JBHSR Recent Issues

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

Volume 32, 2004

Number 1 / January 2004

REGULAR ARTICLES
Psychiatric Service Utilization and Cost for Persons with Schizophrenia in a Medicaid Managed Care Program . . . 1-12
Aileen B. Rothbard, ScD, Eri Kuno, PhD, Trevor R. Hadley, PhD, Judith Dogin, MD
Abstract:
A pre-post study design was used to look at changes in behavioral health care services and costs for Medicaid-eligible individuals with schizophrenia in a managed care carve out compared to a FFS program in Pennsylvania between 1995 and 1998. Statistically significant reductions of 59% were found in hospital expenditures in the managed care program compared to 18.3% in the FFS program. The decline in hospital costs was due to dramatic fee reductions in the managed care site. No significant differences in overall ambulatory utilization was found in either program, however, ambulatory expenditures rose 57% in the managed care program versus a decline of 11% in fee for service. The ambulatory cost increase resulted from a cost shift between county block grant funds and Medicaid funds with no additional revenues provided to outpatient providers. Study implications are that cost reductions from MC are mainly due to reducing utilization and payments to hospitals, similar to the findings for private sector programs.

Identifying Factors Critical to Implementation of Integrated Mental Health Services in Rural VA Community-Based Outpatient Clinics . . .13-25
JoAnn E. Kirchner, MD, Marisue Cody, RN, PhD, Carol R. Thrush, MA, Greer Sullivan, MD, MSPH, and Carla Gene Rapp, RN, CRRN, PhD
Abstract:
The purpose of this study was to gain a better understanding of the critical components associated with implementing integrated mental health care services in rural VA community-based outpatient clinics (CBOCs). In-person semi-structured interviews were conducted with 20 health care providers and staff within a year after placing a trained Advanced Practice Nurse (APN) to provide mental health/substance abuse (MH/SA) care at two rural CBOCs in the southeastern U.S. Four raters independently evaluated interview transcripts and conducted content analysis to summarize the interview results. The results indicate that key contextual factors related to leadership, staff attitudes and beliefs, and unique organizational factors of the clinic and the community can affect the success of such clinical innovations. In addition to providing descriptive information about the attitudes, beliefs and experiences of CBOC personnel regarding implementation of integrated MH/SA services using APNs, the study findings suggest several domains that could be explored in future studies of integrated mental health service delivery to rural veterans through primary care.

Patterns of Medical Resource and Psychotropic Medicine Use among Adult Depressed Managed Behavioral Health Patients . . . 26-37
Francis Azocar, PhD, Loren M. McCarter, PhD, Brian J. Cuffel, PhD, and Thomas W. Croghan, MD
Abstract:
Medical and pharmacy utilization patterns were examined among 782 depressed patients seen by independent clinicians through a Managed Behavioral Health Organization using behavioral, medical and pharmacy claims spanning two years. Two-thirds received psychiatric care in the medical and mental health sector concurrently, 43% had comorbid medical disorders, 61% received psychotropic medications, and 54% were on antidepressants. Fewer depressed medically comorbid patients used medical services while in mental health treatment than before or after treatment, while the per patient costs remained the same. For those with chronic conditions, medical utilization and costs remained the same. A quarter of depressed patients received mental health treatment before seeing a mental health specialist, and a quarter remained in treatment in the medical sector after treatment in the mental health sector. Despite increases in mental health services access made available through managed behavioral health organizations, patients continue receiving mental health treatment in the medical sector.

Perceptions of Mental Health and Substance Abuse Program Administrators and Staff on Service Delivery to Persons with Co-occurring Substance Abuse and Mental Health Disorders . . . 38-49
Christine E. Grella, PhD, Virginia Gil-Rivas, MA, and Leslie Cooper, PhD
Abstract:
Several initiatives in the past 20 years have been implemented in Los Angeles County to improve service delivery across the mental health and substance abuse treatment systems, with the goal of increasing access to and coordination of services for individuals with co-occurring substance abuse and mental disorders. To examine the current status of service delivery to this population, a survey was conducted with administrators of mental health and substance abuse programs that provide services to dually diagnosed patients and with the treatment staff in those programs. Administrators (n = 15) and staff (n = 99) in substance abuse programs rated the accessibility and coordination of services to dually diagnosed patients significantly lower than the mental health administrators (n = 10) and staff (n = 136). Efforts to coordinate service delivery across the two systems need to address these divergent perceptions between staff in programs that are increasingly called upon to work together to jointly deliver services.

The Sensitivity of Substance Abuse Treatment Intensity to Copayment Levels . . . 50-65
Anthony T. Lo Sasso, PhD, and John S. Lyons, PhD
Abstract:
This study exploits variation in copayment levels among different contractual arrangements within a regional managed behavioral healthcare organization to estimate the relationship between copayment levels for substance use treatment services and the intensity of substance use treatment. The substance use treatment benefits involved a range of copayment levels across nearly 400 employers during the years 1993 through 1998. Multiple regression techniques were used to estimate the effect of copayment levels on treatment intensity. The results indicate that copayment levels had a significant negative effect on outpatient and inpatient substance use treatment. For outpatient treatment the effect on intensity implied a copayment elasticity of -0.18, implying that moving from a $10 copayment to a $20 copayment would result in, for example, a reduction from 5 to 4 outpatient visits per episode. However, the effect was larger for persons with combined alcohol and drug use disorders, as they exhibited a copayment elasticity of -0.27. For inpatient days, the copayment elasticity was considerably smaller at -0.017. Given the benefits of maintaining persons with substance use disorders in treatment, employers may have an incentive to take steps to minimize the barriers to treatment.

BRIEF REPORTS
Profiling Hospitals for Length of Stay for Treatment of Psychiatric Disorders . . . 66-74
Jeffery S. Harman, PhD, Brian J. Cuffel, PhD, and Kelly J. Kelleher, MD, MPH
Abstract:
Managed behavioral healthcare organizations (MBHOs) often profile hospitals on length of stay (LOS) and other performance measures. However, previous research has suggested that most of the variation in utilization for general medical conditions is attributable to case-mix indicators and random sources rather than individual providers. Hospital discharge data are used to estimate hierarchical linear models, where hospitals and physicians within hospitals are treated as a random effect. The goal was to determine the intraclass correlation coefficient (ICC) for psychiatric LOS for hospitals and for physicians before and after making case-mix adjustments. After controlling for case-mix, the hospital ICCs for depression, schizophrenia, and bipolar disorder show that 32%, 36%, and 11% of the variation in LOS, respectively, can be attributed to hospitals, while 7%, 5%, and 6% of the variation in LOS, respectively, can be attributed to physicians or provider practice. Unlike health services for other conditions, the variation in LOS for inpatient psychiatric treatment of depression and schizophrenia is quite dependent upon hospitals.

Externally Caused Death for Adults with Substance Use and Mental Health Disorders . . . 75-85
Barbara Dickey, PhD, Bruce Dembling, PhD, Hocine Azeni, MA, and Sharon-Lise T. Normand, PhD
Abstract: For decades there have been reports of shorter life expectancy among those with mental illness, especially those with more serious psychiatric disorders. The purpose of this study was to compare the risk of mortality among Medicaid beneficiaries, age 18-64, treated for mental illness to a comparable group who were not mentally ill and to the general population. The data used were from the Massachusetts Division of Medical Assistance and records of deaths from the Department of Public Health in Massachusetts. Individuals treated for both psychiatric illness and substance use disorders (dual diagnoses) were compared separately from those whose treatment was only for a psychiatric disorder. For all Medicaid beneficiaries, the most common causes of death were attributed to heart disease and cancer. When compared to the general population, adjusted odds ratios estimated death by injury to be twice as likely among the mentally ill when compared to the general population. Medicaid beneficiaries with dual diagnoses are 6-8 times more likely to die of injury, primarily poisoning, than their counterparts treated for medical conditions only.

Designated Case Managers as Facilitators of Medical and Psychosocial Service Delivery in Addiction Treatment Programs . . . 86-97
Peter D. Friedmann, MD, MPH, James C. Hendrickson, MA, Dean R. Gerstein, PhD, and Zhiwei Zhang, PhD
Abstract: This study examines whether having designated case management staff facilitates delivery of comprehensive medical and psychosocial services in substance abuse treatment programs. A multilevel, prospective cohort study of 2,829 clients admitted to selected substance abuse treatment programs was used to study clients from long term residential, outpatient and methadone treatment modalities. Program directors reported whether the program had staff designated as case managers. After treatment discharge, clients reported their receipt of 9 supplemental services during the treatment episode. In multivariate models controlling for multiple program- and client-level factors, program-level availability of designated case managers increased client-level receipt of only 2 of 9 services, and exerted no effect on service comprehensiveness, compared to programs that did not have designated case managers. These findings do not support the common practice of designating case management staff as a means to facilitate comprehensive services delivery in addiction treatment programs.

COMMENTARY
Using Information to Guide Managed Behavioral Health Care . . . 98-110
Christopher Tompkins, PhD, and Jennifer Perloff, MPA
Abstract: This evaluation of substance abuse and mental health treatment services in Arizona discusses and illustrates the use of data already collected by the State to manage and monitor the public behavioral health sector. The authors utilize a framework that focuses on rate-setting and financial incentives; provider profiling and education; and monitoring of data quality and system-wide performance. Information and analysis can contribute to key management activities and forces that guide behavior in the system toward optimal system performance. Using data from 33,208 Medicaid-covered and uninsured adults, service mix varied substantially by region; for example, spending on residential care ranged from zero to 40 percent for substance abuse treatment clients. By focusing on a smaller group of client with functional assessments, it also appears that regional spending levels varied considerably, for reasons not explained by client demographics or clinical measures. Finally, longitudinal data show that the regional managed care organizations are moving in different directions with regard to client mix and spending priorities. All of this variation suggests there may be considerable latitude to guide and improve system-wide performance.

Number 2 / April 2004

REGULAR ARTICLES
Detection of Postpartum Depression and Anxiety in a Large Health Plan . . . 117-133
Ashley O. Coates, MPH, Catherine A. Schaefer, PhD, Jeanne L. Alexander, MD
Abstract:
To determine the prevalence of diagnosed and/or treated postpartum depression and anxiety, records were extracted for one year after delivery from databases of outpatient diagnoses and prescriptions, for women in a health maintenance organization who had delivered a child from July 1997 through June 1998. For comparison, telephone interviews were conducted 5-9 months after delivery with random samples of women who delivered at two facilities from May 1998 through January 1999. Of the women interviewed, 11% met criteria for Major Depression during the first four months postpartum, and an additional 13% met criteria for probable depression at 5-9 months postpartum. In contrast 7.0% of the large cohort had a visit or prescription for depression. The one-year prevalence rate for diagnosed and/or treated anxiety without depression was 3.8%; the rate at time of interview was 14.7%. Overall, less than 33% of women with substantial depression or anxiety symptoms were detected.

Youth Therapeutic Alliance in Intensive Treatment Settings . . .134-148
Leonard Bickman, PhD, Ana Regina Vides de Andrade, PhD, E. Warren Lambert, PhD, Ann Doucette, PhD, Jeff Sapyta, MS
Abstract:
Therapeutic alliance (TA), the helping relationship that develops between a client and clinician, has received little attention in child treatment studies until recently, though it is the factor found to be most predictive of clinical outcomes. Furthermore, TA is cited as one of the most important components to effective therapy according to practicing clinicians. This study examines the therapeutic alliance that develops between teacher/counselors and children in two settings, a partial hospital/day school and a wilderness camp. An important finding in this study is the lack of relationship between the teacher/counselor’s view of TA and the youth’s. Moreover, this correlation does not improve according to how long the counselors have known or have treated the youth. The implications of this and other findings are discussed.

The Relationship Between Type of Mental Health Provider and Met and Unmet Mental Health Needs in a Nationally Representative Sample of HIV Positive Patients . . .149-163
Stephanie L. Taylor, PhD, M. Audrey Burnam, PhD, Cathy Sherbourne, PhD, Ron Andersen, PhD, William E. Cunningham, MD
Abstract:
This study examined mental health service utilization among a nationally representative sample of adults with HIV and psychiatric disorders or perceived need for mental health services. Data are from the HIV Cost and Services Utilization Study (HCSUS) mental health survey (n=1,489) conducted in 1997-1998. Most (70%) needed mental health care. Of these, 30% received no mental health services in the previous six months, 16% received services from general medical providers (GMPs) only, and 54% used mental health specialists. Clients with perceived need for care were more likely to receive any mental health services and services from mental health specialists (versus GMPs) than clients having mental disorders without perceived need. More patients using specialists versus GMPs received psychotherapeutic medications and psychiatric hospitalizations, controlling for psychiatric symptom severity. The findings underscore that the differential mental health service provision between specialists and GMPs existing in the general population also is present among persons with HIV.

Access to Publicly Funded Methadone Maintenance Treatment in Two Western States . . .164-177
Dennis Deck, PhD, Matthew J. Carlson, PhD
Abstract:
This study examined individual and system characteristics associated with access to methadone maintenance treatment (MMT) among Medicaid-eligible adults entering treatment for opiate use in Oregon and Washington. Logistic regression was used to examine the relative contributions of predisposing, need, and enabling characteristics on access to MMT. Although the number of methadone admissions increased in both states, access rates (the percentage of opiate-using adults presenting for treatment who were placed on methadone) declined after 1995. Adults in remote counties were one fifth to one tenth as likely to be placed in a methadone maintenance program than those living in counties with a methadone clinic. Other significant barriers to access included polydrug use, legal system referral, residence in a group home, lack of income, and homelessness. Factors promoting access included prior methadone use, pregnancy, and self-referral to treatment. These results suggest that more can be done to expand access to methadone maintenance.

Regional variation and clinical indicators of antipsychotic use in residential treatment: A four state comparison . . . 178-188
Purva H. Rawal, BA, John S. Lyons, PhD, James C. MacIntyre, II MD, John C. Hunter, PhD
Abstract:
The last decade saw an increase in psychotropic use with pediatric populations. Antipsychotic prescriptions are used frequently in residential treatment settings, with many youth receiving antipsychotics for off-label indications. Residential treatment data from four states were examined to determine if regional variation exists in off-label prescription and what clinical factors predict use. The study used clinical and pharmacological data collected via retrospective chart reviews (N = 732). The Child and Adolescent Needs and Strengths Assessment – Mental Health Version was used to measure symptom and risk severity. Of youth receiving antipsychotics, 42.9% had no history of or current psychosis. Statistical analyses resulted in significant regional variation in use across states and yielded attention deficit/impulsivity, physical aggression, elopement, sexually abusive behavior and criminal behavior as factors associated with antipsychotic prescription in non-psychotic youth. Antipsychotic prescription is inconsistent across states. Off-label prescription is frequent and likelihood of use increases with behavior problems.

BRIEF REPORTS
Minor Depression And Rehabilitation Outcome For Older Adults In Subacute Care . . . 189-198
Bradley P. Allen, PhD, Zia Agha, MD, MS, Edmund H. Duthie, Jr, MD, Peter M. Layde, MD, MS
Abstract:
During recent years, numerous studies have found an association between minor depressive symptoms and physical functioning for older adults recuperating from illness or injury. Whereas earlier research has focused on the effects of minor depression during rehabilitation in acute or long term settings, this study examined 209 patients receiving subacute physical therapy. The dependent measures were total score changes on the Functional Independence Measure (FIM) obtained at admission, discharge and 3 month follow-up. The independent measure was minor depressive symptoms, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, obtained within five days of admission. A binary logistic regression analysis was conducted with dichotomized FIM scores and the presence/absence of minor depressive symptoms. The results indicated a statistically significant relationship between FIM score change and minor depression from admission to discharge, but not from discharge to follow-up.

Confidentiality Measures in Mental Health Delivery Settings: Report of U.S. Health Information Managers . . .199-207
Daniel P. Lorence, PhD
Abstract:
Health and human service organizations are becoming increasingly liable for violations of patient privacy as a result of recent federal mandates at both state and federal levels of government. Under such conditions it would seem likely that managers would act to quickly implement such guidelines and mandates, especially in sensitive specialty areas such as mental health. This study sought to examine the degree and type of patient information confidentiality measures adopted in mental health delivery settings, through a national survey of accredited U.S. health information managers. Results suggest that significant non-adoption of basic confidentiality measures continues to exist, despite federal mandates to the contrary. Further examined was the degree to which confidentiality management varies across adoption levels of computerized patient records. Significant variation was found in adoption of patient confidentiality measures between highly computerized and paper-based medical record functions. Similar levels of variation in adoption across practice settings was also discovered. Ramifications for national policy and patient information protection are discussed.

Injection Drug Users and the Provision of Hepatitis C-Related Services in a Nationwide Sample of Drug Treatment Programs . . .208-216
Zdravko P. Vassilev, MD, MPH, Shiela M. Strauss, PhD, Janetta Astone, PhD, Don C. Des Jarlais, PhD
Abstract:
Drug treatment facilities are important sites for providing targeted prevention and health services to injection drug users (IDUs) who are infected with the hepatitis C virus (HCV). A nationwide survey was conducted to examine whether differences exist in the HCV-related services provided by drug treatment programs that have varying proportions of IDUs among their patients. The results indicate that, overall, drug treatment programs with a greater proportion of IDUs offer significantly more HCV services as compared to programs with a smaller proportion of IDUs. However, important components of hepatitis C-related care, such as universal basic education and counseling about HCV and extensive HCV-antibody testing, are not yet being provided by all programs with a large proportion of IDUs among their patient populations.

Reducing Restraint Use in a Public Psychiatric Inpatient Service . . .217-224
Robert E. McCue, MD, Leonel Urcuyo, MD, Yehezkel Lilu, PhD, Teresa Tobias, RN Michael J. Chambers, MPA
Abstract:
The use of behavioral restraint in psychiatric inpatients can have physically and emotionally damaging effects. However, staff may view the use of restraint as a routine and acceptable means of maintaining safety. The goal of this project was to reduce the use of restraint in a public psychiatric inpatient service that serves an economically disadvantaged urban population. Six interventions that primarily involved changing staff behavior were made to reduce the use of restraint. These included better identification of restraint – prone patients, a stress/anger management group for patients, staff training on crisis intervention, development of a crisis response team, daily review of all restraints, and an incentive system for the staff. The rate of restraint use (number of restraints/1000 patient-days) during the three years before the interventions was compared with the rate during the two years after. There was a significant decrease in the rate of restraint use after the restraint reduction initiatives were implemented. The reduction was not accompanied by a sustained increase in incidents of assault, suicidal behavior, or self-injury, comprehensiveness, compared to programs that did not have designated case managers. These findings do not support the common practice of designating case management staff as a means to facilitate comprehensive services delivery in addiction treatment programs.

Number 3 / July 2004

REGULAR ARTICLES

Creating an Aggregate Outcome Index: Cost-Effectiveness Analysis Substance Abuse Treatment . . .229-241
Mireia Jofre-Bonet, PhD and Jody L. Sindelar, PhD
Abstract:
This paper proposes a method of calculating a practical Index of Improvement for conducting a cost-effectiveness analysis (CEA) of substance abuse treatment (SAT). While the methodology of CEA necessitates the use of a single outcome measure, SAT can produce multiple, important outcomes that must be considered in policy decisions about funding and alternative treatments. Thus, there is a need to aggregates the variety of outcomes from substance abuse treatment into a single index. The proposed index is a preference weighted sum of outcomes using data from the Addiction Severity Index (ASI). The methodology and use of the index for conducting a CEA are illustrated using ASI data from a controlled quasi-experimental field study of case management.

Racial Differences In The Mental Health Needs And Service Utilization Of Youth In The Juvenile Justice System . . . 242-254
Purva Rawal, BA, Jill Romansky, BS, Michael Jenuwine, PhD, JD, John S. Lyons, PhD
Abstract:
Mental health placement rates by the juvenile justice system differ by race. However, it is unknown whether mental health needs differ by race. This study attempts to investigate potential differences in mental health needs and service utilization among Caucasian, African American, and Hispanic juvenile justice involved youth. A stratified random sample of 473 youth petitioned, adjudicated, and incarcerated from 1995-1996 was examined using a standard chart review protocol and the Childhood Severity of Psychiatric Illness measure for mental health needs. Significant and unique mental health needs were demonstrated for all racial groups. African American youth demonstrated the greatest level of needs. Minority status indicated significantly lower rates of mental health service utilization. Minority youth in the juvenile justice system are most at risk for underserved mental health needs. Based on the current data, it can be inferred that the first contact with the state's child and adolescent serving system, which includes the juvenile justice and mental health sectors, appears to be through the juvenile justice sector for many minority youth with delinquency problems.

PROVIDER TURNOVER IN PUBLIC SECTOR MANAGED MENTAL HEALTH CARE...255-265
Carmen E. Albizu-García, MD, Ruth Ríos, PhD, Deborah Juarbe, MS, Margarita Alegría, PhD
Abstract
: The present study examines the extent of turnover in mental health provider networks within public-sector-managed mental health care; over a one-year period and its association to provider and practice characteristics. Telephone interviews were conducted with a sample of mental health services providers listed the previous year in the networks of the three public-sector-managed mental health care organizations operating in Puerto Rico. Thirty-one percent of respondents had dropped out of networks. Drop out was significantly associated (p< 0.05) with increasing number of years in practice and decreasing years under contract. A non-significant trend was observed suggesting that providers with subspecialty training are less likely to drop out. The results may be signaling an emerging problem in public-sector-managed mental health care. Stability of provider networks should be monitored by State agencies contracting out mental health care.

A Test of Mental Health Parity: Comparisons of Outcomes of Hospital Concurrent Utilization Review . . . 266-278
Mary Ellen Murray, PhD, RN and Jeffrey B. Henriques, PhD
Abstract:
The Mental Health Parity Act of 1996 had as its goal the equity of coverage of mental health and physical health care. The purpose of this study was to examine the outcomes of hospital concurrent utilization review as a measure of the progress toward the equity goal. The study examined four years of denials of certification for reimbursement by payers of inpatient care (1998-2001). Psychiatry was first compared to clinical services with a like number of annual admissions and second, compared to clinical services with a like number of concurrent reviews. For each year, psychiatry had the highest numbers of cases denied and patient days denied. The most frequent reason for a psychiatric denial was that the inpatient benefit level had been exceeded. There was only one instance, in four years, when this reason (benefit limit exceeded) was given for a patient with a physical illness. This study provides evidence of the current inequity of reimbursement for treatment of mental illness.

Continuity Of Care: Validation Of A New Self Report Measure For Individuals Using Mental Health Services . . . 279-296
Janet Durbin, MSc, Paula Goering, RN, PhD, David L. Streiner, PhD, Cpsych, George Pink, PhD
Abstract:
The last decade saw an increase in psychotropic use with pediatric populations. Antipsychotic prescriptions are used frequently in residential treatment settings, with many youth receiving antipsychotics for off-label indications. Residential treatment data from four states were examined to determine if regional variation exists in off-label prescription and what clinical factors predict use. The study used clinical and pharmacological data collected via retrospective chart reviews (N = 732). The Child and Adolescent Needs and Strengths Assessment - Mental Health Version was used to measure symptom and risk severity. Of youth receiving antipsychotics, 42.9% had no history of or current psychosis. Statistical analyses resulted in significant regional variation in use across states and yielded attention deficit/impulsivity, physical aggression, elopement, sexually abusive behavior and criminal behavior as factors associated with antipsychotic prescription in non-psychotic youth. Antipsychotic prescription is inconsistent across states. Off-label prescription is frequent and likelihood of use increases with behavior problems.

Gender Differences in Patterns of Risk Factors Among Children Receiving Mental Health Services: Latent Class Analyses . . . 297-311
Christine M. Walrath, PhD, Hanno Petras, PhD, avid S. Mandell, ScD, Robert L. Stephens, PhD, E. Wayne Holden, PhD, Philip J. Leaf, PhD
Abstract:
Latent Class Analyses (LCA) were used to analyze data from a sample of children participating in the national evaluation of the Comprehensive Communities Mental Health Services for Children and Their Families Program (N=6,786). Lifetime risk experiences of the child were analyzed to identify four classes of boys and girls with similar risk patterns. While low-risk, status offense, abuse, and high-risk classes were identified for both boys and girls, there were nearly half the number of girls in the low-risk class, almost as many in the status offense, twice as many in the abuse classes, and over three times as many in the high-risk class as there were boys. These findings suggest that there are specific groups of children entering services who differ as a function of their lifetime risk exposure. In addition, the relationship between class membership and child functioning, and class membership and family lifetime risk experiences. Understanding these differences provides critical information to the service planning process. In addition, it may result in immediate improvement in the triage of children into services, and a better understanding of their behaviors during and after treatment.

BRIEF REPORTS

Health Care Use By Children With Attention Deficit/Hyperactivity Disorder: With And Without Psychiatric Comorbidities . . .312-232
Lynn L. DeBar, PhD, MPH, Frances L. Lynch, PhD, MSPH, Myde Boles, PhD
Abstract:
This study examined healthcare services used by children with attention-deficit hyperactivity disorder (ADHD), with and without psychiatric comorbidities. The study was conducted in a large health maintenance organization in the Pacific Northwest on all continuously enrolled children aged 5-12 from January 1997 through July 1998. The study measured all outpatient medical care, specialty mental health care services, and prescription drug dispensings from computer records. Children with ADHD, with and without other psychiatric comorbidities, use more general medical services than other groups of children, including outpatient visits, acute care (ER/urgent care) visits. ADHD and other psychiatric comorbidities lead to higher use of specialty mental health services, and greater use of psychotropic medications.

A Need-Based Model for Determining Staffing Needs for the Public Sector Outpatient Mental Health Service System . . . 324-333
David Elisha, PhD, MBA, Daphna Levinson, PhD, Alexander Grinshpoon, MD
Abstract:
This article proposes a need-based model for determining staffing needs for regional or national public sector outpatient mental health services. It constitutes a spreadsheet method involving a sequence of calculations relating demographic variables, workers productivity, anticipated demand and standards pertaining to annual visits per-client distributed among the core mental health professions. The authors demonstrate the application of the model to national planning of adult outpatient mental health services using standards based on both expert consensus and existing staffing patterns while they note the need for more rigorously derived and empirically based standards. It is suggested that by using clearly stated assumptions and quantifiable variables the model can facilitate constructive negotiations among various agencies and community organizations involved in policymaking and in budget allocations. The TEFRA Medicaid Eligibility Option for Children with Severe Disabilities: A National Study . . . Rafael M. Semansky, MPP and Chris Koyanagi Abstract: The Tax Equity and Fiscal Responsibility Act (TEFRA) Medicaid Eligibility Option, also known as the Katie Beckett Option, was developed to allow children with disabilities from near-poor and middle-income families to qualify for Medicaid. TEFRA has been available since 1982; however little is known about the number of children served and their qualifying disability. This first national study found that 20 states enrolled nearly 25,000 children in 2001. Only ten of these states allowed children to qualify due to a mental health disability. Additional research is needed to understand the role of TEFRA in providing insurance to children with disabilities.

Number 4 / October 2004

REGULAR ARTICLES
Longitudinal Patterns of Offending During the Transition to Adulthood in Youth from the Mental Health System . . .351-366
Maryann Davis, PhD, Steven Banks, PhD, William Fisher, PhD, Albert Grudzinskas, JD.
Abstract:
Arrest rates among the population of youth served in child mental health systems are known to be high during adolescence and young adulthood, but individual longitudinal patterns have not been examined. The present study used developmental trajectory modeling, a contemporary method used widely in criminology, to examine clusters of individual criminal justice (CJ) involvement patterns at ages 8-25, from database records of 131 individuals in public adolescent mental health services. Three groups of particular concern emerged; one with increasingly high offense rates, and two with moderate to high violent offense rates that did not desist. Offense patterns in these groups indicate early intervention should occur before age 15. Some risk factors were identified. Peak offending for most groups occurred between ages 18-20. Implications of these findings for mental health services during the transition to adulthood are offered.

Substance Abuse Treatment for Women: Changes in the Settings Where Women Received Treatment and Types of Services Provided, 1987 – 1998 . . .367-383
Christine E. Grella, PhD and Lisa Greenwell, PhD.
Abstract:
Changes in social policies during the past two decades have had major implications for the provision of substance abuse treatment services to women. The goal of this analysis was to examine (a) changes in the proportion of women clients served within different types of treatment facilities and (b) the services provided in those facilities. Data were analyzed from national surveys of treatment providers for the period of 1987 to 1998. Overall, there were gradual increases in the proportion of women clients across treatment facilities and greater concentrations of women in more intensive treatment modalities. The provision of childcare increased over time, particularly in programs with only women clients. Treatment facilities in which there were higher proportions of women generally had higher rates of providing services related to pregnancy, parenting, and domestic violence. These findings can be used to assess the adequacy of service delivery to women in substance abuse treatment.

A Multi-Site Study of Medicaid-Funded Managed Care Versus Fee-for-Service Plans’ Effects on Mental Health Service Utilization of Children with Severe Emotional Disturbance . . .383-402
Judith A. Cook, PhD, Craig Anne Heflinger, PhD, Christina W. Hoven, DrPH, Kelly J. Kelleher, MD, Virginia Mulkern, PhD, Robert I. Paulson, PhD, Al Stein-Seroussi, PhD, Genevieve Fitzgibbon, BA, Jane Burke, MS, Melissa Williams, MEd
Abstract:
Although Medicaid-funded managed care arrangements are commonly used in the delivery of mental health and substance abuse services to low-income children and youth, little is known about the effectiveness of such efforts. This article examines differences in mental health services utilization between children and youth with severe emotional disturbance covered by Medicaid-funded managed care behavioral health plans and those covered by fee-for-service plans. Data are from a federally-funded multisite study. In multivariate analyses controlling for child and caregiver demographic and clinical factors, enrollment in a managed care behavioral health plan was associated with lower inpatient/residential, psychiatric medication, and non-traditional services utilization. No difference was found in outpatient services utilization. Medicaid-funded managed care behavioral health plans appear to reduce use of some types of mental health services, but it is important to address the question of whether low-income children’s enrollment in such programs deprives them of needed services.

Predominantly Female Caseloads: Identifying Organizational Correlates in Private Substance Abuse Treatment Centers . . .403-417
Shannon M. Tinney, MA, Carrie B. Oser, MA, J. Aaron Johnson, PhD, Paul M. Roman, PhD.
Abstract:
This study uses a national sample of private substance abuse treatment centers to identify the organizational attributes characterizing facilities with a predominantly female caseload (PFC). Data were drawn from the National Treatment Center Study (NTCS), a nationally representative study of private-sector alcohol and drug abuse treatment centers (n=365). Bivariate and multivariate analyses were conducted to explore which organizational characteristics are associated with higher percentages of women in treatment. Private substance abuse treatment facilities were more likely to have a PFC if they (1) offered child care programs, (2) had a higher percentage of families participating in treatment, (3) treated psychiatric disorders, (4) employed a greater percentage of counselors with at least a Master’s degree, (5) received a higher proportion of referrals from mental health sources and a lower proportion of referrals from workplace-based referral sources, and (6) accepted higher proportions of Medicare and/or Medicaid clients.

Factors Associated with Perceived Stigma for Alcohol Use and Treatment Among At-Risk Drinkers . . .418-429
John Fortney, PhD, Snigdha Mukherjee, PhD, Geoffrey Curran, PhD, Stacy Fortney, MA, Xiaotong Han, MS, Brenda M. Booth, PhD
Abstract:
This study examined perceived public stigma for at-risk drinking and alcohol treatment among a sample of 733 at-risk drinkers living in the South. Substantial levels of perceived stigma were reported for the community’s judgment about at-risk drinking (86.1%), community’s judgment about seeking primary care treatment for alcohol disorders (48.9%), community’s judgment about seeking specialty treatment (56.3%), and primary care providers’ judgment about their patients who are at-risk drinkers (35.7%). Similarly, respondents perceived a substantial lack of privacy associated with primary care treatment (42.0%), and specialty treatment (45.2%). African-Americans were more likely to perceive a lack of treatment privacy, but less likely to perceive community judgment about seeking specialty treatment. Those with greater social network contact intensity were more likely to perceive community judgment about at-risk drinking and more likely perceive a lack of treatment privacy. Rural at-risk drinkers were more likely to perceive a lack of privacy in primary care.

New York State Case Manager Survey: Urban and Rural Differences in Job Activities, Job Stress, and Job Satisfaction . . .430-440
Zvi D. Gellis, PhD, Jongchun Kim, PhD, Sung Chul Hwang
Abstract:
The impact of stress in the workplace on employee wellbeing and effectiveness has been increasingly recognized in recent years. The purpose of this research was to study the quality of worklife of case managers in urban and rural community mental health programs in New York State. The objectives were to describe specific job activities and examine differences in the perceptions of job stress and job satisfaction. Urban case managers attributed greater job stress intensity and frequency than did rural workers to stressors relating to collaborating and coordinating services. Urban case managers reported higher levels of perceived job stress due to organizational support deficits than rural workers. No differences were found for the two groups on job pressure stressors. The significance of the findings for mental health agencies is discussed.

BRIEF REPORTS

Long Term Effectiveness of the ACCESS Program in Linking Community Mental Health Services to Homeless Persons with Serious Mental Illness . . .441-449
Aileen B. Rothbard, ScD, So-Young Min, PhD, Eri Kuno, PhD, Yin-Ling Irene Wong, PhD
Abstract
: This study examined the long-term effectiveness of the ACCESS project (Access to Community Care and Effective Services and Supports) on service utilization and continuity of care among homeless persons with serious mental illness. A three-year longitudinal analysis, using Medicaid claims data, tracked behavioral health service utilization among 146 Medicaid-eligible participants in the Pennsylvania ACCESS program. Utilization patterns of inpatient, outpatient, and emergency room services for psychiatric and substance abuse treatment were examined during the year prior to, during, and one year after the implementation of ACCESS. Use of psychiatric ambulatory care significantly increased among intervention participants and remained greater following ACCESS intervention. Better continuity of care following hospitalization was achieved during and after the intervention. The number of days spent hospitalized significantly decreased during the intervention. These results suggest that the ACCESS intervention was effective in linking hard-to-reach homeless persons with serious mental illness to the community mental health service system, and that this effect maintained after termination of the intervention.

Aging and Outpatient Service Use among Persons with Schizophrenia-Spectrum Disorders in a Statewide Behavioral Health Care System . . .450-457
Weili Lu, PhD, Philip T. Yanos, PhD, Shula Minsky, EdD, Gerard L. Kiely, PhD
Abstract:
This investigation explored the demographic and service use correlates of age among young, midlife, and older adults diagnosed with schizophrenia-spectrum disorders (n = 513), using the administrative dataset of a statewide behavioral healthcare system. More African-American persons were represented in the younger groups (age 18-35, 36-44) than in the older group (age 45+). Nearly two thirds of persons with schizophrenia-spectrum disorders seeking outpatient treatment were younger than 45. With the exception of crisis/emergency room (ER) services, persons in different age groups did not differ in the amount and type of outpatient service utilized, and did not differ in the likelihood of dropping out of services early. However, persons between ages 18 and 44 used significantly more crisis/ER services than those aged 45+. The findings suggest the importance of relapse prevention for persons aged 18 to 44 treated in outpatient settings.