JBHSR Recent Issues

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

Volume 32, 2005

Number 1 / January 2005

REGULAR ARTICLES
Mental Health Problems of Adolescents as Reported by Their Caregivers: A Comparison of European, African and Latino Americans ... 1-13
Robert E. Roberts, PhD, Margarita Alegria, PhD, Catherine Ramsay Roberts, MPH, PhD, Irene Ger Chen, MPH
Abstract: This paper examines problem recognition across ethnic groups by focusing on parental reports of mental health problems in adolescents. Data were collected from one youth (age 11-17) and one caregiver from a community-based sample of households in the Houston metropolitan area. The sample was 4,175 youths and their caregivers (37.8% European, 35.00% African, 25.4% Latino, and 1.8% Other American). Indicators of mental health were perceived mental health, life dissatisfaction and whether adolescents had a mental health problem in the past year. European Americans were more likely to rate the mental health of adolescents as fair or poor, were about twice as likely to report that adolescents were dissatisfied with their lives, and that adolescents had a mental health problem in the past year. Interventions to help minority families in the identification of youth’s mental health problems may need to address cultural differences in the definition of mental health problem or in the benefit of labeling mental health problems that may serve as barriers to help seeking.

Measuring Preferences for Schizophrenia Outcomes with the Time Tradeoff Method . . .14-26
Martha Shumway, PhD, Tandy L. Choulijian, MS, Cynthia L. Battle, PhD
Abstract: Measuring preferences for schizophrenia outcomes facilitates meaningful integration of multiple outcome measures and multiple perspectives on treatment outcomes. The Time Tradeoff (TTO) technique, specifically developed for measuring health state preferences, is used widely in health research, but some evidence suggests that the TTO may work less well with schizophrenia than with other health conditions. This study tested the hypotheses that tailoring the time frame of the standard TTO to the course of schizophrenia and simplifying its presentation format would improve its feasibility and efficiency. Forty clinicians provided TTO ratings using one of four combinations of time frame and presentation format. Numeric ratings and quantitative and qualitative measures of feasibility showed that while participants preferred the simpler format, none of the alterations improved feasibility. Participants’ ratings were prone to logical inconsistencies and participants found all four versions of the TTO confusing and poorly suited to the context of schizophrenia treatment.

State Child Mental Health Efforts to Support Youth in Transition to Adulthood . . .27-42
Maryann Davis, PhD and Diane L. Sondheimer, MSN, MPH, CPNP
Abstract: The ability of state child mental health (MH) systems to facilitate the transition into adulthood of adolescents in their systems was studied by interviewing members of the Children, Youth and Families Division of the National Association of State Mental Health Program Directors (NASMHPD). Results demonstrated that transition services within state child MH systems are sparse, nationally. Continuity of services as youth age into adulthood was hampered because of generally separate child and adult MH systems, each with separate policies defining who accesses those services, lack of clarity about procedures to access adult MH services, and lack of shared client planning between adult and child MH systems. These findings suggest that adolescents in state child MH systems have difficulty accessing services that will help them with the difficult task of learning to function as an adult. Public MH systems should examine their capacity to provide transition supports and make needed improvements.

Retention in Publicly Funded Methadone Maintenance Treatment in Two Western States . . .43-60
Dennis Deck, PhD and Matthew J. Carlson, PhD
Abstract: This study examined individual and system characteristics associated with retention in methadone maintenance treatment (MMT) among Medicaid-eligible adults in treatment for opiate use in Oregon and Washington. Logistic regression was used to examine the contributions of predisposing, need, and enabling characteristics on 365 day retention in MMT. Older patients, patients with a history of methadone treatment and persons with stable Medicaid eligibility had higher rates of retention. Patients with disabilities, poly substance users, and those with an arrest record had lower rates of retention. In Oregon, which delivers MMT through managed care, retention rose sharply from 28% to 51% between 1994 and 1998 and then leveled off. During the same time period, retention in Washington State grew from 28% to 34%. The higher rates of retention in Oregon, in part, can be explained by differences in service delivery influenced by financing. Faced with long waiting lists, Washington providers were more than twice as likely to administratively discharge patients for rule violations as their Oregon counterparts. Given the importance of retention, policies and practices that influence retention should be carefully considered. Because Medicaid eligibility has a dramatic impact on retention, policies that help extend eligibility, or stabilize eligibility among individuals actively engaged in treatment, should be carefully considered.

Development and Testing of a Scale Measuring Parent Satisfaction with Staff Interactions . . .61-73
Janis E. Gerkensmeyer, PhD, RN, APRN, BC and Joan K. Austin, DNS, RN, FAAN
Abstract: This study tested the psychometric properties of the Parent Satisfaction Scale (PSS), a new scale measuring parent=s satisfaction with their children=s mental health services, primarily focusing on staff’s interpersonal interactions. Data were collected by postal surveys 5 to 10 months after a child=s admission to one of 5 mental health treatment programs. Completed surveys were received from parents of 121 of a potential 232 children (52% response rate), with an additional 15 spouses returning surveys for a total of 136. Internal consistency reliability of the PSS was strong (alpha = .96). Construct validity was supported by significant relationships between the PSS and constructs considered to be antecedent variables influencing parent satisfaction, including met expectations (r=.64, p<.001), met desires (r=.34, p<.001), and met needs (r=.43, p<.001). Convergent validity was supported with the PSS having Pearson correlations of .85 (p< .001) with the Client Satisfaction Questionnaire-8 and .74 (p< .001) with parents= ratings of satisfaction with specific services received.

BRIEF REPORTS
Outpatient Mental Health Service Use by Older Adults after Acute Psychiatric Hospitalization . . .74-84
Hong Li, PhD, Enola Proctor, PhD, Nancy Morrow-Howell, PhD
Abstract: This study describes outpatient mental health service use by elderly patients discharged from acute inpatient psychiatric treatment for depression, assesses services barriers that these elderly patients experienced, and identifies factors related to using mental health services. The sample consists of 199 elder patients discharged home from a geropsychiatric unit of an urban mid-western hospital. Multivariate logistic regression was used to identify factors associated with use of various mental health services. Almost three-quarters of the elderly patients saw a psychiatrist within 6 weeks post-discharge, but few used other outpatient mental health services. The most frequently reported barriers to use included: 1) cost of services, 2) personal belief that depression would improve on its own, and 3) lack of awareness of available services. The use of various outpatient services was differentially related to predisposing, need, and enabling factors. Female patients, those who resided in rural areas, and those who wanted to solve their problems on their own were less likely to use outpatient mental health services. Patients who reported greater levels of functional impairment, who resided in rural areas, and who perceived that getting services required too much time were less likely to see a psychiatrist in the post-acute period. African American elders were more likely than their white counterparts to use day treatment programs, which may be related to the fact that most day treatment centers were located in areas where the majority of residents were African Americans.

Predictors of Antipsychotic Medication Change . . .85-94
Michael J. Sernyak, MD, Douglas Leslie, PhD, Robert Rosenheck, MD
Abstract: Atypical antipsychotics account for over 60% of antipsychotic prescriptions written for the treatment of schizophrenia. While switching from one antipsychotic to another is a dynamic process, there has been no research on individual patient and institutional characteristics that predict antipsychotic switching. VA national administrative data were used to identify patients (n=9660) with schizophrenia maintained on antipsychotic medication. Logistic regression was used to identify predictors of medication switching. Independent variables included information about service utilization, socio-demographic and clinical variables as well as institutional characteristics. This model was repeated for more specific switches between classes of medications and between specific medications. High levels of outpatient and inpatient service use were the most powerful predictors of switching. Socio-demographic, institutional, diagnostic and functional measures were also predictive in some cases. Controlling for independent socio-demographic, diagnostic and functional measures, frequency of clinical contact was the most robust predictor of switching antipsychotics.

A Comparison of Client and Mental Health Worker Assessment of Needs and Unmet Needs . . .95-104
Carrie Gibbons, MA, Michel Bédard, PhD, Gary Mack, HBA
Abstract: This study was set up to examine agreement on needs identified by mental health clients and their primary mental health workers. Mental health workers assessed a convenience sample of clients who completed an interview about the services they receive. Data were collected from 78 client and staff dyads regarding eleven need domains. Mental health workers and clients did not agree on the number of needs (ICC = 0.42). Kappa coefficients indicated significant agreement between staff and clients for only one of the eleven need domains (vocational need kappa = 0.67; others ranged from 0 to 0.58). The data further revealed that mental health workers and clients disagreed about unmet needs (kappas ranged from –0.07 to 0.46). These findings show that clients and staff have divergent opinions regarding needs. Integrating clients’ perspectives into treatment plans may help address this issue.

A Feasibility Study to Assess Service Provider Perspectives Regarding Use of the Child and Adolescent Functional Assessment Scale in Ontario...105-109
Katherine M. Boydell, MHSc, PhD, Melanie Barwick, PhD, CPsych, H. Bruce Ferguson, PhD, CPsych, Rebecca Haines
Abstract: This brief report describes a feasibility study conducted to assess the satisfaction with training, ease of achieving inter-rater reliability, and clinical utility of the Child and Adolescent Functional Assessment Scale (CAFAS) as an outcome measurement tool for the province of Ontario, from the perspective of service providers. This study has been instrumental in the development of a four-year province-wide measurement initiative. The study proved useful to government policy and decision-makers, mental health administrators, clinicians and mental health service researchers interested in the implementation of outcome measurement tools. It highlighted the fact that at least 85 percent of respondents were satisfied with CAFAS training and the ease of achieving inter-rater reliability. The majority identified the usefulness of the tool in case formulation and the value in tracking changes over time.

Number 2 / October 2005

SPECIAL ISSUE
Introduction to the impact of co-occurring disorders and violence on women: Findings from the SAMHSA Women, Co-occuring Disorders, and Violence Study...111-112

The Assessment of Trauma History in Women with Co-Occurring Substance Abuse and Mental Disorders and a History of Interpersonal Violence . . .113-127
Gregory J. McHugo, PhD, Yael Caspi, ScD, Nina Kammerer, PhD, Ruta Mazelis, BS, Elizabeth W. Jackson, PhD, Lisa Russell, PhD, Colleen Clark, PhD, Jane Liebschutz, MD, and Rachel Kimerling, PhD
Abstract: The Women, Co-Occurring Disorders, and Violence Study (WCDVS) was a large (N=2729) multi-site study of the effectiveness of integrated and trauma-informed services for women with substance use and mental health disorders and a history of interpersonal violence (physical or sexual abuse). Study participants’ exposure to lifetime and current traumatic events was assessed at baseline and follow-up via in-person interviews. This paper describes the choice of the Life Stressor Checklist-Revised (LSC-R) to assess trauma history, in order to meet the WCDVS’s research aims and to respond to consumer input. Quantitative data address the breadth and prevalence of potentially traumatic events in the past and current lives of study participants, the formation and properties of summary measures, and test-retest reliability. Qualitative data address tolerance of the instrument by interviewers and respondents and the generalizability of quantitative findings about trauma prevalence. Finally, recommendations are offered for improvements to the WCDVS version of the LSC-R for use in future research.

Physical Health Burdens of Women with Trauma Histories and Co-Occurring Substance Abuse and Mental Disorders . . .128-140
Mary Jo Larson, PhD, Lisa Miller, PhD, Marion Becker, PhD, Erin Richardson, Nina Kammerer, PhD, Jennifer Thom, Joanne Gampel, MA, and Andrea Savage, PhD
Abstract: This paper documents the physical health burdens of participants in a large, federally funded cross-site study of specialized services for women with histories of trauma (physical or sexual abuse) and co-occurring substance abuse and mental health disorders. Nearly one half of the 2,729 women in the study (48%) reported serious physical illnesses and these physical illnesses frequently limited daily life activities or required use of special equipment. Nearly one-half (46%) rated their health status as only fair or poor. Given the prevalence of physical illnesses in this population, behavioral service providers should discuss with clients their overall health and how it might hinder their participation in treatment for trauma, substance abuse, and mental illness and policy-makers should consider this need when designing behavioral health requirements, setting reimbursement rates, and allocating funds.

Building Resilience in Children of Mothers Who Have Co-Occurring Disorders and Histories of Violence: Intervention Model and Implementation Issues . . .141-154
Norma Finkelstein, PhD, Elke Rechbergeri, PhD, Lisa A. Russell, PhD, Nancy R. VanDeMark, MSW, Chanson D. Noether, MA, Maura O'Keefe, PhD, Karen Gould, MSW, Susan Mockus, BA, and Melissa Rael, RN, MPA
Abstract: Historically, children of parents with co-occurring substance abuse and mental health disorders and histories of violence/trauma have been overlooked in behavioral health treatment systems. The Women, Co-Occurring Disorders and Violence study (WCDVS) was a five-year initiative funded by the United States Substance Abuse and Mental Health Services Administration (SAMHSA) that included a Children’s Study that explored the treatment needs for children of women with these multiple disorders. This article describes the development of the Children’s Study intervention which included clinical assessment, group intervention, and resource coordination/advocacy for children ages 5-10, in order to build resilience through increasing coping skills, improving interpersonal relationships, and helping coalesce positive identity and self-esteem. Innovative procedures, including the participation of Consumer/Survivor/Recovering women and mothers in the planning, implementation, and administrative applications of this intervention and study are also highlighted. It is recommended that programs begin to implement family focused integrated treatment approaches that can potentially increase protective factors for children affected by parental mental illness, substance abuse and violence.

The Relationship Between Mothers’ Child Abuse Potential and Current Mental Health Symptoms: Implications for Screening and Referral . . .155-166
Deborah J. Rinehart, MA, Marion A. Becker, PhD, Pamela R. Buckley, PhD, Kathy Dailey, MEd, Charles S. Reichardt, PhD, Carla Graeber, BA, Nancy R. VanDeMark, MSW, and Ellen Brown, PhD
Abstract: This analysis examined data from mothers at two of the nine sites participating in SAMHSA’s national Women Co-Occurring Disorders and Violence Study (WCDVS). Based on previous literature, it was hypothesized that women in the WCDVS would be at high risk of perpetrating child abuse. This research examined mothers’ potential for physical child abuse and assessed the association between child abuse potential, current mental health symptoms, alcohol and drug use severity, and trauma. Results revealed that participants had significant potential for child abuse. Hierarchical regression analyses revealed that current mental health symptoms were the strongest predictor of mothers’ scores on the Child Abuse Potential (CAP) Inventory. This study highlights the important relationships between commonly used instruments across the mental health, substance and child welfare fields and the potential dual use of these instruments. Implications for policy and practice are discussed.

The Role of Coercion in the Treatment of Women with Co-Occurring Disorders and Histories of Abuse . . .167-181
Colleen Clark, PhD, Marion Becker, PhD, Julienne Giard, MSW, Ruta Mazelis, BS, Andrea Savage, PhD, and Wendy Vogel, MPA
Abstract: Debate continues on issues of involuntary treatment for individuals with behavioral healthcare problems. Women with co-occurring disorders and histories of abuse are an especially vulnerable population. This study seeks to increase our knowledge about the experiences of coercion for women in the behavioral healthcare system. Patterns of coercion are explored. This study did not find the predicted relationship between high levels of interpersonal violence and frequent involuntary treatment experiences. The results do offer support for the hypothesis that women are more likely to be currently mandated to treatment if they have been recently arrested, and that being mandated to treatment does not appear to be related to clinical issues such as recidivism and acute symptoms. As expected, women currently required to be in treatment report having less choice in other aspects of their care. Implications for future research in the current climate of increasingly coercive policies are presented.

Social Roles in Women’s Lives: Changing Conceptions of Self . . .182-198
Vanja M. K. Stenius, MA, Bonita M. Veysey, PhD, Zachary Hamilton, MA, and Rene Andersen, MS
Abstract: As part of an effort to improve services and outcomes for women with histories of trauma and co-occurring mental health and substance abuse disorders, the Franklin County Women and Violence Project sought to assess women’s perceptions about their social roles and provide them with opportunities to adopt valued social roles. Social role theory suggests that individuals with devalued roles may benefit through the acquisition of valued roles. This paper outlines the findings regarding the women’s initial assessments of their social roles as well as real and desired changes three months after the baseline interview. Findings suggest that valued social roles play a significant role in helping women heal and recover, contributing to greater self-esteem, confidence and happiness. Conversely, the adoption of devalued roles or worsening of roles contributes to depression and makes it more difficult for women to heal and recover.

Tangled in a Web of Affiliation: Social Support Networks of Dually Diagnosed Women who are Trauma Survivors . . .199-214
Andrea Savage, PhD, and Lisa A. Russell, PhD
Abstract: The goal of this paper is to describe the social support networks of women with co-occurring substance abuse and mental health problems who are survivors of interpersonal abuse using baseline interview data from two sites (n=644) from the national Women Co-Occurring Disorders and Violence Study (WCDVS). The size and composition of women’s networks, the tangible and socio-emotional support available, as well as the stance of the support network towards substance use, treatment and trauma are described. Family members are described by women as offering less emotional support and less encouragement for healing from trauma than friends. Analyses demonstrated only modest support in either sample for the hypothesis that support network characteristics moderate the effects of traumatic stress on mental health and trauma symptoms among these samples of very burdened and poor women. The results point to the need for using caution in relying on women’s existing social support network to help them heal.

Religious/Spiritual Coping among Women Trauma Survivors with Mental Health and Substance Use Disorders . . .215-226
Roger D. Fallot, PhD and Jennifer P. Heckman, PhD
Abstract: This study examines the types of religious/spiritual coping used by women trauma survivors with co-occurring mental health and substance use disorders. Analyses based on data from two large racially diverse samples indicate that women from the study population rely considerably more on positive, than negative, religious coping, and that their reliance on religious coping, in general, is significantly higher than that of the general population. Numerous significant relationships were also found between the severity of trauma-related and mental health symptoms and more negative religious coping. This study further suggests that more frequent childhood abuse and childhood sexual violence are especially associated with negative religious coping in adulthood. Findings support the importance of spiritual coping for women trauma survivors with co-occurring disorders and suggest the value of increased attention to spirituality in behavioral health services, especially in assessment and therapeutic relationships.

Relational Systems Change: Implementing a Model of Change in Integrating Services for Women with Substance Abuse and Mental Health Disorders and Histories of Trauma . . .227-240
Laurie S. Markoff, PhD, Norma Finkelstein, PhD, Nina Kammerer, PhD, MPH, Peter Kreiner, PhD and Carol A. Prost, MEd
Abstract: This paper describes the “relational systems change” model developed by the Institute for Health and Recovery, its implementation in Massachusetts from 1998-2002 to facilitate systems change to support the delivery of integrated and trauma-informed services for women with co-occurring substance abuse and mental health disorders and histories of violence and empirical evidence of resulting systems changes. The federally funded WELL Project utilized relational strategies to facilitate systems change within and across three systems levels: local treatment providers, community (or region), and state. The WELL Project demonstrates that a highly collaborative, inclusive, and facilitated change process can effect services integration within agencies (intra-agency), strengthen integration within a regional network of agencies (interagency), and foster state support for services integration.

Number 3 / October 2005

Does Service Diversification Enhance Organizational Survival? Evidence from the Private Substance Abuse Treatment System
Hannah K. Knudsen, PhD, Paul M. Roman, PhD, and Lori J. Ducharme, PhD
Abstract: The rate of closure among US substance abuse treatment facilities in the private sector is considerable, further reducing access to treatments that are already in short supply in many locales. This research considers the extent to which specific types of service diversification reduces the likelihood of treatment center closure in the private sector using a nationally representative sample of 450 substance abuse treatment centers. Over the study period, 26.4% of centers ceased to offer substance abuse treatment services. There was mixed evidence that centers offering a more diversified array of services had a lower likelihood of closure. Specifically, the number of treatment tracks tailored to specific demographic groups was negatively associated with the likelihood of closure. There was a positive association between closure and offering an inpatient psychiatric program. These findings suggest that there may be strategic benefits in expanding services to meet the needs of diverse clientele.

Medicaid Chemical Dependency Patients in a Commercial Health Plan: Do High Medical Costs Come Down Over Time?
Lawrence J. Walter, MA, Lynn Ackerson, PhD, and Steven Allen, PhD
Abstract: A cohort of 197 Medicaid-insured patients presenting for treatment in Kaiser Permanente’s outpatient chemical dependency (CD) treatment program were observed the year prior to their program intake visit and followed for 3 years afterwards, to compare their medical costs and utilization to demographically-matched commercially insured patients entering the same programs. The Medicaid-insured patients on average incurred medical costs 60% higher than non-Medicaid patients during the 12 month pre-intake period ($5,402 versus $3,277). During the 3 years subsequently, however, both groups of CD patients displayed significant declines in medical costs averaging 30% from the baseline period to the 3rd year of follow-up. Cost trends reflected declines in use of hospital days, emergency room visits, and non-emergent outpatient visits. These results may help address concerns among Medicaid managed care providers and payers by giving a more realistic account of the long term costs of this group of high utilizing enrollees.

Youths Living Away From Families in the U.S. Mental Health System: Opportunities for Targeted Intervention
Kathleen J. Pottick, MSW, PhD, Lynn A. Warner, MPP, MSW, PhD, and Kevin A. Yoder, PhD
Abstract: This study examines the clinical characteristics of youths who lived away from families at the time of admission to specialty mental health services, and investigates the association between type of non-family living situation and admission to residential versus outpatient programs. Of 3,995 youths sampled from 1,598 mental health programs in the U.S., 14% lived away from their own families, either in foster care, group care settings, correctional settings, or were emancipated. As a group, youths living away from families were more seriously emotionally disturbed and more likely to receive treatment in residential care programs. Youths who lived in foster care were more likely to be admitted to outpatient programs, while youths who lived in group care settings or correctional settings were more likely to be admitted to residential care programs, controlling on demographic and clinical characteristics. Targeting resources to enhance the availability and therapeutic capacity of foster care may facilitate community living, and decrease time spent in institutional settings.

Mental Health and Substance Abuse Treatment Utilization among Individuals Served by Multiple Public Agencies in Three States
Jeremy W. Bray, PhD, Keith L. Davis, MA, Linda Graver, Don Schroeder, PhD, Jeffrey A. Buck, PhD, Joan Dilonardo, PhD, and Rita Vandivort, MSW
Abstract: Patterns of mental health (MH) and substance abuse (SA) treatment utilization among populations receiving services through multiple public programs are not well known. This study examines the extent to which populations with MH and/or SA conditions utilize treatment services through Medicaid and State MH/SA Agencies. Data are from the SAMHSA Integrated Database, a multi-year file for three states combining Medicaid and State MH/SA Agency administrative data into a uniform database. Although populations with co-occurring conditions and those served by both Medicaid and State MH/SA Agencies have substantial contact with the public treatment system, a majority of the MH/SA populations examined here utilize few services over brief periods of time. Utilization is most limited among individuals with MH-only conditions and those served exclusively by Medicaid. While a lack of data on clinical outcomes prevents us from drawing conclusions about the effectiveness of MH/SA services, results of this analysis do indicate that public programs in the states examined here do not provide services that are primarily utilized on a frequent or chronic basis.

The Use of Propensity Scores to Evaluate Outcomes for Community Clinics: Identification of an Exceptional Home-Based Program
Kay Hodges, PhD, and Heidi Grunwald, PhD
Abstract: This paper presents a model for mental health programs to estimate causal effects of treatment in community settings, where experimental studies, in which subjects are randomly assigned to treatment and control groups, are not feasible. This paper describes an observational study, which used a propensity score analysis with stratification and a repeated measures ANCOVA model to estimate treatment effects. This paper includes results from one example site that was identified as having an exceptional home-based community program. The results include treatment effects for three outcomes identified as useful goals for home-based community programs. The study also serves as a model of how local programs can establish credibility where no evidence-based treatments exist for severely impaired youths.

Workplace Health Promotion and Utilization of Health Services: Follow-up Data Findings
Diane Deitz, PhD, Royer Cook, PhD, and Rebekah Hersch, PhD
Abstract: This paper reports findings from a workplace substance abuse prevention program designed to investigate best practices. The study sought to: assess the effects of the worksite wellness program and employee assistance program (EAP) on health care utilization and costs, identify predictors of outpatient costs and visits, and assess the effect of the intervention on health attitudes, behaviors, and behavioral health-related costs and visits. Results indicated that visits to the EAP increased as did overall health care visits, that utilization of health care services and costs were higher in the population receiving substance abuse prevention intervention, and that employees in the substance abuse prevention intervention reported lower heavy drinking and binge drinking. Data suggest that substance abuse prevention may result in higher health care costs and utilization in the short-term, but a reduction in health risk behaviors such as heavy drinking may result in lower health care costs and utilization in the long-term.

Denial and Its Association with Mental Health Care Use: A Study of Island Puerto Ricans
Alexander N. Ortega, PhD, and Margarita Alegría, PhD
Abstract: In clinical practice, denial has long been thought to be a determinant of treatment initiation and retention; however, little empirical research has focused on denial as a mechanism. For example, denial has not been standardized or operationalized in epidemiological studies for mental health services research and, thus, the magnitude of the effects of denial on mental health care use are unknown. This study makes use of the “Mental Health Care among Puerto Ricans” study, a three-wave island-based probability epidemiological study conducted from 1992 to 1998. For all three waves, 2,928 subjects participated (81.5% response). The analyses were limited to only those subjects who were objectively determined to have severe need for mental health care (n = 742). The findings from this study show that admitting to a mental health problem is related to increased odds of using any mental health care, any specialty care, any psychotropic drugs, and retention in mental health care, after adjusting for potential confounding. Similar patterns were observed even after the data were limited to those subjects who did not previously seek mental health care, and the trends persisted when determining changes from denial to recognizing a mental health problem. The study confirms that denial is a significant factor for treatment initiation and retention, particularly for Puerto Ricans, and denial should be considered an important mechanism in planning interventions to eliminate mental health care disparities.

Factors that Impact Adolescents’ Intentions to Utilize Alcohol-Related Prevention Services
Elizabeth J. D’Amico, PhD
Abstract: The current study is the first to examine factors that may be associated with middle school students’ intentions to use alcohol-related prevention services. Youth (N = 1527; 46% male; 11-14 years old) completed surveys on their intentions to use alcohol-related services, beliefs about services, previous use of services, and substance use. Students who reported stronger positive beliefs reported greater intentions to use services. Girls, younger students, and whites also reported stronger interest in using services than boys, older students, and youth of mixed ethnicity, respectively. Adolescents who reported current use of substances were less willing to use prevention services. Current research highlights the importance of creating prevention services for this age group that are developmentally relevant and that focus on features that will attract youth, such as utilizing an interactive discussion format. Beginning to understand what motivates adolescents to seek help can facilitate the creation of better prevention programs.

Behavior and Symptom Identification Scale 32: Sensitivity to Change over Time
Jeanette M. Jerrell, PhD
Abstract: To be useful in assessing treatment efficacy, an outcome measure must be sensitive to changes in ratings of symptoms and psychosocial functioning over time and to differences in change across consumers, and be interpretable as to extent of clinical improvement. Results are presented regarding the sensitivity of the BASIS-32 to change in ratings of symptoms and psychosocial functioning among 1188 persons with severe and persistent mental illness after receiving a variety of clinical and psychosocial interventions in one behavioral health center over a three-year period. Utilizing the Reliable Change Index, evidence was found for the sensitivity of the BASIS-32 to detect statistically reliable and clinically significant changes on two subscales of psychosocial functioning (Relations with Others and Daily living/Role functioning) and on the Depression/ Anxiety subscale. For Impulsive/Addictive Behavior and Psychosis, and the overall BASIS 32 score, substantially less reliable change could be detected, although statistically significant differences were present.

Number 4 / October 2005

Outcomes for Medicaid Clients with Substance Abuse Problems Before and After Managed Care
Bentson H. McFarland, MD PhD, Dennis D. Deck, PhD, Lynn E. McCamant, MA, Roy M. Gabriel, PhD, and Douglas A. Bigelow, PhD
Abstract: Medicaid conversion from fee for service to managed care raised numerous questions about outcomes for substance abuse treatment clients. For example, managed care criticisms include concerns that clients will be under-treated (with too short and-or insufficiently intense services). Also of interest are potential variations in outcome for clients served by organizations with assorted financial arrangements such as for-profit versus not-for-profit status. In addition, little information is available about the impact of state Medicaid managed care policies (including client eligibility) on treatment outcomes. Subjects of this project were Medicaid clients aged 18 to 64 years enrolled in the Oregon Health Plan during 1994 (before substance abuse treatment managed care, N = 1,751) or 1996 -1997 (after managed care, N = 14,813) who were admitted to outpatient non-methadone chemical dependency treatment services. Outcome measures were retention in treatment for 90 days or more, completion of a treatment program, abstinence at discharge, and readmission to treatment. With the exception of readmission, there were no notable differences in outcomes between the fee for service era clients versus those in capitated chemical dependency treatment. There were at most minor differences among various managed care systems (such as for-profit versus not-for-profit). However, duration of Medicaid eligibility was a powerful predictor of positive outcomes. Medicaid managed care does not appear to have had an adverse impact on outcomes for clients with substance abuse problems. On the other hand, state policies influencing Medicaid enrollment may have substantial impact on chemical dependency treatment outcomes.

Alcohol Consumption, Risk of Injury, and High-Cost Medical Care
Helena J. Salomé, MA, Michael T. French, PhD. Helen Matzger, MPH, and Constance Weisner, DrPH, MSW
Abstract: This study examined the effect of alcohol use on the probabilities of injury, inpatient hospital stay, and emergency room visit. Data were obtained from a sample of adults (N=1,219) recruited from a Northern California county. Alcohol use measures included number of drinks, heavy drinking days, and an indicator variable for problem drinking. Models were estimated for men and women separately while controlling for confounders. Results indicate that most alcohol use measures were not significantly related to injury probability or medical care utilization. Among the exceptions, problem drinking was a significant positive predictor of any ER visit for both sexes. When drinkers during the past year were divided into light, moderate, and heavy drinking groups and compared to lifetime abstainers, all male drinkers had a higher probability of injury, and light and moderate female drinkers had a lower probability of an ER visit.

Cost-Effectiveness of Bupropion, Nortriptyline and Psychological Intervention in Smoking Cessation
Sharon M. Hall, PhD, James M. Lightwood, PhD, Gary L. Humfleet, PhD, Alan Bostrom, PhD, Victor I. Reus, MD, and Ricardo Muñoz, PhD
Abstract: Sustained-release bupropion and nortriptyline have been shown to be efficacious treatments for cigarette smoking. Psychological intervention is also recognized as efficacious. The cost and cost-effectiveness of the two drug therapies have not been estimated. It was hypothesized that nortriptyline would be more cost effective than bupropion. Hypotheses were not originally proposed concerning the cost-effectiveness of psychological versus drug treatment, but the two were compared using exploratory analyses. This was a 3 (bupropion versus nortriptyline versus placebo) by 2 (medical management alone versus medical management plus psychological intervention) randomized trial. Participants were 220 cigarette smokers. Outcome measures were cost and cost-effectiveness computed at week 52. Nortriptyline cost less than bupropion. Nortriptyline was more cost-effective than bupropion; the difference was not statistically significant. Psychological intervention cost less than the two drug treatments, and was more cost-effective, but not significantly so. Prospective investigations of the cost and cost-effectiveness of psychological and pharmacological intervention, using adequate sample sizes, are warranted.

The Invisible Children’s Project: Key Ingredients of an Intervention for Parents with Mental Illness
Beth R. Hinden, PhD, Kathleen Biebel, PhD, Joanne Nicholson, PhD, and Elizabeth Mehnert, MSW
Abstract: The current study used a collective case-study design to identify key ingredients of the Invisible Children’s Project, an intervention program for families in which a parent has a mental illness. Data were obtained from interviews with parents and service providers, and from family file records. Qualitative analyses were used to generate hypotheses regarding key ingredients and targeted outcomes, and to develop a testable intervention model. Key ingredients were defined as core processes, essential services, and mediators. Strong convergence across parents and providers suggested core processes defined by family-centered, strengths-based, emotionally supportive, comprehensive approaches; essential services including family case management, 24-hour availability, access to flexible funds, and liaison and advocacy, and mediators reflecting parent-provider trust, parent-provider communication/cooperation, provider-provider trust, adoption of strengths-based approaches, development of appropriate treatment plans, parent engagement, and parent self-esteem/self-efficacy. A model of the intervention is presented, and results are discussed with respect to research and policy implications.

Cost Effectiveness of Public Sector Substance Abuse Treatment: Comparison of a Managed Care Approach to a Traditional Public Sector System
Martha C. Beattie, PhD, Teh-Wei Hu, PhD, Rui Li, MM, and Jason C. Bond, PhD
Abstract: Costs and cost effectiveness of public sector substance abuse treatment in two California counties with similar substance abuse treatment system histories are compared; one county (MidState) has adopted managed care principles. As hypothesized, MidState’s costs for the index treatment episode were significantly lower than SouthState’s, although unexpectedly due to lower outpatient utilization. Treatment benefits in the seven Addiction Severity Index functional areas were examined through cost effectiveness analyses. MidState can claim greater cost effectiveness for its treatment dollars for significant improvement in alcohol and medical functioning (compared to unsuccessful clients and those reporting no problems). When comparing both improved clients and those maintaining no problems to unsuccessful clients, MidState is more cost effective for improving alcohol, medical, legal and family/social functioning; and three outcomes important to community stakeholders and taxpayers (legal, medical, and psychiatric functioning) are more cost effective than alcohol, drug, and employment improvement.

Sociodemographic and Economic Comparisons of Children Prescribed Longer-Acting versus Short-Acting Stimulant Medications for ADHD
Jack Stevens, PhD, Jeffrey S. Harman, PhD, and Kelly J. Kelleher, MD, MPH
Abstract: Little research has been conducted on sociodemographic and cost disparities regarding longer-acting stimulants for pediatric use. Demographic characteristics and health care expenditures of children taking short-acting stimulants versus longer-acting stimulants for Attention Deficit Hyperactivity Disorder (ADHD) were compared. Data from the 2000 and 2001 Medical Expenditure Panel Survey (MEPS), a nationally representative household survey, were analyzed of 221 children taking exclusively short-acting stimulants and 153 children taking exclusively longer-acting stimulants. No disparities in receiving short-acting as opposed to longer-acting stimulants were found by age, gender, race/ethnicity, region of the country, or insurance status. However, children in the latter group were more likely to come from higher income backgrounds and had greater psychotropic medication costs and total health care expenditures. For the most part, sociodemographic disparities in medication treatment for ADHD do not appear to exist once a diagnosis has been made. Children with ADHD taking longer-acting stimulants have particularly high health care expenditures.

Rehospitalization Rates of Patients with Bipolar Disorder Discharged on a Mood Stabilizer Versus a Mood Stabilizer Plus an Atypical Antipsychotic.
Nick C. Patel, PharmD, M. Lynn Crismon, PharmD, and Michael Pondrom, PharmD
Abstract: One-year rehospitalization rates of patients with bipolar disorder discharged while taking a mood stabilizer alone, a mood stabilizer plus a typical antipsychotic, or a mood stabilizer plus an atypical antipsychotic were examined. Time to rehospitalization was measured by the product-limit (Kaplan-Meier) formula. Twenty-three percent of patients on a mood stabilizer alone, 27% of patients on a mood stabilizer plus a typical antipsychotic, and 25% of patients on a mood stabilizer plus an atypical antipsychotic were rehospitalized within one year after discharge. There were no significant differences in rehospitalization rate or time to rehospitalization between groups. One-year rehospitalization rates for patients on a mood stabilizer plus olanzapine or risperidone was 25%. The number of previous psychiatric hospitalizations contributed to the risk of readmission. Risk factors and medication costs should be considered when designing the optimal treatment plan for an individual patient. Long-term prospective studies are needed to better delineate the effectiveness of different pharmacotherapeutic regimens on the long-term treatment outcomes in patients with bipolar disorder.