthcare needs. Post-intervention evaluations indicated intentions to practice skills learned in the intervention. As hypothesized, the PC and ED instituted formal screening mechanisms to identify CDUs following the intervention. This intervention revealed encouraging potential to build bridges between health care providers and CDUs. By overcoming provider resistance, primary care access can be realized for CDUs and potentially for other disadvantaged populations.

BRIEF REPORTS
Self-Reported Lifetime Psychiatric Hospitalization Histories of Jail Detainees with Mental Disorders: Comparison with a Non-Incarcerated National Sample…458-465
William H. Fisher, Ph.D., Ira K. Packer, Ph.D., Steven M. Banks, Ph.D., David Smith, Ph.D., Lorna J. Simon, M.S. and Kristen Roy-Bujnowski, B.S.
Abstract: Lack of access to hospitalization is an often-cited risk factor for incarceration among persons with severe mental illness. This proposition is examined by comparing self-reports of lifetime psychiatric hospitalization histories of mentally ill jail inmates with data from a national sample of non-incarcerated mentally ill. Roughly 52% of mentally ill jail detainees reported at least one psychiatric hospitalization, a rate nearly three times that of the comparison group. The data call into question the notion that mental ill jail inmates have had reduced access to psychiatric inpatient treatment, without addressing adequacy of the treatment received. Longitudinal studies are needed to explore temporal relationships to better understand the relationship between mental health treatment and criminal justice involvement.

Home-Based Treatment, Rates of Ambulatory Follow-up, and Psychiatric Rehospitalization in a Medicaid Managed Care Population…466-475
Scott Frederick, Ph.D., Karen Caldwell, Ph.D., and Doris McGartland Rubio, Ph.D.
Abstract: This study reports on the effect of home based mental health treatment following psychiatric hospitalization on ambulatory follow-up rates and readmission rates in a Medicaid managed care population. Logistic regression models were used to predict the odds of ambulatory treatment after hospitalization and to predict rehospitalization. A consumer who received in-home treatment was 22 times more likely to follow-through with aftercare treatment of more than one visit than were those who did not receive in-home treatment. However, in-home treatment, age, gender and previous hospitalization did not significantly predict the odds of rehospitalization. While home-based services did not reduce the incidence of rehospitalization, providing services within the home has the potential to increase attendance in aftercare services by Medicaid managed care recipients.

Current Evaluation and Future Needs for a Mental Health Data Linkage System in a Remote Region: A Canadian Experience…476-480
Larry Squire, MA, Michel Bédard, PhD, Leslie Hegge, MSW and Vicki Polischuk, CCHRA (C)
Abstract: Linking client data across care sectors and agencies is becoming essential to ensure continuity of care, evaluation, and planning of mental health services delivery. The Data Linkage System (DLS), a record-linked, client-based, mental health database in northwestern Ontario, was established in response to this need. It is a voluntary system currently used by 30 of 40 mental health programs. The study surveyed program administrators to determine the system’s utilization, perceived value, and future needs regarding data collection. The survey results delineated the perceived usefulness of the DLS in a remote region. The findings will provide direction for continued development of the DLS.

The Influence of Patient Characteristics on Ratings of Managed Behavioral Health Care…481-489
Matthew J. Carlson, Ph.D., James A. Shaul, M.H.A., Susan V. Eisen, Ph.D. and Paul D. Cleary, Ph.D.
Abstract: Despite the current emphasis on consumer-based performance measures, little is known about factors that influence consumer ratings of behavioral health care. This study examines the influence of patient characteristics, health care use, and insurance coverage on patients’ ratings of their managed behavioral health care in both commercial and public plans. Older and healthier patients rated their behavioral health care and health plan more highly than other patients. Patients with less education and those whose insurance paid all the costs of care gave consistently higher plan ratings. Women and frequent users enrolled in commercial plans gave more positive care ratings. After adjusting for enrollee characteristics and coverage, there were no differences between ratings of patients in commercial and public plans. These results are consistent with other research that illustrates the importance of adjusting health care ratings for patient characteristics when comparing plans.

Frequent Visitors to Psychiatric Emergency Services: Staff Attitudes and Temporal Patterns…490-496
Cynthia L. Arfken, PhD, Lori Lackman Zeman, PhD, Lindsay Yeager, BA, Edward Mischel, MSW and Alireza, Amirsadri, MD
Abstract: Providing quality psychiatric emergency services is becoming more difficult as utilization rates soar, especially by individuals who are frequent visitors. To start addressing this issue, a staff survey and analysis of admission patterns were conducted. The staff was more likely to believe that frequent visitors sought care because they had difficulty accessing alternative services, had basic needs unmet, were substance abusers, wanted inpatient admission and were noncompliant with treatment plans than infrequent visitors. The 1999 temporal admission pattern documented that frequent visitors’ admissions were higher during the first week of the month and inclement weather. Surprisingly, the infrequent visitors’ admissions were also higher during the first week of the month. Together, these findings suggest that in this urban location frequent visitors are disadvantaged individuals lacking support and alternative treatment settings who utilize psychiatric emergency services to meet basic needs.