JBHSR Recent Issues

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

Volume 30, 2003

Number 1 / January 2003

REGULAR ARTICLES
State Substance Abuse and Mental Health Managed Care Evaluation Program…7-17
Dennis McCarty, PhD, Joan Dilonardo, PhD, and Milton Argeriou, PhD
Abstract: The article in this special section of the Journal of Behavioral Health Services & Research (30:1) present results from evaluations of publicly funded managed care initiatives for substance abuse and mental health treatment in Arizona, Iowa, Maryland, and Nebraska. The four managed care programs are outlined in this overview and results from the studies are summarized. The evaluations used administrative data and suggest a continuing challenge to structure plans so that undesired deleterious effects associated with adverse selection are minimized. Successful plans balanced risk with limited revenues so that they permitted greater access to less intensive services. Shifts from inpatient services to outpatient care were noted in most States. Future evaluations might conduct patient interviews to examine the effectiveness and quality of services for mental health and substance abuse problems more closely.

The Iowa Managed Substance Abuse Care Plan (IMSACP): Access, Utilization and Expenditures for Medicaid Recipients … 18-25
Dennis McCarty, PhD and Milton Argeriou, PhD
Abstract: The Iowa Managed Substance Abuse Care Plan (IMSACP) used a behavioral health care organization to manage expenditures for treatment of alcohol and drug dependence financed through Medicaid, the block grants, and state appropriations but maintained relatively distinct eligibility and benefit structures for Medicaid-eligible individuals. Medicaid claims, encounters and eligibility files were reviewed for 2 years before and 3 years after implementation of IMSACP to evaluate changes in access, utilization and expenditures. The rate of substance abuse treatment doubled, use of inpatient hospital services decreased, and residential and outpatient services increased. Direct care costs decreased, while total expenditures held steady. The Iowa experience suggests that a well-planned initiative can control costs and improve access and utilization.

How Did the Introduction of Managed Care for the Uninsured in Iowa Affect the Use of Substance Abuse Services?…26-40
Susan L. Ettner, PhD, Milton Argeriou, PhD, Dennis McCarty, PhD, Joan Dilonardo, PhD, and Hui Liu
Abstract: Concerns about access under managed care have been raised for vulnerable populations such as publicly funded patients with substance abuse problems. To estimate the effects of the Iowa Managed Substance Abuse Care Plan (IMSACP) on substance abuse service use by publicly funded patients, service use before and after IMSACP was compared; adjustments were made for changes in population sociodemographic and clinical characteristics. Between fiscal years 1994 and 1997, patient case mix was marked by a higher burden of illness and the use of inpatient, residential non-detox, outpatient counseling and assessment services declined, while use of intensive outpatient and residential detox services increased. Findings were similar among women, children and homeless persons. Thus, care moved away from high-cost inpatient settings to less costly venues. Without knowing the impact on treatment outcomes, these changes cannot be interpreted as improved provider efficiency versus simply cost containment and profit maximization.

The Impact of Managed Care on the Substance Abuse Treatment Patterns and Outcomes of Medicaid Beneficiaries: Maryland’s HealthChoice Program…41-62
Susan L. Ettner, PhD, Gabrielle Denmead, Joan Dilonardo, PhD, Hui Cao, BA, and Albert J. Belanger, MA
Abstract: The introduction of Medicaid managed care raises concern that profit motives lead to the undersupply of substance abuse (SA) services. To test effects of the Maryland Medicaid HealthChoice program on SA treatment patterns and outcomes, Medicaid eligibility files were linked to treatment provider records. Two study designs were used to estimate the impact of the HealthChoice program: a quasi-experimental design with matched comparison groups and a natural experiment. Patient sociodemographic and clinical characteristics were adjusted using multiple regressions. Under managed care, there was a shift from residential, correctional-only, and detoxification-only treatment toward outpatient care-only. Among beneficiaries entering treatment, those enrolled in an MCO had similar utilization and outcomes to those in Medicaid fee-for-service; those enrolling in MCOs during treatment episodes had longer and more intensive episodes and, as a result, better outcomes. Thus, the study disclosed no empirical evidence that health plans respond to capitation by reducing SA services.

Do Adjusted Clinical Groups Eliminate Incentives for HMOs to Avoid Substance Abusers? Evidence from the Maryland Medicaid HealthChoice Program…63-77
Susan L. Ettner, PhD and Steven Johnson, PhD
Abstract: The adequacy of risk adjustment to eliminate incentives for managed care organizations (MCOs) to avoid enrolling costly patients, such as those with substance disorders, has been questioned. This study explored systematic differences in expenditures between beneficiaries with and without substance disorders assigned to the same capitation rate group under Maryland Medicaid’s HealthChoice program. The investigators used fiscal year (FY) 1995 to 1997 Medicaid data to assign beneficiaries to rate cells based on FY 1995 diagnoses and compare the distribution of expenditures for beneficiaries with and without substance disorders, defined using FY 1997 and FY 1995 diagnoses. Results showed that differences in FY 1997 expenditures between beneficiaries with and without FY 1995 substance disorders were negligible. However, MCOs could expect greater average losses and lower average profits on beneficiaries with FY 1997 substance disorders. Thus, the adjusted clinical groups methodology used to adjust capitation payments in the HealthChoice program attenuated but did not eliminate financial incentives for MCOs to avoid substance abusers.

Evaluating Selection Out of Health Plans for Medicaid Beneficiaries with Substance Abuse…78-92
Sharon-Lise T. Normand, PhD, Albert J. Belanger, MA and Richard G. Frank, PhD
Abstract: In the absence of adequate risk adjustment, capitation for enrollees creates incentives for health plans to enroll and retain good risks and to avoid bad risks. This article examines whether Maryland Medicaid beneficiaries with histories of substance abuse disenroll from health plans more frequently than those without such histories. The findings indicate that enrollees with a history of substance abuse were more likely to switch plans than other enrollees, regardless of whether they chose the health plan or were randomly assigned to the plan. These results suggest that current risk adjustment systems may fail to offset selection incentives in modern capitated health plans.

The Nebraska Medicaid Managed Behavioral Health Care Initiative: Impacts on Utilization, Expenditures, and Quality of Care for Mental Health…93-108
Ellen Bouchery, MS and Henrick Harwood
Abstract: This study evaluates the impact of Nebraska’s Medicaid managed care program for behavioral health services on mental health service utilization, expenditures, and quality of care. Implementation of the program correlated with progressive reductions in both total (about 13 % over 3 years) and per eligible per month (20 %) expenditures and a rapid, extensive decline in inpatient utilization and admissions. The percentage of enrollees receiving any type of treatment for a mental disorder actually increased modestly. Most importantly, several indicators of quality of care (eg, timely receipt of ambulatory care following discharge from inpatient care and readmission to inpatient care shortly following discharge) suggest that quality of care did not materially change under the carve-out. Although a thorough assessment of quality of care impacts is warranted, this study suggests implementation of a managed care program may allow states to reduce Medicaid expenditures without compromising quality of care.

BRIEF REPORTS
The Impact of Evidence-Based Guideline Dissemination for the Assessment and Treatment of Major Depression in a Managed Behavioral Healthcare Organization…109-118
Francisca Azocar, PhD, Brian Cuffel, PhD, William Goldman, MD and Loren McCarter, PhD
Abstract: This study tests whether a managed behavioral health organization can influence adherence to practice guidelines for the treatment of major depression in a randomized trial of guideline dissemination. Guidelines were disseminated to mental health clinicians (N= 443) under one of three conditions: (1) a general mailing of guidelines to clinicians, (2) a mailing in which guidelines were targeted to a patient starting treatment with the clinician, and (3) no mailing of guidelines. The results showed no effects of guideline dissemination as measured by self-report of patients and clinicians and through episode characteristics derived from claims data, despite sentinel effects. Results also showed high rates of clinician-reported guideline adherence that were not detected in the claims data, indicating significant undertreatment of depression. Results suggest that mental health systems must look to other dissemination strategies to improve adherence to standards of care and raise the performance of independent practicing clinicians.

What proportion of failure to complete secondary school in the U.S. population is attributable to adolescent psychiatric disorder?…119-124
Ann Vander Stoep, PhD, Noel S. Weiss, MD, DrPH, Elena Saldanha, BS
And Patricia Cohen, PhD
Abstract: Using information available from the longitudinal Children in Community Study, population attributable risk percent was calculated to estimate the amount of failure to complete secondary school in the United States that is associated with adolescent psychiatric disorder. Over half of the adolescents in the U.S. who fail to complete their secondary education have a diagnosable psychiatric disorder. The proportion of failure to complete school that is attributable to psychiatric disorder is estimated to be 46%. School failure among young persons with psychiatric disorder exacts a large toll from individuals and society.

Case-Mix Adjustment of Adolescent Mental Health Treatment Outcomes…125-136
Susan D. Phillips, MSW, Teresa L. Kramer, PhD, Scott N. Compton, PhD, Barbara J. Burns, PhD, and James M. Robbins, PhD
Abstract: Case-mix adjustment methods are needed to account for differences between providers when the youth they treat have characteristics that adversely affect treatment success. This study explores variables for adjusting mental health treatment outcomes for adolescents and the differential effects of case-mix adjustment on providers’ performance. Linear regression modeling was used to identify case-mix variables for five outcomes. Predictive equations for each outcome were developed for models based on intake clinical data alone, clinical data plus administrative data, and clinical data plus data describing youth history and family environment. Variance explained by intake clinical data alone did not increase appreciably with the addition of administrative data or data describing youth history and family environment. Adjusting outcomes changed the relative performance of certain individual providers substantially, but had a more moderate impact on the overall interpretation of providers’ performance.

Number 2 / October 2003

REGULAR ARTICLES
Trends in Acute Mental Health Care: Comparing Psychiatric and Substance Abuse Treatment Programs…145-160
Christine Timko, PhD, Michelle Lesar, BA, Noël J. Calvi, EdM, and Rudolf H. Moos, PhD
Abstract: This study compared psychiatric and substance abuse acute care programs, within both inpatient and residential modalities of care, on organization and staffing, clinical management practices and policies, and services and activities. A total of 412 (95% of those eligible) Department of Veterans Affairs’ programs were surveyed nationwide. Some 40% to 50% of patients in psychiatric and substance abuse programs, in both inpatient and residential venues of care, had dual diagnoses. Even though psychiatric programs had a sicker patient population, they provided fewer services, including basic components of integrated programs, than substance abuse programs did. Findings also showed that there is a strong emphasis on the use of clinical practice guidelines, performance monitoring, and obtaining client satisfaction and outcome data in mental health programs. The authors suggest how psychiatric programs might better meet the needs of acutely ill and dually diagnosed patients (e.g., by incorporating former patients as role models and mutual help groups, as substance abuse programs do; and by having policies that balance patient choice with program demand).

Managed Care and Access to Substance Abuse Treatment Services…161-175
Jeffrey A. Alexander, PhD, Tammie A. Nahra, PhD and John R.C. Wheeler, PhD
Abstract: Using nationally representative data from 1995 and 2000, this study examined how managed care penetration and other organizational characteristics were related to accessibility to outpatient substance abuse treatment. At an organizational level, access was measured as the percentage of clients unable to pay for services; the percentage of clients receiving a reduced fee; and the percentage of clients with shortened treatment because of their inability of pay. Treatment units with both relatively low and relatively high managed care penetration were more likely to support access to care; these units provided care to higher percentages of clients unable to pay and were less likely to shorten treatment because of client inability to pay. Treatment units with mid-range managed care penetration were least likely to support access to care. The complexity of managing in an environment of conflicting incentives may reduce the organization’s ability to serve those with limited financial means.

Barriers to Detection, Help-Seeking and Service Use for Children with ADHD Symptoms…176-189
Regina Bussing, MD, MSHS, Bonnie T. Zima, MD, MPH, Faye A. Gary, EdD, RN, and Cynthia Wilson Garvan, PhD
Abstract: This study describes four help-seeking steps among children at high risk for ADHD, and identifies barriers to ADHD symptom detection and treatment. Using a district-wide stratified random sample of 1,615 elementary school students screened for ADHD risk, predictors of four help-seeking steps among a high-risk group (n=389) and parent-identified barriers to care among children with unmet need for ADHD care (n=91) were assessed. Study findings indicate that although 88% of children were recognized as having a problem, only 39% had been evaluated, 32% received an ADHD diagnosis, and 23% received current treatment. Older children and those with more severe behavior problems were more likely to be perceived by their parents as having a problem. Additionally, gender and ethnic disparities in the subsequent help seeking process emerged. Boys had over 5 times the odds than girls of receiving an evaluation, an ADHD diagnosis and treatment. Compared to African American youth, Caucasian children had twice the odds of taking these help-seeking steps. For those children with unmet need for ADHD care, poverty predicted lower treatment rates and was associated with the most pervasive barriers. The gap between parental problem recognition and seeking services suggests that thresholds for parental recognition of a child behavior problem and for seeking ADHD services may be different. Future research examining the help-seeking process for ADHD should include a qualitative component to explore the potential mechanisms for gender and ethnic differences.

Factors Associated with Adolescents’ Receiving Drug Treatment: Findings from the National Household Survey on Drug Abuse…190-201
Ping Wu, PhD, Christina W. Hoven, DrPH, and Cordelia J. Fuller, MA
Abstract: This article examines factors associated with adolescents’ receiving treatment for drug related problems. Data on adolescents (aged 12-17) from the 1995 and 1996 National Household Survey on Drug Abuse (NHSDA, N=9,133) were used. Information was obtained concerning adolescent drug use, smoking, drinking and related problems, as well as socio-demographics. Many adolescents with drug related problems did not receive treatment. Among predisposing factors, gender and age were associated with drug treatment. Severity of drug problems and comorbid emotional and health problems also predicted seeking treatment. The results call for an improved service delivery system. Screening for drug problems in primary care settings, at school and in mental health programs will help in the early identification and treatment of drug use disorders in youth.

Continuity of Care and Clinical Effectiveness: Treatment of Posttraumatic Stress Disorder in the Department of Veterans Affairs…202-214
Greg A. Greenberg, PhD, Robert A. Rosenheck, MD, and Alan Fontana, PhD
Abstract: Evaluation of the quality of outpatient treatment for patients with severe psychiatric or addictive disorders has often focused on the assessment of continuity of care (COC) as measured with administrative data. However, there has been little empirical evaluation of the relationship of measures of COC and treatment outcomes. This study used hierarchical linear modeling to examine the relationship between six indicators of COC and six outcome measures in a multi-site monitoring effort for veterans with war related posttraumatic stress disorder. There were few consistently significant associations between COC and outcome measures. Although measures of COC at the level of individual patients was associated with reductions in substance abuse symptoms, when COC measures were averaged to the site level and examined with hierarchical linear models, thereby reducing the impact of intra-site selection bias, they were not associated with any desired outcomes. COC measures, at least in the sample used for this study, are not consistently associated with desirable client outcomes and may therefore be less than ideal performance measures in outcome evaluations following inpatient treatment, except to the extent that COC is considered to be an intrinsic indicator of higher quality regardless of its relationship to outcomes.

Case Finding and Mental Health Services for Children in the Aftermath of the Oklahoma City Bombing…215-227
Betty Pfefferbaum, MD, JD, Guy M. Sconzo, PhD, Brian W. Flynn, EdD, Lauri J. Kearns, MD, Debby E. Doughty, PhD, Robin H. Gurwitch, PhD, Sara Jo Nixon, PhD and Shajitha Nawaz, MD
Abstract: The 1995 Oklahoma City bombing killed 168 people, including 19 children, and injured hundreds more. Children were a major focus of concern in the mental health response. Most services for them were delivered in the Oklahoma City Public Schools (OCPS) where approximately 40,000 students were enrolled at the time of the explosion. Middle and high school students in the OCPS completed a clinical assessment seven weeks after the explosion. The responses of 2720 students were analyzed to explore predictors of posttraumatic stress symptomatology, functioning, and treatment contact. Posttraumatic stress symptomatology was associated with initial reaction to the incident and to bomb-related television exposure. Functional difficulty was associated with initial reaction and posttraumatic stress symptomatology. Only 5% of the students surveyed had received counseling. There was no relationship between posttraumatic stress symptomatology and counseling contact for students with the highest levels of posttraumatic stress. Implications for school-based services are discussed.

BRIEF REPORTS
Children’s Use of Mental Health Services in Different Medicaid Insurance Plans…228-237
David S. Mandell, ScD, Roger A. Boothroyd, PhD, and Paul G. Stiles, JD, PhD
Abstract: This study examined the effect of different Medicaid insurance plans on children’s mental health service use through survey, claims and encounter data collected between February 1998 and February 1999. Participants were assigned to one of three insurance plans: fee-for-service (FFS), an HMO, and a pre-paid carve-out. Logistic and stratified logistic regression were used to examine the effect of plan on service utilization, adjusting for caregiver report of need for services and psychosocial functioning. There was no difference in service use by plan controlling for demographic characteristics; however when psychopathology and caregiver report of need for services were included in the model, the odds of using services in the HMO was half of and the odds in the carve-out 29% less than the odds of using services in FFS. Characteristics of the interaction between need, psychopathology and insurance plan that may be associated with the reduction in service use are discussed.

Levels of Substance Use and Willingness to Use the Employee Assistance Program…238-248
G. Shawn Reynolds, MS, and Wayne E. K. Lehman, PhD
Abstract: Individuals with drinking and drug problems may become particularly reluctant to seek help. To remove barriers to services more needs to be understood about factors that influence help-seeking decisions. It was hypothesized that certain social psychological influences (attitudes, group cohesion, trust in management) might buffer a reluctance to use services provided by an external Employee Assistance Program (EAP). A random sampling of municipal employees (n = 793) completed anonymous questionnaires that assessed willingness to use the EAP, individual drinking and drug use, attitudes toward policy, work group cohesion, and trust in management. Data from the questionnaires were analyzed with multivariate regression analyses to examine the interacting effects of substance abuse and proposed moderators (gender, race, awareness of the EAP, perceptions of policy, cohesion) on willingness to use the EAP. The results demonstrated that although substance abusers were less willing to use the EAP than were non-users, substance abusers who were aware of the EAP, who had favorable attitudes toward policy, and who did not tolerate coworker substance abuse were as willing to use the EAP as were non-users. The results also showed that employees with greater awareness of the EAP, support for policy, and perceptions of work group cohesion reported significantly greater willingness to use the EAP than did employees with relatively less awareness of the EAP, policy support, and cohesion. Workplace prevention efforts that are designed to increase the use of EAP services should intentionally target the workplace environment and social context. Creating the awareness and favorability of the EAP, policy, and work group cohesion might buffer substance abusers’ reluctance to seek help.

Number 3 / October 2003

REGULAR ARTICLES
Implementing psychiatric advance directives: Service Provider Issues and Answers…253-268
Debra Srebnik, PhD and Lisa Brodoff, JD
Abstract: Psychiatric advance directives (PADs) are an emerging method for adults with serious and persistent mental illness to document treatment preferences in advance of periods of incapacity. This paper presents and responds to issues most frequently raised by service providers when planning for implementation of PADs. Issues discussed include: access to PADs; competency to execute PADs; the relationship of PADs to standards of care, resource availability, and involuntary treatment; roles of service providers and others in execution of PADs; timeliness and redundancy of PAD information; consumer expectations of PADs; complexity of PADs; revocation and "activation"; legal enforceability of PADs; the role and powers of agents; liability for honoring and not honoring PADs; and use of PADs to consent for release of health care information. Recommendations are made for training staff and consumers, consideration of statute development, and methods to reduce logistical, attitudinal, and system barriers to effective use of PADs.

Variability in Community Functioning of Mothers with Serious Mental Illness…269-289
Deborah Bybee, PhD, Carol T. Mowbray, PhD, Daphna Oyserman, PhD, and Lisa Lewandowski, PhD
Abstract: In the post-deinstitutionalization era, everyday community functioning is an important aspect of assessment and treatment of individuals with serious mental illness. The current study focuses on correlates of community functioning among 332 low-income mothers with serious mental illness. Results revealed significant relationships between everyday functioning and a number of demographic, psychiatric, contextual, and mental health treatment variables. Current psychiatric symptoms accounted for the greatest amount of variance and completely mediated the effects of diagnosis and substance abuse history on community functioning; yet contextual variables such as financial worries and social support were also significant predictors, even after controlling for symptoms and other clinical characteristics. Additionally, use of mental health services was a significant moderator of the effect of social stress on community functioning. Implications of results for future research and practice are discussed.

The Long-term Outcomes of Drug Use by Methadone Maintenance Patients
Gregory Bovasso, PhD and John Cacciola, PhD
Abstract: The aim of the study is to predict long-term outcomes of Methadone Maintenance (MM), other than continued heroin use based on drug use occurring early in MM treatment. In previous research, the weak association of initial drug use during MM with measures of rehabilitation status may be due to the use of measures that do not differentiate trends in different types of drug use. In the present study, 222 patients who completed six months of MM were assessed at program intake, evaluated for opiates and cocaine in the first six months of treatment, and given a follow up assessment two years after treatment entry. The intake status of the patients was assessed using the Addiction Severity Index. Opiate and cocaine use during the first six months of MM was assessed by urine toxicology. Outcomes were assessed using a structured interview and official criminal records at follow-up. Cluster analysis of urine toxicologies during treatment identified three trajectory classes of MM patients: A) variably high levels of opiate use, but consistently low cocaine use, B) low and diminishing opiate and cocaine use, and C) consistently high cocaine use, with diminishing opiate use. In an 18-month period, after these trends were observed, Cluster C had significantly more criminal charges than Cluster B (three times as many), but not significantly more than Cluster A. Clusters A and B did not differ significantly in criminal charges. Regardless of cluster membership, subjects with increasing levels of cocaine use in the first six months of MM had more hospitalizations for drug and alcohol problems during the follow up period than subjects without increasing levels of cocaine use. The results provide evidence of negative sequelae of cocaine use during MM that underscore the importance of clinical efforts to reduce levels of cocaine and other non-opiate drug use by MM patients.

Is it ACT Yet? Real-World Examples of Evaluating the Degree of Implementation for Assertive Community Treatment…304-320
Michelle P. Salyers, PhD, Gary R. Bond, PhD, Gregory B. Teague, PhD, Judith F. Cox, MA, Mary E. Smith, PhD, Mary Lou Hicks, MA, and Jennifer I. Koop, MS
Abstract: Despite growing interest in assessment of program implementation, little is known about the best way to evaluate whether a particular program has implemented the intended service to a level that is minimally acceptable to a funding source, such as a state mental health authority. Such is the case for assertive community treatment (ACT), an evidence-based practice being widely disseminated. Using an exploratory, actuarial approach to defining program standards, this study applies different statistical criteria for determining whether or not a program meets ACT standards using the 28-item Dartmouth Assertive Community Treatment Scale (DACTS). The sample consists of 51 ACT programs, 25 Intensive Case Management Programs, and 11 Brokered case management programs to identify levels of fidelity that discriminated between programs, but were still attainable by the majority of ACT programs. A grading system based on mean total score for a reduced set of 21 items appeared to be most attainable, but still discriminated ACT programs from other forms of case management. Implications for setting and evaluating ACT program standards are discussed.

Chronic Drug Use and Reproductive Health Care Among Low-Income Women in Miami, Florida: A Comparative Study of Access, Need, and Utilization…321-331
Lee A. Crandall, PhD, Lisa R. Metsch, PhD, Clyde B. McCoy, PhD, Dale D. Chitwood, PhD and Hayley Tobias, BA
Abstract: Interviews of low-income women in Miami, Fl, addressed reproductive health issues in a stratified, network-referred sample of chronic drug users (CDUs) and socially and ethnically similar women who were not CDUs. Women who were not CDUs were significantly more likely to report a regular source of health care than CDUs. About one third of each group reported experiencing reproductive health problems (other than pregnancy) in the 12 months preceding their interview. Chronic drug users were twice as likely to report that these problems remained untreated. Measures of use of preventive services (physical exam, breast exam, pelvic exam, family planning visit) consistently showed lower use by CDUs. A higher proportion of women who were not CDUs reported pregnancies in the 12 months preceding interview. The 32 pregnant CDUs were much less likely to have received prenatal care than the 42 pregnant women who were not CDUs. For women who reported a pregnancy in the year preceding interview, logistic regression analysis showed a strong and robust negative effect of being a CDU on receiving prenatal care even when the effects of having a usual source of care and having third-party coverage were controlled.

BRIEF REPORTS
Trends in Elderly Patients’ Office Visits for the Treatment of Depression According to Physician Specialty: 1985-1999…332-341
Jeffrey S. Harman, PhD, Stephen Crystal, PhD, James Walkup, PhD, and Mark Olfson, MD, MPH
Abstract: Changes from 1985 to1999 in diagnosis of depression and prescription of antidepressant medications during visits by elderly patients to primary care physicians, psychiatrists, and other specialists were examined. Using nationally representative surveys of office-based practices, estimates of the proportion of office visits by elderly patients during which a physician diagnosed depression or prescribed an antidepressant medication were obtained. Between 1985 and 1993-1994, a significant increase in the rate of depression diagnosis was seen, but no change was observed between 1993-1994 and 1998-1999. Rates of prescribing of antidepressants more than doubled between 1985 and 1998-1999. The majority of depression visits and visits where an antidepressant was prescribed were to primary care physicians in all time periods examined. Primary care depression treatment initiatives should place greater emphasis on elderly patients.

Predicting Rehospitalization and Outpatient Services From Administration and Clinical Databases…342-351
Michael S. Hendryx, PhD, Joan E. Russo, PhD, Bruce Stegner, PhD, Dennis G. Dyck, PhD, Richard K. Ries, MD and Peter Roy-Byrne, MD
Abstract: The study tests whether psychiatric services utilization may be predicted from administrative databases without clinical variables equally as well as from databases with clinical variables. Persons with a psychiatric hospitalization at an urban medical center were followed for 1 year postdischarge (N = 1384.) Dependent variables included statewide rehospitalization and the number of hours of outpatient services received. Three linear and logistic regression models were developed and cross-validated: a basic model with limited administrative independent variables, an intermediate model with diagnostic and limited clinical indicators, and a full model containing additional clinical predictors. For rehospitalization, the clinical cross-validated model accounted for twice the variance accounted by the basic model (adjusted R2 = .13 and .06, respectively). For outpatient hours, the basic cross-validated model performed as well as the clinical model (adjusted R2 = .36 and .34, respectively.) Clinical indicators such as assessment of functioning and co-occurring substance use disorder should be considered for inclusion in predicting rehospitalization.

Assessing the Wraparound Process During Family Planning Meetings…352-362
Michael H. Epstein, EdD, Philip D. Nordness, MA, Krista Kutash, PhD, Al Duchnowski, PhD, Sheryl Schrepf, MSW, Greg Benner, MEd, and J. Ron Nelson, PhD
Abstract: Research and evaluation of the wraparound process has typically focused on outcomes, service providers, and costs. While many of these studies describe a process that is consistent with the wraparound approach, few studies have reported attempts to monitor or measure the treatment fidelity of the wraparound process. The purpose of this study was to assess the fidelity of the wraparound process in a community-based system of care using the Wraparound Observation Form-Second Version. Results from 112 family planning meetings indicated some strengths and weaknesses within the current system. Families and professionals were frequently involved in the planning and implementation of the wraparound process. However, informal supports and natural family supports were not present in a majority of the meetings. Given the significant number of youth served in wraparound programs, the benefits of using the Wraparound Observation Form-Second Version as an instrument to monitor the fidelity of the wraparound approach should not be ignored.

Number 4 / October 2003

REGULAR ARTICLES
Changes in Managed Care Activity in Outpatient Substance Abuse Treatment Organizations, 1995-2000…369-381
Jeffrey A. Alexander, PhD, Christy Harris Lemak, PhD, and Cynthia Campbell, MPH
Abstract: Using nationally representative data from 1995 and 2000, this study examines trends in managed care penetration and activity among outpatient drug treatment organizations in the United States. Further, it investigates how managed care activity varies across different types of treatment providers and for public and private managed care programs. Overall, managed care activity has increased with a greater proportion of units having managed care arrangements and a larger percentage of clients covered by managed care. In general, public managed care activity has increased and private managed care activity has decreased. Treatment providers report that they have fewer managed care arrangements, which may reflect consolidation in the managed behavioral care sector. Finally, growth in managed care among outpatient substance abuse treatment units affiliated with hospitals and mental health centers may signal a preference for providers that can effectively link substance abuse treatment with medical and social service provision, or, alternatively, that linkages with such organizations may provide the size necessary to assume the risks associated with managed care contracts.

The Relationship Between School Characteristics and the Availability of Mental Health and Related Health Services in Middle and High Schools in the US…382-392
Eric Slade, PhD
Abstract: Problems related to mental illness are increasingly becoming the focal point of public concern over the safety and performance of schools, yet little is known about the availability and quality of school-based mental health services in the United States. In this article it is estimated that approximately 50% of US middle and high schools have any mental health counseling services available onsite and approximately 11% have mental health counseling, physical examinations, and substance abuse counseling available on-site. There are substantial differences in mental health counseling availability by region, urbanicity, and school size, with rural schools, schools in the Midwest and South regions, and small schools being least likely to offer mental health counseling. Multivariate estimates suggest that disparities between schools in the availability of mental health counseling and related health services may be partly explained by differences in access to Medicaid for financing of health services provided at school.

Clinicians and Outcome Measurement: What’s the Use?
Ann F. Garland, PhD, Marc Kruse, BA, and Gregory A. Aarons, PhD
Abstract: The goal of this study was to learn more about clinicians’ experiences with, and perceptions of the utility, validity, and feasibility of standardized outcome measures in practice. Fifty randomly selected clinicians from multiple disciplines and multiple service agencies in a large children’s public mental health service system were interviewed individually (n=30) or in focus groups (n=20) using semistructured interviews. There was great variability across clinicians in attitudes about empirical methods of treatment evaluation. There was consensus regarding feasibility challenges of administering standardized measures, including time burden and literacy barriers. Although all participants had received scored assessment profiles for their clients, the vast majority reported that they did not use the scores in treatment planning or monitoring. Their suggestions for improved clinical utility of outcome measurement are included. With increased attention and resources devoted to performance outcome assessment, it is concerning that most clinicians perceive little clinical utility of outcome measurement.

Length of Stay for Psychiatric Inpatient Services: A Comparison of Admissions of People With and Without Developmental Disabilities…406-417
Haider Saeed, MSc, H´el`ene Ouellette-Kuntz, MSc, Heather Stuart, PhD, and Philip Burge, MSW
Abstract: This study investigated associations between the presence of developmental disabilities and length of inpatient stay for mental health care. All psychiatric admissions of people with developmental disabilities over a 5-year period were selected (n=294), and were compared using survival analysis to a random sample of admissions from the general psychiatric population (n = 287). Overall, people with developmental disabilities stayed in hospital longer than those without developmental disabilities, and this extra stay was partially attributed to casemix differences between the cohorts. Subanalyses in both cohorts showed that those going back to their usual living arrangement stayed a shorter period than those who were discharged elsewhere, and that people with developmental disabilities were less likely to be discharged to their usual living arrangement than were people without the disability. This study highlighted the importance of specialized residential and personal supports for people with developmental disabilities and a coexisting mental disorder.

Mental Health Case Management as a Locus for HIV Prevention: Results From Case-Manager Focus Groups…418-433
John A. Encandela, PhD, Wynne S. Korr, PhD, Kathleen Hulton, MPH, Gary F. Koeske, PhD, W. D. Klinkenberg, PhD, Laura L. Otto-Salaj, PhD, Anthony J. Silvestre, LSW, PhD, and Eric R. Wright, PhD
Abstract: HIV infection among people with severe mental illness (SMI) is a growing concern, and interventions have been designed to address HIV prevention among these individuals. However, little is known about the preparedness of mental health providers to support these interventions. This study concentrated on mental health case management as a locus for HIV-prevention services. Focus groups of case managers were conducted to learn participants’ motivation to adopt HIV-prevention services and barriers/facilitators to such adoption. Participants reported they would be motivated to offer HIV prevention if services were to be presented in the context of existing client relationships and case-management tasks. Barriers and facilitators were discussed at client, provider, and community levels, and recommendations for training were offered. Findings have implications for diffusion of HIV-prevention services in case management, and the line of questioning in focus groups provides a basis for learning about other behavioral health service contexts as loci for disease prevention.

National Spending on Mental Health and Substance Abuse Treatment by Age of Clients, 1997…433-443
Henrick J. Harwood, Tami L. Mark, PhD, David R. McKusick, PhD, Rosanna M. Coffey, PhD, Edward C. King, and James S. Genuardi
Abstract: This article examines 1997 national expenditures on mental health and substance abuse (MH/SA) treatment by 3 major age groups: 0–17, 18–64, and 65 and older. Of the total $82.4 billion in MH/SA expenditures, 13% went to children, 72% to adults, and 15% to older adults. MH/SA treatment expenditures made up 9% of total health care expenditures on children, 11% of total health care expenditures on adults, and 3% of total health care expenditures on older adults. Across the 3 age groups, distinct differences emerged in the distribution of MH/SA expenditures by provider-type. For example, about 85% of spending for youth was for specialty MH/SA providers, compared to 76% for adults and 51% for older adults. In addition, 33% of MH/SA spending for older adults went to nursing home care, while other age groups had almost no expenditures in nursing homes. Age specific estimates enable policymakers, providers, and researchers to design programs and studies more appropriately tailored to specific age groups.

BRIEF REPORTS
Medical Versus Nonmedical Mental Health Referral: Clinical Decision-Making by Telephone Access Center Staff…444-451  Myron L. Pulier, MD, Donald S. Ciccone, PhD, Cherie Castellano, MA, CSW, Karen Marcus, LCSW, and Steven J. Schleifer, MD
Abstract: A database review investigated decisions of clinicians staffing a university-based telephone access center in referring new adult patients to nonpsychiatrists versus psychiatrists for initial ambulatory behavioral health care appointments. Systematically collected demographic and clinical data in a computer log of calls to highly trained care managers at the access center had limited predictive value with respect to their referral decisions. Furthermore, while 28% of the 610 study patients were initially referred to psychiatrists, billing data revealed that in-person therapists soon cross-referred at least 20% more to a psychiatrist. Care managers sent 56% of callers already taking psychotropic medications to nonpsychiatrists, 51% of whom were then cross-referred to psychiatrists. Predictive algorithms showed no potential to enhance efficiency of decisions about referral to a psychiatrist versus a nonpsychiatrist. Efforts to enhance such efficiency may not be cost-effective. It may be more fiscally efficient to assign less-experienced personnel as telephone care managers.

Child Functioning in Rural and Nonrural Areas: How Does It Compare When Using the Service Program Site as the Level of Analysis?…452-461
Christine Walrath, PhD, Richard Miech, PhD, E. Wayne Holden, PhD, Brigitte Manteuffel, PhD, Rolando Santiago, PhD, and Philip Leaf, PhD
Abstract: The current study uses data from the national evaluation of the Comprehensive Communities Mental Health Services for Children and Their Families Program to examine child functioning in rural (n=8) as compared to nonrural (n=18) system of care communities across the United States. In this study, the topic of rural versus nonrural differences is approached from a community-level perspective with aggregated functional impairment scores as the dependent variable of interest in weighted least squares regression. The demographic characteristics of children, particularly age, were more important predictors of functional impairment than geographic locale (ie, rural vs nonrural). Specifically, while children served in nonrural communities were older than those served in rural communities, after controlling for this difference functional impairment levels were similar. It appears from these analyses that youth served in rural and nonrural communities with systems of care were more similar than they were different with regard to their level of functional impairment. This lack of aggregate functional difference between the rural and nonrural sites reminds policymakers and funding agents that youth in rural areas need equity in both access and resource for mental health services. As indicated by the findings in the current investigation youth in rural areas are not immune to the types of mental health challenges often publicized by researchers examining youth in nonrural areas.

Agreement Between CASA Parent Reports and Provider Records of Children’s ADHD Services…462-470
Regina Bussing, MD, MSHS, Dana M. Mason, BS, Christina E. Leon, BS, and Karabi Sinha, MStat
Abstract: This study examines agreement between parental reports of children’s ADHD outpatient services ascertained with the Child and Adolescents Services Assessment (CASA) and provider records among a sample of elementary school students who participated in an epidemiologically based health services study. Parental reports of any outpatient mental health treatment, services intensity, and medication regimens were compared to records of the specified mental health and primary care providers using intraclass correlations and kappa estimates. Results indicated that parental reports using the CASA produced valid data on whether any outpatient ADHD services had been received in the past 12 months (83% agreement), and on details of the child’s medication regimens (kappas above 0.90), but that agreement was poor on how many times the child had been seen (intraclass correlation 0.29), without agreement differences by provider type. These findings support the validity of using parental report for ADHD services in primary care settings and for study of medication regimens.