JBHSR Recent Issues

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

Volume 33, 2006

Number 1 / January 2006

Quality of Care for Depressed Elders in Post-Acute Care
Enola Proctor, PhD, Nancy Morrow-Howell, PhD, Mi Jin Lee, MSW, Jessica Gledhill, MSW, and Wayne Blinne, MA
Abstract: This paper addresses quality of post-acute care for older adults going home after hospitalization for depression. Quality was conceptualized and assessed in terms of services received for four domains of need: psychiatric, medical, functional, and psychosocial. At discharge, needs for care was assessed using medical records, standardized instruments, and patient interviews; quality of care was assessed by whether or not needs were met by services through the first six weeks of post-acute care. Quality of care varied across type of need: Psychiatric needs were most likely, and psychosocial needs were least likely, to be met. Urban elders received better psychiatric care than did rural elders. Elders in worse physical health received better medical and psychosocial care, but poorer psychiatric care. Elders with psychoses and living with others had better care for functional dependencies. The competing demands perspective suggests that medical illness may take priority over psychiatric care. Availability of Services for Women in Outpatient Substance Abuse Treatment: 1995-2000 Cynthia Campbell, PhD, MPH and Jeffrey A. Alexander, PhD

Consumer and Case Manager Perspectives of Service Empowerment: Relationship to Mental Health Recovery
Dushka Crane-Ross, Ph.D., Wilma J. Lutz, Ph.D., R.N., and Dee Roth, M.A.
Abstract: This study examines the relationship between service empowerment and recovery. Service empowerment is defined as the extent to which consumers participate in service decisions and the level of reciprocity and respect within the relationship with their case managers. Assessments were made from two perspectives, consumers and their case managers. Structural equation models were developed to examine the direct and indirect effects of service empowerment on four recovery outcomes: Quality of Life, Level of Functioning, Consumer-Reported Symptomatology, and Case Manager-Reported Symptomatology. Consumers’ perceptions of service empowerment were the most powerful predictor of recovery outcomes across the four models. Consumers’ and case managers’ perceptions were related but the magnitude of the relationship was small, indicating that considerable differences exist between their perceptions of service empowerment.

Organizational Management: What Service Providers are Doing While Researchers are Disseminating Interventions
Susan D. Phillips, PhD, and Charlene A. Allred, PhD
Abstract: Much of the recent discussion about how to make interventions with demonstrated effectiveness more routinely available to clients emphasizes the role of change agents in promoting service providers’ use of new interventions. This study provides a complimentary perspective; it describes what happens in service provider organizations as they go about making changes in the services they provide. The data used in this study come from quarterly progress reports of participants in the National Child Traumatic Stress Network. The results provide a roadmap for anticipating the types of efforts and extent of changes that may need to occur for organizations to learn about interventions, form favorable opinions toward them, and integrate them into the services they offer.

Toward the Implementation of Mental Health Consumer Providers Services
Matthew Chinman, PhD, Alexander S. Young, MD, MSHS, Joseph Hassell, MA, and Larry Davidson, PhD
Abstract: Encouraged by the New Freedom Commission, mental health systems such as the VA are now becoming more recovery-oriented. Consumer providers (CPs)—those with serious mental illness who are further along in recovery who provide services to others with similar mental health problems—are viewed as a key part of this change. However, organizational change theories suggest that careful consideration of implementation issues is critical when disseminating new and sometimes controversial services into existing organizations. Therefore, to guide the dissemination of CP services, the literature on the effectiveness of CPs was reviewed and interviews, focus groups, and a brief survey of 110 administrators, providers, and patients were conducted at three large VA clinics in Southern California. Questions focused on their perceptions of feasibility and acceptability of CP services. Using literature and study findings, an organizational change framework and other strategies to overcome potential implementation challenges of CP services are suggested.

MHSPY: A Children’s Health Initiative for Maintaining At-Risk Youth in the Community
Katherine E. Grimes, MD, MPH, and Brian Mullin
Abstract: Massachusetts-MHSPY is a home-based clinical intervention which seeks to maintain youth with severe functional impairment in the community via delivery of integrated primary care, mental health, substance abuse, and social services. Using blended public agency funding, traditional and non-traditional services are provided within a private, not-for-profit, managed care organization. Individualized, comprehensive care plans are developed by a MHSPY Care Manager, who works intensively with the family and the Care Planning Team to identify needs and resources. Data on clinical functioning is collected at baseline and every six months during the program. Service utilization and cost are measured on a quarterly basis. Family, youth, and agency satisfaction ratings are collected at disenrollment. Aggregate analyses based on four years of data show that MHSPY participants have improved clinical functioning, including significant reduction in risk to self and others. They also experience reduced service utilization and cost and high rates of family satisfaction.

The Use of Logistic Regression to Enhance Risk Assessment and Decision Making by Mental Health Administrators
Anthony A. Menditto, PhD, Donald M. Linhorst, PhD, MSW, James C. Coleman, PhD, and Niels C. Beck, PhD
Abstract: Development of policies and procedures to contend with the risks presented by elopement, aggression, and suicidal behaviors are long standing challenges for mental health administrators. Guidance in making such judgments can be obtained through the use of a multivariate statistical technique known as logistic regression. This procedure can be used to develop a predictive equation that is mathematically formulated to use the best combination of predictors, rather than considering just one factor at a time. This paper presents an overview of logistic regression and its utility in mental health administrative decision making. A case example of its application is presented using data on elopements from Missouri’s long-term state psychiatric hospitals. Ultimately, the use of statistical prediction analyses tempered with differential qualitative weighting of classification errors can augment decision making processes in a manner that provides guidance and flexibility while wrestling with the complex problem of risk assessment and decision making.

A Comparison of Mothers with Co-occurring Disorders and Histories of Violence Living with or Separated from Minor Children
Joanne Nicholson, PhD, Norma Finkelstein, PhD, Valerie Williams, MA, MS, Jennifer Thom, MA, Chanson Noether, MA, and Megan DeVilbiss, BSW
Abstract: Data from the Women with Co-occurring Disorders and Histories of Violence Study are used to examine characteristics distinguishing mothers currently providing care for all their minor children (n = 558), from mothers separated from one or more minor children (n = 1396). Mothers are described and compared on background characteristics and experiences, well being and current functioning, situational context, and services used. Analyses control for number of children, race, and years of education. Mothers separated from children have more children, less education, have more often been homeless, in juvenile detention or jail, and have lower incomes than mothers living with all their children. Mothers separated from children have more extensive experiences of traumatic and stressful life events, and the groups differ in current functioning and patterns of services used. While cross-sectional data do not allow causal inferences, challenges faced by mothers have significant implications for policy and programs.

Measuring Use of Health Services for At-Risk Drinkers: How Brief Can You Get?
Brenda M. Booth, PhD, JoAnn E. Kirchner, MD, Stacy M. Fortney, MA, Xiaotong Han, MS,Carol R. Thrush, MA, and Michael T. French, PhD
Abstract: This study examines the validity, utility, and costs of using a brief telephone-administered instrument, the Brief Health Services Questionnaire (BHSQ), for self-reported health care provider contacts relative to collection and Abstract:ion of complete medical records. The study sample was 441 community-dwelling at-risk drinkers who participated in an 18-month longitudinal study. Agreement between BHSQ self-reports and Abstract:ed provider contacts was good to very good for general medical (79% agreement, kappa = .50) and specialty mental health contacts (93% agreement, kappa = .60), but low for “other” miscellaneous health contacts (61% agreement, kappa = .04). Average cost to collect and Abstract: complete medical records was $424 per study participant whereas average cost to administer only the BHSQ was $31 per participant. Although it is not possible to conduct a formal cost-effectiveness analysis, results suggest the BHSQ is a viable option for collecting self-reported health provider contacts in a sample of at-risk drinkers, with definite cost advantages over more elaborate data collection methods.

A Neuroscientist – Consumer Alliance to Transform Mental Health Care
Amelia Compagni, PhD and Ronald W. Manderscheid, PhD
Abstract: The field of mental health has long suffered from a lack of convergence of disciplines that deal with the mind, the brain and behavior. This mind-brain dualism has been particularly detrimental for consumers and their families who daily face stigma and discrimination. The understanding of the brain and its dysfunctions has benefited from the study of the human genome and, in particular, of the mutations and variations in its code. This analysis permits a better understanding of the biological basis of mental disease and will soon inform a generation of new diagnostic tools and individualized pharmacological therapies. A biological perspective on mental illness will be complemented by the analysis of the social factors influencing people’s behavior and their impact on brain biology and gene function. Neurobiology has progressed to a level for which the knowledge that is generated, even if still colored with uncertainty, could represent a catalyst for the creation of an alliance between neuroscientists and consumers. This partnership has the potential to benefit both parties but will require some concrete steps that might be outside of the usual courses of action for both consumers and scientists. It is by building collaborations based on personal contact and information sharing that a transformation of the mental health care system can occur.

Number 2 / October 2006

Quality of Care for Depressed Elders in Post-Acute Care...127-141
Enola Proctor, PhD, Nancy Morrow-Howell, PhD, Mi Jin Lee, MSW, Jessica Gledhill, MSW, and Wayne Blinne, MA
Abstract: This paper addresses quality of post-acute care for older adults going home after hospitalization for depression. Quality was conceptualized and assessed in terms of services received for four domains of need: psychiatric, medical, functional, and psychosocial. At discharge, needs for care was assessed using medical records, standardized instruments, and patient interviews; quality of care was assessed by whether or not needs were met by services through the first six weeks of post-acute care. Quality of care varied across type of need: Psychiatric needs were most likely, and psychosocial needs were least likely, to be met. Urban elders received better psychiatric care than did rural elders. Elders in worse physical health received better medical and psychosocial care, but poorer psychiatric care. Elders with psychoses and living with others had better care for functional dependencies. The competing demands perspective suggests that medical illness may take priority over psychiatric care.

Availability of Services for Women in Outpatient Substance Abuse Treatment: 1995-2000
Cynthia Campbell, PhD, MPH and Jeffrey A. Alexander, PhD

Consumer and Case Manager Perspectives of Service Empowerment: Relationship to Mental Health Recovery...142-155
Dushka Crane-Ross, Ph.D., Wilma J. Lutz, Ph.D., R.N., and Dee Roth, M.A.
Abstract: This study examines the relationship between service empowerment and recovery. Service empowerment is defined as the extent to which consumers participate in service decisions and the level of reciprocity and respect within the relationship with their case managers. Assessments were made from two perspectives, consumers and their case managers. Structural equation models were developed to examine the direct and indirect effects of service empowerment on four recovery outcomes: Quality of Life, Level of Functioning, Consumer-Reported Symptomatology, and Case Manager-Reported Symptomatology. Consumers’ perceptions of service empowerment were the most powerful predictor of recovery outcomes across the four models. Consumers’ and case managers’ perceptions were related but the magnitude of the relationship was small, indicating that considerable differences exist between their perceptions of service empowerment.

Organizational Management: What Service Providers are Doing While Researchers are Disseminating Interventions...156-175
Susan D. Phillips, PhD, and Charlene A. Allred, PhD
Abstract: Much of the recent discussion about how to make interventions with demonstrated effectiveness more routinely available to clients emphasizes the role of change agents in promoting service providers’ use of new interventions. This study provides a complimentary perspective; it describes what happens in service provider organizations as they go about making changes in the services they provide. The data used in this study come from quarterly progress reports of participants in the National Child Traumatic Stress Network. The results provide a roadmap for anticipating the types of efforts and extent of changes that may need to occur for organizations to learn about interventions, form favorable opinions toward them, and integrate them into the services they offer.

Toward the Implementation of Mental Health Consumer Providers Services...176-195
Matthew Chinman, PhD, Alexander S. Young, MD, MSHS, Joseph Hassell, MA, and Larry Davidson, PhD
Abstract: Encouraged by the New Freedom Commission, mental health systems such as the VA are now becoming more recovery-oriented. Consumer providers (CPs)—those with serious mental illness who are further along in recovery who provide services to others with similar mental health problems—are viewed as a key part of this change. However, organizational change theories suggest that careful consideration of implementation issues is critical when disseminating new and sometimes controversial services into existing organizations. Therefore, to guide the dissemination of CP services, the literature on the effectiveness of CPs was reviewed and interviews, focus groups, and a brief survey of 110 administrators, providers, and patients were conducted at three large VA clinics in Southern California. Questions focused on their perceptions of feasibility and acceptability of CP services. Using literature and study findings, an organizational change framework and other strategies to overcome potential implementation challenges of CP services are suggested.

MHSPY: A Children’s Health Initiative for Maintaining At-Risk Youth in the Community...196-212
Katherine E. Grimes, MD, MPH, and Brian Mullin
Abstract: Massachusetts-MHSPY is a home-based clinical intervention which seeks to maintain youth with severe functional impairment in the community via delivery of integrated primary care, mental health, substance abuse, and social services. Using blended public agency funding, traditional and non-traditional services are provided within a private, not-for-profit, managed care organization. Individualized, comprehensive care plans are developed by a MHSPY Care Manager, who works intensively with the family and the Care Planning Team to identify needs and resources. Data on clinical functioning is collected at baseline and every six months during the program. Service utilization and cost are measured on a quarterly basis. Family, youth, and agency satisfaction ratings are collected at disenrollment. Aggregate analyses based on four years of data show that MHSPY participants have improved clinical functioning, including significant reduction in risk to self and others. They also experience reduced service utilization and cost and high rates of family satisfaction.

The Use of Logistic Regression to Enhance Risk Assessment and Decision Making by Mental Health Administrators..213-224
Anthony A. Menditto, PhD, Donald M. Linhorst, PhD, MSW, James C. Coleman, PhD, and Niels C. Beck, PhD
Abstract: Development of policies and procedures to contend with the risks presented by elopement, aggression, and suicidal behaviors are long standing challenges for mental health administrators. Guidance in making such judgments can be obtained through the use of a multivariate statistical technique known as logistic regression. This procedure can be used to develop a predictive equation that is mathematically formulated to use the best combination of predictors, rather than considering just one factor at a time. This paper presents an overview of logistic regression and its utility in mental health administrative decision making. A case example of its application is presented using data on elopements from Missouri’s long-term state psychiatric hospitals. Ultimately, the use of statistical prediction analyses tempered with differential qualitative weighting of classification errors can augment decision making processes in a manner that provides guidance and flexibility while wrestling with the complex problem of risk assessment and decision making.

A Comparison of Mothers with Co-occurring Disorders and Histories of Violence Living with or Separated from Minor Children...225-243
Joanne Nicholson, PhD, Norma Finkelstein, PhD, Valerie Williams, MA, MS, Jennifer Thom, MA, Chanson Noether, MA, and Megan DeVilbiss, BSW
Abstract: Data from the Women with Co-occurring Disorders and Histories of Violence Study are used to examine characteristics distinguishing mothers currently providing care for all their minor children (n = 558), from mothers separated from one or more minor children (n = 1396). Mothers are described and compared on background characteristics and experiences, well being and current functioning, situational context, and services used. Analyses control for number of children, race, and years of education. Mothers separated from children have more children, less education, have more often been homeless, in juvenile detention or jail, and have lower incomes than mothers living with all their children. Mothers separated from children have more extensive experiences of traumatic and stressful life events, and the groups differ in current functioning and patterns of services used. While cross-sectional data do not allow causal inferences, challenges faced by mothers have significant implications for policy and programs.

Evidence-based Treatments in the Field: A Brief Report on Provider Knowledge, Implementation, and Practice...244-253
Christine M. Walrath, PhD, Angela K. Sheehan, MPA, E. Wayne Holden, PhD, Mario Hernandez, PhD, and Gary M. Blau, PhD
Abstract: This study examined familiarity, perceived effectiveness, and implementation of evidence-based treatments for children in community settings. A sample of service providers in agencies affiliated with federal programs to improve children's mental health services was identified using a snowball sampling procedure. Forty-four percent of the sample (n = 616) responded to a Web-based survey designed to collect data on evidence-based treatments. High familiarity with, relatively high-perceived effectiveness, and generally high use of evidence-based treatments were reported. Partial implementation of treatment protocols within the context of few agency mandates and widely ranging supports for the implementation of evidence-based treatments was found. Results support the inclusion of more complex models of diffusion, dissemination and implementation in research, and development efforts for evidence-based treatments.

Measuring Use of Health Services for At-Risk Drinkers: How Brief Can You Get?...254-264
Brenda M. Booth, PhD, JoAnn E. Kirchner, MD, Stacy M. Fortney, MA, Xiaotong Han, MS,Carol R. Thrush, MA, and Michael T. French, PhD
Abstract: This study examines the validity, utility, and costs of using a brief telephone-administered instrument, the Brief Health Services Questionnaire (BHSQ), for self-reported health care provider contacts relative to collection and Abstract:ion of complete medical records. The study sample was 441 community-dwelling at-risk drinkers who participated in an 18-month longitudinal study. Agreement between BHSQ self-reports and Abstract:ed provider contacts was good to very good for general medical (79% agreement, kappa = .50) and specialty mental health contacts (93% agreement, kappa = .60), but low for “other” miscellaneous health contacts (61% agreement, kappa = .04). Average cost to collect and Abstract: complete medical records was $424 per study participant whereas average cost to administer only the BHSQ was $31 per participant. Although it is not possible to conduct a formal cost-effectiveness analysis, results suggest the BHSQ is a viable option for collecting self-reported health provider contacts in a sample of at-risk drinkers, with definite cost advantages over more elaborate data collection methods.

A Neuroscientist – Consumer Alliance to Transform Mental Health Care...265-274
Amelia Compagni, PhD and Ronald W. Manderscheid, PhD
Abstract: The field of mental health has long suffered from a lack of convergence of disciplines that deal with the mind, the brain and behavior. This mind-brain dualism has been particularly detrimental for consumers and their families who daily face stigma and discrimination. The understanding of the brain and its dysfunctions has benefited from the study of the human genome and, in particular, of the mutations and variations in its code. This analysis permits a better understanding of the biological basis of mental disease and will soon inform a generation of new diagnostic tools and individualized pharmacological therapies. A biological perspective on mental illness will be complemented by the analysis of the social factors influencing people’s behavior and their impact on brain biology and gene function. Neurobiology has progressed to a level for which the knowledge that is generated, even if still colored with uncertainty, could represent a catalyst for the creation of an alliance between neuroscientists and consumers. This partnership has the potential to benefit both parties but will require some concrete steps that might be outside of the usual courses of action for both consumers and scientists. It is by building collaborations based on personal contact and information sharing that a transformation of the mental health care system can occur.

Number 3 / October 2006

REGULAR ARTICLES
Treatment Outcomes for Substance Abuse among Adolescents with Learning Disorders...275-286
Jennifer Yu, ScD, Stephen Buka, ScD, Garrett Fitzmaurice, ScD, and Marie McCormick, MD, ScD
Abstract: This paper assesses whether chemically dependent adolescents with comorbid learning disorders (LD) derived less effective treatment results when compared to chemically dependent adolescents without LD, and examines the moderating effects of prior treatments, treatment length, and treatment completion. 201 adolescents were recruited between 1992-1993 from Massachusetts residential treatment centers, and subsequently followed up six months after enrollment. Compared to chemically dependent teenagers without LD, those with LD were twice as likely to re-use substances at least once by follow-up. LD teenagers were more likely to attend Alcoholics/Narcotics Anonymous if they had prior admissions to treatment programs and longer treatment length. LD teenagers who completed treatment also experienced a greater decrease in current depression compared to LD teenagers not completing the treatment. This study is the first to consider outcomes of substance abuse treatment for adolescents with LD and contributes to the growing literature on comorbidity and substance abuse treatment.

Employment and Mental Health Service Utilization in Washington State...287-303
Gordon Hannah, PhD and Judy Hall, PhD
Abstract: This study examined employment among individuals utilizing publicly funded mental health services in Washington State during a two-year period through the analysis of archival administrative data. The mean income found in this study was higher than that reported in the supported employment literature. This difference likely reflects the inclusion of individuals with less severe mental illness and ongoing employment who are typically excluded from studies of supported employment. Individuals in this study were employed in all industrial sectors in a distribution similar to the general population, although somewhat over-represented in service industries. Employment rates varied from 15% to 21% over a three-year period and did not appear to increase after treatment. Employment rates tended to decline after the receipt of public support. Among individuals who lost employment, service utilization was found to increase prior to the loss of employment. Policy implications are discussed.

Reliability and Validity of the BASIS-24 Mental Health Survey for Whites, African-Americans, and Latinos...304-323
Susan Eisen, PhD, Mariana Gerena, PhD, Gayatri Ranganathan, MS, David Esch, PhD, and Thomas Idiculla, MSW
Abstract: Increasing racial and ethnic diversity calls for mental health assessment instruments that are appropriate, reliable and valid for the wide range of cultures that comprise the current U.S. population. However, most assessment instruments have not been tested on diverse samples. This study assessed psychometric properties and sensitivity to change of the revised Behavior and Symptom Identification Scale (BASIS-24©) among the three largest race/ethnicity groups in the U.S.: Whites, African-Americans and Latinos. BASIS-24© assessments were obtained for 2,436 inpatients and 2,975 outpatients treated at one of 27 mental health and/or substance abuse programs. Confirmatory factor analysis and several psychometric tests supported the factor structure, reliability, concurrent validity and sensitivity of the instrument within each race/ethnicity group, although discriminant validity may be weaker for African-Americans and Latinos than for Whites. Further research is needed to test and validate assessment instruments with other race/ethnicity groups.

Medicaid Coverage and Access to Publicly Funded Opiate Treatment...324-334
Dennis Deck, PhD, Wyndy Wiitala, PhD, and Kathy Laws
Abstract: This observational study examines changes in access to methadone maintenance treatment following Oregon’s decision to remove substance abuse treatment from the Medicaid benefit for an expansion population. Access was compared before and after the benefit change for two cohorts of adults addicted to opiates presenting for publicly funded treatment. Propensity score analysis helped model some selective disenrollment from Medicaid that occurred after the benefit change. Logistic regression was used to compare access to methadone by cohort controlling for client characteristics. Opiate users presenting for publicly funded treatment after the change were less than half as likely (OR = .40) to be placed in an opiate treatment program compared to the prior year. Further analysis revealed that those with no recent treatment history were less likely to present for treatment after the benefit change. These results have implications for states considering Medicaid cuts, especially if the anticipated increases in illegal activity, emergency room utilization, unemployment, and mortality can be demonstrated.

Medical Cost Offset Following Treatment Referral for Alcohol and Other Drug Use Disorders in a Group Model HMO...335-346
Michael Polen, PhD, Donald Freeborn, PhD, Frances Lynch, PhD, John Mullooly, PhD, and Daniel Dickinson, MA, CADC
Abstract: The purpose of this study was to determine whether specialty alcohol and other drug (AOD) treatment is associated with reduced subsequent medical care costs. AOD treatment costs and medical costs in a group model health maintenance organization (HMO) were collected for up to 6 years on 1472 HMO members who were recommended for specialty AOD treatment, and on 738 members without AOD diagnoses or treatment. Addiction Severity Index measures were also obtained from a sample of 293 of those recommended for treatment. Changes in medical costs did not differ between treatment and comparison groups. Nor did individuals with improved treatment outcomes have greater reductions in medical costs. AOD treatment costs were not inversely related to subsequent medical costs, except for a subgroup with recent AOD treatment. In the interviewed sample, better treatment outcomes did not predict lower subsequent medical costs. Multiple treatment episodes may hold promise for producing cost-offsets.

Use of Depression Education Materials to Improve Treatment Compliance of Primary Care Patients...347-353
Francisca Azocar, PhD and Robert Branstrom, PhD
Abstract: In a collaborative effort between a managed behavioral health organization, an HMO and a state employer, this pilot study tested the value of mailing a depression education flyer to primary care patients recently prescribed antidepressant medications and an informational letter to their physician. The intervention, designed to improve use of behavioral health care services and antidepressant medication adherence, had a moderate impact on consistency of antidepressant medication use and on use of psychotherapy in combination with antidepressant medications. Additionally, intervention patients on combination treatment were more likely to stay on antidepressant medications into the continuation phase of treatment.

An Examination of Fulfilled Housing Preferences and Quality of Life among Homeless Persons with Mental Illness and/or Substance Use Disorders...354-365
Maria O’Connell, PhD, Robert Rosenheck, MD, Wesley Kasprow, PhD and Linda Frisman, PhD
Abstract: This study examined the types of housing features considered important to a sample of homeless persons diagnosed with a mental illness and/or substance use disorder and the relationship between the degree to which important features were obtained in subsequent housing and subjective quality of life, clinical and housing outcomes at three-month and one-year follow-up periods. After controlling for significant clinical and sociodemographic covariates, results from regression analyses indicate that the degree to which a client’s individual housing preferences were realized in dwellings is significantly associated with greater quality of life in the future, but not clinical outcomes or housing tenure.

Medical Problems among Adolescents in U.S. Mental Health Services: Relationship to Functional Impairment...366-379
Lynn Warner, PhD
Abstract: This study provides information about the extent of comorbidity between medical and behavioral problems among adolescents in mental health services, describes the clinical and sociodemographic characteristics of adolescents with both problems, and discusses the consequences or comorbidity for service delivery. Nationally representative mental health service use data for adolescents (age 12-17) in inpatient, outpatient and residential mental health service settings (weighted N=296,755) were used. Close to one fifth (18.9%) of the adolescents had a medical problem, and adolescents with anxiety and pervasive developmental disorders had the highest rates of medical problems. In multivariate logistic regressions, having a medical problem significantly increased the odds of serious functional impairment; having a secondary or dual psychiatric diagnosis was only significant in interaction with a medical problem. The results underscore the need for adolescent behavioral health research and practice to attend to multiple influences on functioning.

Number 4 / October 2006

Emotional Distress and Mental Health Service Use among Urban Homeless Adolescents...381-393
M. Rosa Soloio, MD, MPH, Norweeta G. Milburn, PhD, Ronald M. Andersen, PhD, Sharone Trifskin, MA, and Michael A. Rodriguez, MD, MPH.
Abstract: The Expanded Behavioral Model for Vulnerable Populations was used to examine the predisposing, enabling, and need factors associated with mental health service use in a homeless adolescent sample (N=688). Among all youth, 32% perceived a need for help with mental health problems and 15% met Brief-Symptom Inventory (BSI) criteria for emotional distress. The rate of mental health service use in our sample was 32%. One enabling factor, having a case manager/discussed mental health concerns, and one need factor, which met criteria for BSI, were found to be associated with mental health service use in the past 3 months. The majority of youth who used mental health services had obtained services from crisis centers. Among those who perceived a need for help with mental health problems but who did not use services, the most common barrier was not knowing where to go or what service to use (57%). These findings suggest that due to the high prevalence of mental health problems among homeless youth, it would be helpful for service providers coming into contact with youth to make them aware of existing community resources for mental health services; making youth aware of these resources may in turn decrease the rate of crisis center use and instead allow youth to receive mental health services in outpatient settings that provide continuity of care.

Addiction Treatment Agencies' Use of Data: A Qualitative Assessment...394-407
Jennifer Wisdom, PhD, MPH, James H. Ford II, PhD, Randy A. Hayes, MS, LCPC, Eldon Edmundson, PhD, Kim Hoffman, BA, and Dennis McCarty, PhD
Abstract: Addiction treatment agencies typically do not prioritize data collection, management, and analysis, and these agencies may have barriers to integrating data in agency quality improvement. This article describes qualitative findings from an intervention designed to teach 23 addiction treatment agencies how to make data-driven decisions to improve client access to and retention in care. Agencies demonstrated success adopting process improvement and data-driven strategies to make improvements in care. Barriers to adding a process improvement and data-driven focus to care included a lack of a data-based decision making culture, lack of expertise and other resources, treatment system complexity, and resistance. Factors related to the successful adoption of process-focused data include agency leadership valuing data and providing resources, staff training on data collection and use, sharing of change results, and success in making data-driven decisions.

Caregiver, Child, Family and Service System Contributors to Caregiver strain in Two Child Mental Health Service Systems...408-422
Ana Maria Brannan, PhD and Craig Anne Heflinger, PhD
Abstract: Children's mental health researchers are increasingly recognizing the importance of caregiver strain (i.e., the impact on families of caring for children with emotional and behavioral disorders). This study examined the caregiver, child, family, and service variables associated with caregiver strain with special attention to the role of barriers to care. These relationships were compared across enrollees in a managed care Medicaid and a traditional fee-for-service system. Findings indicated that severity of child problems was the most consistent predictor of caregiver strain. Although there was considerable similarity in the variables associated with caregiver strain across the two systems, important differences were also evident. Caregivers in the managed care setting were significantly more likely to report provider/payer-related barriers to care. Provider/payer barriers predicted strain in the managed care sample. In the fee-for-service system, barriers related to family perceptions and inconvenient location and appointment times were significant predictors.

Attitudes About Stimulant Medication for ADHD Among African-American Families in an Inner City Community...423-430
Susan dosReis, PhD, Arlene Butz, ScD, RN, Paul H. Lipkin, MD, Julia S. Anixt, MD, Courtney L. Weiner, BS, and Robin Chernoff, MD
Abstrac: Limited information exists on views among African American families living in low-income, inner-city communities regarding the treatment of children with attention-deficit/hyperactivity disorder (ADHD). Parents of children treated for ADHD in an urban primary care setting were recruited to complete a survey to assess attitudes toward stimulant medications. Although most (71%) were initially hesitant to use stimulants based on what they heard in the lay press, 63% would recommend stimulant medication to a relative/friend whose child had ADHD. Approximately 17% believed stimulants led to drug abuse, 21% preferred counseling over medication, 21% felt medications had bad side effects, and 23% believed that too many children were medicated for ADHD. Most (90%) felt the medication was safe if a physician recommended it. Views did not differ between participants whose child had or had not received counseling. Additional studies are needed to clarify whether such views impact treatment choices and health outcomes.

Pregnant Women in Women-Only and Mixed-Gender Substance Abuse Treatment Programs: A Comparison of Client Characteristics and Program Services..431-443
Yih-Ing Hser, PhD, and Noosha Niv, PhD
Abstract: This study compared characteristics of pregnant women treated in women-only (WO) and mixed-gender (MG) substance abuse treatment programs and compared services provided by these two types of programs. Participants were 407 pregnant women who were admitted to 7 WO programs and 29 MG programs in 13 counties across California during 2000–2002. Pregnant women treated in WO programs demonstrated greater severity in drug use, legal problems, and psychiatric problems than those treated in the MG programs. They were also less likely to be employed and more likely to be homeless. Women-only programs were more likely to offer child care, children’s psychological services, and HIV testing. The greater problem severity of pregnant women treated in WO programs suggests that these specialized services are filling an important gap in addiction services, although further expansion is warranted in psychiatric, legal, and employment services.

Child Sociodemographic Characteristics and Common Psychiatric Diagnoses in Medicaid Encounter Data: Are they Valid?...444-452
Penelope K. Knapp, MD, Michael S. Hurlburt, PhD, Eric C. Kostello, PhD, Heather Ladd, MS, Lingqi Tang, PhD, and Bonnie T. Zima, MD, MPH
Abstract: This study describes the rate that Medicaid encounter data on gender, race/ethnicity, and diagnosis matched information in the medical record, among a statewide sample of Medicaid children who received ongoing care for attention deficit hyperactivity disorder (ADHD), conduct disorder (CD), and major depression (MD) in outpatient specialty mental health clinics in 1998–1999. The match rate for gender was 99%; and for race/ethnicity it was 71.8%, 90.5%, and 89.7% for Caucasian, African American, and Hispanic children, respectively. Misidentified Caucasian children were more likely to be recorded as African American or Hispanic than misidentified minority children to be recorded as Caucasian. Diagnosis match rates were high (ADHD: 98%, CD: 89%, MD: 89%). If the California Department of Mental Health relied solely on Medicaid encounter data, misclassification of African American or Hispanic children as Caucasian could produce an underestimate of their service use.

Seeking Safety Therapy for Adolescent Girls with PTSD and Substance Use Disorder: A Randomized Controlled Trial..453-463
Lisa M. Najavits, PhD, Robert J. Gallop, PhD, and Roger D. Weiss, MD
Abstract: This randomized, controlled trial evaluated a manualized psychotherapy, Seeking Safety (SS), for posttraumatic stress disorder (PTSD) and substance use disorder (SUD) in adolescent females. To our knowledge, no prior study has evaluated any psychotherapy designed for this population. SS was compared to treatment as usual (TAU) for 33 outpatients, at intake, end-of-treatment, and 3 months follow-up. SS evidenced significantly better outcomes than TAU in a variety of domains at posttreatment, including substance use and associated problems, some trauma-related symptoms, cognitions related to SUD and PTSD, and several areas of pathology not targeted in the treatment (e.g., anorexia, somatization). Effect sizes were generally in the moderate to high range. Some gains were sustained at follow-up. SS appears a promising treatment for this population, but needs further study and perhaps additional clinical modification.

Psychometrics of the Recovery Process Inventory...464-473
Jeanette M. Jerrell, PhD, Victoria C. Cousins, and Katherine M. Roberts, MPH
Abstract: The reliability and validity of the Recovery Process Inventory (RPI) were assessed in a statewide sample of 459 persons with severe mental illness from a public mental health system. Six factors were identified that reflect important aspects of the recovery process, have good internal consistency and fair to moderate test–retest reliability, and yield moderate to good convergent validity on the majority of subscales. The 22-item RPI performance across these dimensions and its comparability to the Recovery Assessment Scale and related instruments, e.g., empowerment, confidence, and healing, make it a potentially valuable tool in survey research regarding the process and outcomes of recovery among mental health consumers. Suggestions for its further research and development, and use of the scale in conjunction with the Mental Health Statistics Improvement Program Adult Consumer Survey are discussed.

Caregivers’ Perceptions of Child Mental Health Needs and Service Utilization: An Urban 8-Year Old Sample...474-482
Richard Thompson, PhD and Maria A. May, BA
Abstract: This study extended previous research on mental health utilization to a sample of 214 preadolescent children and their caregivers. Predictors of two distinct phases of service utilization were tentatively examined in multivariate analyses: caregivers' perceptions that children needed services and receipt of those services by children. Of these children, 24.8% were perceived by their caregivers as needing mental health services; 11.7% received mental health services and 13.1% did not. Internalizing behavioral problems increased children's likelihood of being seen as needing services, but failed to increase likelihood of receiving services. Four factors predicted receipt of mental health services: relative lack of poverty, non-African American ethnicity, externalizing behavior problems, and child history of maltreatment. Implications for services targeted at preadolescent children are discussed.

Psychometrics of the MHSIP Adult Consumer Survey...483-488
Jeanette M. Jerrell, PhD
Abstract: The reliability and validity of the Mental Health Statistics Improvement Program (MHSIP) Adult Consumer Survey were assessed in a statewide convenience sample of 459 persons with severe mental illness served through a public mental health system. Consistent with previous findings and the intent of its developers, three factors were identified that demonstrate good internal consistency, moderate test–retest reliability, and good convergent validity with consumer perceptions of other aspects of their care. The reliability and validity of the MHSIP Adult Consumer Survey documented in this study underscore its scientific and practical utility as an abbreviated tool for assessing access, quality and appropriateness, and outcome in mental health service systems.