JBHSR Recent Issues

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

Volume 35, 2008

Number 1 / January 2008

COMMENTARY
Co-Occurring Disorders — Progress?
Linda Rosenberg
Without Abstract

REGULAR ARTICLES
Changing Mental Health Gatekeeping: Effects on Performance Indicators...3-19
Elizabeth Levy Merrick, Dominic Hodgkin, Constance M. Horgan, Deborah W. Garnick and Thomas J. McLaughlin
Abstract: This study evaluated how a change in gatekeeping model at a health maintenance organization affected performance indicators for specialty outpatient mental health care. Gatekeeping in one division changed from in-person evaluations to a call center with routine authorization for the first eight visits. Using 1996–1999 claims data (including 2 years pre- and 2 years postintervention), the study compared performance indicator results in the affected division and another where the model did not change. Subjects included 122,751 continuously enrolled persons. Dependent variables were mental health emergency room use, treatment initiation, treatment engagement, and family treatment for child patients. After controlling for secular trends at the other division and enrollee characteristics, the division that changed gatekeeping experienced no significant impact on most indicators and an increase in family treatment for children. The move to call-center gatekeeping did not appear to have a negative impact on treatment process as reflected in these indicators.

Disparities in Use of Mental Health and Substance Abuse Services by Asian and Native Hawaiian/Other Pacific Islander Women...20-36
Van M. Ta, Hee-soon Juon, Andrea C. Gielen, Donald Steinwachs and Anne Duggan
Abstract: The purpose of this study was to determine if disparities exist in lifetime utilization of mental health/substance abuse services among Asian, Native Hawaiian/Other Pacific Islander (NHOPI) and white mothers. The study sample was comprised of mothers assessed to be at-risk (n = 491) and not at-risk (n = 218) for child maltreatment in the Hawaii Healthy Start Program study. Multiple logistic regression models were used to test the effects of predisposing, need, and enabling factors on utilization of services. Results revealed that, among mothers with depressive symptoms, compared with whites, Asians and NHOPI were significantly less likely to have received services. There were no significant racial differences in use of mental health/substance use services by other factors. These results suggest that racial disparities exist in utilization of mental health/substance abuse services among mothers with depressive symptoms. Future research is needed to identify barriers and facilitators to accessing needed services for Asian and NHOPI women.

Depression in Public Community Long-Term Care: Implications for Intervention Development...37-51
Nancy Morrow-Howell, Enola Proctor, Sunha Choi, Lisa Lawrence and Ashley Brooks, et al.
Abstract: The objective of this paper is to increase understanding of geriatric depression in the public community long-term care system to guide intervention development. Protocols included screening 1,170 new clients of a public community long-term care agency and interviewing all clients with major, dysthymia, or subthreshold depression (n = 299) and a randomly selected subset of nondepressed older adults (n = 315) at baseline, 6-month, and 1 year. Six percent had major depression, one-half of a percent had dysthymia only, and another 19% had subthreshold depression. Over the year observation period, 40% were persistently depressed; 32% were assessed as depressed only at the first observation; and the remainder was intermittently depressed. There were high levels of comorbid medical, functional, and psychosocial conditions. Mental health service use was low, and clients reported attitudinal and other barriers to depression treatment. Findings suggest the need for universal screening for depression with some strategies for triaging the most severely and persistently depressed for treatment. Although there will be challenges to the development of depression interventions, the public community long-term care system has high potential to assist vulnerable older adults receive help with depression.

Outcomes for Youths with Early- and Very-Early-Onset Bipolar I Disorder...52-59
Jeanette M. Jerrell and Ervin D. Prewette
Abstract: To examine differences between children and adolescents with bipolar I disorder in a public mental health system, medical records and computerized data files were reviewed for 82 newly admitted patients, focusing on documented diagnoses, clinical features, services and medications received, and psychosocial functioning changes over 18 months. Suicidality, violent or aggressive behavior, psychotic features, and severe/frequent mood changes were prevalent in 40–70% of the cohort, with children more likely to have comorbid attention deficit hyperactivity disorder and adolescents more likely to have substance-related problems. For clients who remained in treatment, functioning ratings improved over 18 months on multiple dimensions but were unrelated to type of service or pharmacotherapy received.

Using the Resident Assessment Instrument-Mental Health (RAI-MH) to Determine Levels of Care for Individuals with Serious Mental Illness...60-70
Carrie Gibbons, Sacha Dubois, Stephanie Ross, Barbara Parker and Kelly Morris, et al.

Abstract: This paper outlines the development of an algorithm to determine appropriate levels of care (LOC) for individuals with a serious mental illness (SMI). The algorithm, drew on several domains of the Resident Assessment Instrument-Mental Health (RAI-MH) to support a statistical model that would explain a maximum of variance with the gold standard, a consensus-based global rating of required LOC. The RAI-MH model explained 67.5% of the variance. The validity of the model was further examined by determining how the discrepancy between the current and predicted levels of care related to psychiatric outcomes. The results demonstrated that undersupported clients experienced significant negative psychiatric outcomes compared to clients receiving adequate care. Although the model based on the RAI-MH is not perfect, the results warrant further research to determine its usefulness in predicting required LOC.

Consumer Perceptions of Integrated Trauma-Informed Services Among Women with Co-Occurring Disorders...71-90
Colleen Clark, M. Scott Young, Elizabeth Jackson, Carla Graeber and Ruta Mazelis, et al.
Abstract: As part of a national, multi-site treatment outcome study, an instrument was designed to assess consumers’ perceptions of key services integrating trauma, mental health, and substance abuse issues, the Consumer Perceptions of Care (CPC). This study evaluates the psychometric properties of this instrument and analyzes consumers’ perceptions of the services they received. The results suggest that the measure has four factors: services integration, choice in services, trauma-informed assessment, and respect for cultural identity. These factors demonstrated adequate reliability, and the overall results suggested that the measure is a reliable, sensitive, and valid reflection of consumers’ perceptions of their services and their providers for diverse racial and ethnic groups. Women in the intervention programs perceived their services as more highly integrated for trauma, mental health, and substance use than women in the services as usual or comparison programs, supporting its utility as a measure of programs designed to provide integrated services.

BRIEF REPORTS
Healthcare Utilization of Individuals with Opiate Use Disorders: An Analysis of Integrated Medicaid and State Mental Health/Substance Abuse Agency Data...91-106
Jeremy Bray, Rita Vandivort, Joan Dilonardo, Laura Dunlap and Don Schroeder, et al.
Abstract: Data from the Substance Abuse and Mental Health Services Administration’s Integrated Database (IDB) were used to examine the service use patterns of individuals with possible opiate use disorders in Washington State. Results indicate that regardless of Medicaid enrollment status, individuals who received mental health (MH) or substance abuse (SA) services only through state agencies received no inpatient substance abuse service. Furthermore, when compared with individuals who received at least one MH/SA service through Medicaid, those who received services only through the state agencies were less likely to have received any MH services and were more likely to have received residential SA services. This analysis highlights the importance of using integrated client data in providing a more comprehensive understanding of services to inform policy and raises significant questions about how regulatory requirements affecting different funding mechanisms might drive settings of care in ways not related to the care needed.

Eliminating The Wait For Mental Health Services...107-114
Marian E. Williams, James Latta and Persila Conversano
Abstract: Timely access to mental health services is critical to successful treatment of adults with severe and persistent mental illness, and timeliness is a key quality indicator in calls for improvement to the health care system. Waiting weeks for a psychiatric appointment results in increased psychiatric hospitalizations, decompensation, and risk for suicide. However, many community mental health administrators assume that waiting lists for services are inevitable given the high demand for services. The present study evaluates the successful efforts of a large urban community mental health center to eliminate the wait for psychiatric services in an adult outpatient setting. Through systematic changes in the service delivery system, the wait time for a psychiatric appointment was reduced from 13 days to 0 days, and the no-show rate dropped from 52 to 18%. Furthermore, these changes were associated with reduced psychiatric hospitalizations and improved staff morale and teamwork. The change processes implemented can be successfully applied to other systems problems confronting mental health agencies.

Time Trends and Predictors of Suicide Among Mental Health Outpatients in the Department of Veterans Affairs...115-124
Mayur M. Desai, Robert A. Rosenheck and Rani A. Desai
Abstract: Using merged Veterans Affairs (VA) and National Death Index data, this study examined changes in suicide rate among three cohorts of VA mental health outpatients during a time of extensive bed closures and system-wide reorganization (1995, N = 76,105; 1997, N = 81,512; and 2001, N = 102,184). There was a decreasing but nonsignificant trend in suicide rates over time—13.2, 11.4, and 10.3 per 10,000 person-years, respectively. Multivariable predictors of suicide included both younger and older ages (U-shaped association). At the facility level, there was an association between greater per capita outpatient mental health expenditure and reduced suicide risk. The model also showed a protective effect associated with increased mental health spending on inpatient services, and that outpatients at facilities with larger mental health programs, as measured by patient volume, were at greater risk for suicide than were those in smaller programs. Although more chronic patients may have been underrepresented to some extent as a result of the sampling methodology, these findings provide generally reassuring evidence that overall suicide rates have not been adversely affected by VA system changes. Nevertheless, they highlight the importance of funding for mental health services as well as the implications of changing demographics in the VA population.

Number 2 / April 2008

COMMENTARY
Lack of Diversity in Behavioral Healthcare Leadership Reflected in Services...125-127
Linda Rosenberg
Abstract: America’s rapidly changing demographics present an enormous challenge for today’s healthcare leaders to redesign the organization and delivery of care to accommodate people who now represent every language, culture and religious belief in the world. So will mental health and addictions services in this country be ready to address the unique needs of these multicultural patients? A survey of the present landscape in 2008 tells us that we have a long, long way to go. Not only are mental health and addictions fields lacking in cultural competency, but there is little diversity in our leadership ranks. Top administrators and executives in behavioral health today are overwhelmingly non-Hispanic whites. This lack of cultural diversity among our leaders will lead to an ever-widening gap in the current chasm of racial and ethnic disparities in healthcare.

REGULAR ARTICLES
Racial and Ethnic Disparities in the Use of Mental Health Services...128-141
Aram Dobalian and Patrick A. Rivers
Abstract: The authors used data from the 1998–1999 Community Tracking Study (CTS) household survey to examine variations in predictors of use of mental health services among different racial and ethnic groups (white, African American, Hispanic, and other). African Americans and Hispanics were less likely to have visited a mental health professional (MHP) in the prior year than were whites. Independent of health insurance and health status, low- to middle-income African Americans may be at particular risk for inadequate use of an MHP compared to higher-income African Americans. Similarly, upper-income Hispanics were more likely to have visited an MHP than Hispanics in the lowest income range. Adults aged 50 and older were less likely to visit an MHP than individuals aged 18–49. Depressed men were more likely to visit an MHP than depressed women. Efforts to reduce disparities should focus on lower-income racial and ethnic minorities.

The Use of Public Mental Health Services by Older Californians and Complementary Service System Effects...142-157
Brian Kaskie, Daniel Gregory and Joseph Cavanaugh
Abstract: Older adults with mental disorders are less likely to use specialty care than any other population group. In this study, we created a multisource secondary data file and examined the use of public mental health services by older adults across California’s county-based community mental health systems. We specifically considered complementary service system effects relative to compositional effects representing individual service users and more general contextual effects. Service use was defined in terms of treated prevalence rates, repeat service use, and intensity of service use. Differences across 49 county-based systems were evaluated by regressing the 3 service use measures onto compositional characteristics including client age, diagnosis, and insurance status; variables reflecting complementary service systems including mental health, health, long-term care, and aging services; and other contextual effects such as the size of the county population and average education level. The analyses were adjusted statistically for regional, yearly, and seasonal differences, and for longitudinal clustering within the 49 counties over 12 quarters of observation. Results suggested that older adults’ service use varied significantly from one county to the next, and differences were associated with both compositional and contextual effects. As the aging population continues to grow and place an increasing demand on public mental health service systems, this research may help policy makers and program administrators understand some of the critical elements that affect service use patterns among older adults.

Challenges Substance Abuse Treatment Agencies Faced in Adoption of Computer-Based Technology to Improve Assessment...158-169
Jennifer Wisdom, Roy Gabriel, Eldon Edmundson, Sarann Bielavitz and Joe Hromco
Abstract: The Oregon Practice Improvement Collaborative provided resources and technical assistance to help five Oregon drug treatment agencies adopt computer-based technology of their choice to support client progress in treatment. This manuscript describes agency processes related to that adoption of technology. Agencies chose computer programs to improve clinical outcomes, reduce staff burden, and respond to external pressures. Agencies used a combination of top-down and bottom-up approaches to involve staff in decision making. Agencies guided staff from current practice to a standardized paper-and-pencil tool, then from the paper-and-pencil tool to its electronic version. Staff experienced barriers in technology-related training, logistical challenges in integrating the technology, and sustaining the technology.

Influences on Practitioner Treatment Selection: Best Research Evidence and Other Considerations...170-178
Timothy D. Nelson and Ric G. Steele
Abstract: The recent movement toward evidence-based practice in mental health services has highlighted the importance of research evidence in treatment decisions. However, the fact that many treatments with strong research support are not widely used in clinical settings suggests that practitioners’ decisions are not based on research alone but rather are influenced by other considerations. This study examines the relative importance of various considerations on practitioner treatment selection using a national survey of mental health practitioners including doctoral-level psychologists, master’s-level psychologists, and master’s-level clinical social workers (N = 206). Results indicate that practitioners are influenced by a range of considerations including empirical evidence from applied field studies, the perceived flexibility of a treatment, and the appeal of a treatment to colleagues and clients. These findings are discussed within the context of efforts to design, evaluate, and disseminate treatments with research support into clinical settings.

A Spatial Needs Assessment of Indigent Acute Psychiatric Discharges in California...179-194
Jim E. Banta, Seth Wiafe, Sam Soret and Charles Holzer
Abstract: State and local mental health agencies have responsibility for the psychiatric care of Medicaid beneficiaries and indigents meeting pre-defined criteria. A significant uninsured caseload may prove draining to agencies and hospitals mandated to provide emergency services, resulting in limited access. A spatial needs assessment was conducted to find areas having a greater relative proportion of indigent psychiatric hospitalizations. Robust descriptive and inferential spatial techniques were applied to California 1999–2003 public-use Zip-Code-level hospital discharge data to create maps. These maps reveal a more stable view of spatial variation in the proportion of indigent discharges compared to all psychiatric discharges. Synthetic estimation techniques were also applied to U.S. Census data to estimate the proportion of severe mental illness among households at less than 200% poverty level compared to estimated mental illness among all households. Visually comparing these maps suggests areas of potential mismatch. These results and methods may inform public decision-making.

Development and Validation of Short Versions of the Internal Mental Distress and Behavior Complexity Scales in the Global Appraisal of Individual Needs (GAIN)...195-214
Janet C. Titus, Michael L. Dennis, Richard Lennox and Christy K. Scott
Abstract: Co-occurring mental distress and behavior problems are the norm in substance abuse treatment but are often poorly assessed due to resource constraints. This paper describes the development and validation of scales measuring internalizing mental distress and externalizing behavior problems that are shorter versions of comorbidity scales found in the full Global Appraisal of Individual Needs (GAIN). GAIN data from two treatment outcome studies, one involving adolescents and the other on adults, were used in the creation and testing of the scales. Subsets of items from the full GAIN scales were selected for the short scales through the application of standard psychometric principles. The short comorbidity scales still have moderate to high reliability and are highly correlated with the full scales. Parallel tests of construct validity show no substantial loss when moving from the longer to shorter versions. The short scales maintain good sensitivity and specificity for predicting diagnostic impressions.

Employment Outcomes in a Randomized Trial of Second-Generation Antipsychotics and Perphenazine in the Treatment of Individuals with Schizophrenia...215-225
Sandra G. Resnick, Robert A. Rosenheck, Jose M. Canive, Cyril De Souza and T. Scott Stroup, et al.
Abstract: Employment has been increasingly recognized as an important goal for individuals with schizophrenia. Previous research has shown mixed results on the relationship of specific antipsychotic medications to employment outcomes, with some studies finding greater benefits for second-generation antipsychotic medications (SGAs) over first-generation antipsychotic medication (FGAs). A randomized controlled trial (CATIE) examined medication assignment and both employment outcomes and participation in psychosocial rehabilitation (PSR) among 1,121 individuals with a diagnosis of schizophrenia randomized to SGAs (olanzapine, quetiapine, risperidone, ziprasidone) or one FGA (perphenazine). Service use and employment were assessed at quarterly interviews. There were no differences between medication groups on employment outcomes or participation in PSR. Consistent with other CATIE results, there were no differences in employment or participation in PSR among these five medications, including the FGA perphenazine.

BRIEF REPORT
Associations in Sense of Coherence and Depression in Caregivers of Stroke Survivors Across 2 Years...226-234
Neale R. Chumbler, Maude R. Rittman and Samuel S. Wu
Abstract: The objective of this longitudinal study was to detect the relationship between the sense of coherence (SOC), which is an adaptive coping response, and depression in informal caregivers of stroke survivors across 2 years. One-hundred-fifteen veterans, who were hospitalized after experiencing an acute stroke, and their informal caregivers were enrolled prior to discharge. Data were collected via face-to-face in-home interviews at 1, 6, 12, 18, and 24 months after discharge. A linear mixed model was fitted to estimate the effects of the time-dependent covariates (SOC) while considering the dependence of outcome measures at repeated times. Based on the linear mixed model, caregivers with a stronger SOC were associated with lower levels of caregiver depression across 2 years following a stroke (p < 0.0001). SOC seems to be an important aspect of a caregiver’s capacity to cope after tending to the needs of a stroke patient.

BOOK REVIEW
Mindless Eating: Why We Eat More Than We Think
Brian Wansink, Ph.D.
288 Pages. ISBN: 0-553-80434-0
Julia A. Watkins
Without Abstract...235-236

Number 3 / July 2008

COMMENTARY
To Preserve, Strengthen, and Expand America’s Mental Health and Addictions Treatment Capacity...237-239
Linda Rosenberg
Without Abstract

REGULAR ARTICLE
Is It Wraparound Yet? Setting Quality Standards for Implementation of the Wraparound Process...240-252
Eric J. Bruns, Jesse C. Suter and Kristen Leverentz-Brady
Abstract:The wraparound process has increasingly been used as a mechanism to plan and coordinate services for children with behavioral health needs and their families. This has led to growing interest in assessing wraparound implementation against standards for quality. However, there has been little consideration of how best to establish such benchmarks or guidelines. Using both a norm-referenced and criterion-referenced approach, this study established preliminary criteria for assessing the adequacy of wraparound implementation using the Wraparound Fidelity Index, version 3, a multi-informant interview that assesses conformance to wraparound principles. The evaluation system was then applied to ten wraparound programs and 11 different study samples assessed via the Wraparound Fidelity Index version 3 in research studies. The system was constructed to discriminate different wraparound conditions assessed in research studies while still being attainable by the ten established wraparound programs. Implications for evaluating wraparound programs and for setting fidelity benchmarks in behavioral health services research are discussed.

REGULAR ARTICLE
The Potential to Reduce Mental Health Disparities Through the Comprehensive Community Mental Health Services for Children and Their Families Program...253-264
Richard Miech, Melissa Azur, Tracy Dusablon, Keri Jowers and Amy B. Goldstein, et al.
Abstract: Few service systems are currently in place with the explicit purpose to reduce youth mental health disparities across socioeconomic status and race–ethnicity, despite substantial interest by the federal government and other institutions to redress health disparities. This study examines the potential for the Comprehensive Community Mental Health Services for Children and Their Families Program to address health disparities, even though this program was not explicitly designed for disparity reduction. Specifically, this study examines whether program sites disproportionately provide services within their catchment areas for youth who come from poor families, who are Black, and who are Hispanic. Data for this study come from 45 sites and 19,189 youth who were enrolled in program sites from 1997 to 2005. Meta-analysis was used to generate Forest plots and to obtain single, pooled estimates of risk ratios and their standard errors across all Children’s Mental Health Initiative communities. The results indicate that in comparison to the targeted catchment area (a) the percentage poor youth in the programs was almost three times higher, (b) the percentage Black in the programs was about twice as high, and (c) the percentage Hispanic in the programs was about the same. These results indicate that the program successfully reaches disadvantaged youth and can bring substantial infrastructure to address youth mental health disparities. In fact, to the extent that the program successfully improves mental health among enrollees it may be serving as one of the largest initiatives to redress health disparities, although its role in disparity reduction is not widely recognized.

REGULAR PAPER
Reliability of Self-Reported Health Service Use: Evidence from the Women with Co-occurring Disorders, and Violence Study...265-278
Sukyung Chung, Marisa Elena Domino, Elizabeth W. Jackson and Joseph P. Morrissey
Abstract: In behavioral health services research, self-reporting provides comprehensive information on service use, but may have limited reliability because of recall bias and misclassification. This study examines test–retest reliability of self-reported health service use, factors affecting reliability, and the impact of inconsistent reporting on the robustness of cost estimates using the test–retest data from the Women, Co-occurring Disorders, and Violence Study (n = 186). Reliability varies widely across service types: moderate to substantial (k = 0.65–0.94) for any use; slight to substantial (ICC = 0.12–0.93) for quantity of use; and none to moderate (k = −0.06–0.79) for service content, but is not affected by psychiatric symptom severity. Cost estimates do not differ according to the use of test or retest data. Findings suggest that self-reporting provides reliable data on service quantity and is adequate for economic evaluations. However, self-reporting of treatment content in highly specified service categories (e.g., individual counseling during residential treatment) may not be reliable.

REGULAR ARTICLE
Mental Health and Substance Abuse Spending by Age, 2003...279-289
Tami L. Mark, Henrick J. Harwood, David C. McKusick, Edward C. King and Rita Vandivort-Warren, et al.
Abstract: This article presents national estimates of mental health and substance abuse (MHSA) spending in 2003 by age groups. Overall, 121 billion was spent on MHSA treatment across all age groups in 2003. Of the total100 billion spent on MH treatment, about 17% was spent on children and adolescents, 68% on young and mid-age adults, and 15% on older adults. MH spending per capita by age was 232 per youth,376 per young and mid-age adult, and 419 per older adult. Of the total21 billion spent on SA treatment, about 9% was spent on children and adolescents, 86% on adults ages 18 through 64, and 5% on older adults age 65 and older. SA spending per capita by age was 26 per youth,98 per mid-age adult, and $28 per older adult.

REGULAR ARTICLE
Expenditures in Mental Illness and Substance Use Disorders among Veteran Clinic Users with Diabetes...290-303
Ranjana Banerjea, Usha Sambamoorthi, David Smelson and Leonard M. Pogach
Abstract: Few studies have looked at the health-care expenditures of diabetes patients based on the type of co-occurring conditions of mental illness (MI) or substance use disorders (SUD). Our study analyzes the health-care expenditures associated with various diagnostic clusters of co-occurring drug, alcohol, tobacco use, and mental illness in veterans with diabetes. We merged Veteran Health Administration and Medicare fee-for-service claims database (fiscal years 1999 and 2000) for analysis (N = 390,253) using generalized linear models; SUD/MI were identified using International Classification of Diseases, 9th edition codes. The total average expenditures (fiscal year 2000) were lowest ($6,185) in the “No MI and No SUD” and highest ($19,801) for individuals with schizophrenia/other psychoses and alcohol/drug use. High expenditures were associated with both SUD and MI conditions in diabetes patients, and veterans with alcohol/drug use had the highest expenditures across all groups of MI. These findings reinforce the need to target groups with multiple comorbidities specifically those with serious mental illnesses and alcohol/drug use for interventions to reduce health-care expenditures.

REGULAR ARTICLE
Implementation of MET/CBT 5 for Adolescents...304-314
Katherine J. Riley, Traci Rieckmann and Dennis McCarty
Abstract: Implementation of effective substance abuse treatment programs in community settings is a high priority. The selection of a proven cost-effective model is a first step; however, difficulty arises when the model is imported into a community setting. The Center on Substance Abuse Treatment selected a brief substance abuse treatment program for adolescents, the MET/CBT-5 program, determined to be the most cost-effective protocol in the Cannabis Youth Treatment trial, for implementation in two cohorts of Effective Adolescent Treatment grantees. A qualitative investigation of the protocol implementation with nine sites in the second cohort chronicled adaptations made by grantees and prospects for sustainability. The study found that agencies introduced adaptations without seeming to be aware of potential effects on validity. In most sites, sessions were lengthened or added to accommodate individual client needs, address barriers to client participation, and provide consistency with current norms of treatment. Implications for fidelity of future implementation projects are addressed.

REGULAR ARTICLE
Predicting Time-to-Independent-Release from Current Level of Functioning for Psychiatric Inpatients: A “Survivor” Analysis...315-333
Justin R. Springer and Gordon L. Paul
Abstract: Non-optimal psychiatric discharges occur frequently and result in high costs. The Time-Sample Behavioral Checklist (TSBC) has been demonstrated to be the best method for determining successful independent discharge within 2 weeks of assessment for adult inpatients. This study examined the extent to which TSBC indexes and perceived dangerousness predict staff independent discharge-readiness judgments up to 6 months after initial assessment. Data from 22 acute and chronic/mixed units (N = 362) were analyzed using Cox proportional hazard regression. TSBC appropriate interpersonal interaction and appropriate behavior variability predicted shorter time-to-independent-release (TTIR). TSBC bizarre facial expressions and verbalizations predicted longer TTIR. Post hoc analyses suggest that acutely admitted inpatients perceived to be dangerous were discharged sooner than others—a finding that is likely attributable to differential psychotropic medication responsiveness. Implications are discussed for TSBC implementation for earlier identification of discharge-ready inpatients and for tailoring interventions to target behavior that predicts independent discharge success.

REGULAR ARTICLE
Money, Case Complexity, and Wait Lists: Perspectives on Problems and Solutions at Children’s Mental Health Centers in Ontario...334-346
Graham J. Reid and Judith Belle Brown
Abstract: Senior managers of children’s mental health centers across Ontario, Canada were interviewed regarding the challenges and solutions of access and delivery of care. The central challenges—funding, case complexity, waitlists, staffing, and system integration—revealed a complex interplay between the policies and financing of children’s mental health services and the provision of clinical services at the agency level and within the community. The desire for integration and collaboration was countered by competition for funding and service demands. A need for policies that allow for local solutions while providing leadership for sustained improvements in the ease and timeliness of access to care and effective clinical services emerged.

BRIEF REPORT
Racial Differences in Behavioral Inpatient Diagnosis: Examining the Mechanisms using the 2004 Florida Inpatient Discharge Data...347-357
Yuhua Bao, John Fisher and James Studnicki
Abstract: This study used the 2004 Florida Inpatient Discharge Data to examine the existence and the underlying mechanisms of the African American (AA)/white differences in behavioral inpatient diagnosis across a diverse patient population. Findings suggest that discharges of AA patients in Florida were at least twice as likely to have received a primary psychotic vs. affective or substance-related diagnosis, and this held true after between-hospital differences were controlled for. Furthermore, AA (vs. white) race was associated with a ratio of 3.3 in the population rate of hospitalization with a primary psychotic diagnosis, as compared to a ratio of 0.8 and 0.7 for affective and substance-related disorders, respectively. These findings demonstrated the wide existence of racial differences in behavioral inpatient diagnosis and the important role of clinician diagnostic behaviors as opposed to systems-level factors (such as racial differences in access to care and care-seeking behaviors) in leading to observed differences.

Number 4 / October 2008

Special Issue: Transition to Adulthood Research: Process & Outcome Findings
Guest Editors: Hewitt B. Rusty Clark, Nancy Koroloff, Jeffrey Geller and Diane L. Sondheimer
ACKNOWLEDGMENT Appreciation to Reviewers...359-361

COMMENTARY
Building a Meaningful Future for Young People with Mental Illness...362-364
Linda Rosenberg
Abstract: Transitioning to adulthood is challenging for young people who have a mental illness or substance use disorder, especially those who are transitioning from institutional care. For young people with serious mental illnesses to succeed in the adult world, they need more than treatment.These youth need to be truly integrated into their communities. They need jobs that offer skills, dignity, independence, and peers. They need a responsible and caring older adult who can help them to make better choices, learn from their mistakes, and applaud their successes, no matter how small. Community providers can create these opportunities through their own programs or appropriate community collaborations.

INTRODUCTION
Research on Transition to Adulthood: Building the Evidence Base to Inform Services and Supports for Youth and Young Adults with Serious Mental Health Disorders...365-372
Hewitt B. “Rusty” Clark, Nancy Koroloff, Jeffrey Geller and Diane L. Sondheimer
Abstract: Since the mid-1990s, research has established a clear picture of the poor real-life outcomes achieved by transition-age youth and young adults who have been diagnosed with a serious mental health disorder. The purpose of this article is to: (1) introduce the reader to the other eight articles in this special issue on Transition to Adulthood Research; (2) illustrate how each is contributing to the research base available to more fully understand these challenges as well as guide the creation of developmentally appropriate and effective services and supports for youth and young adults and their families; and (3) suggest future directions for continuing to advance this field of research and program implementation to improve outcomes though practice and policy improvements.

REGULAR ARTICLES
US Patterns of Mental Health Service Utilization for Transition-Age Youth and Young Adults...373-389
Kathleen J. Pottick, Scott Bilder, Ann Vander Stoep, Lynn A. Warner and Mike F. Alvarez
Abstract: This study examines rates of admission and patterns of mental health service use by persons of transition age (16–25 years) in the USA based on the nationally representative 1997 Client/Patient Sample Survey and population data from the US Census Bureau. A precipitous decline in utilization was observed at the age of emancipation: the yearly admission rate for inpatient, outpatient, and residential services was 34 per 1,000 for 16- and 17-year-olds and 18 per 1,000 for 18- and 19-year-olds. Among 20- and 21-year-olds, more were referred from criminal justice and fewer from family or friends and social services, and proportionately more were Medicaid recipients. Targeting resources to enhance shared planning between child and adult systems may facilitate continuity of care for young adult clients who are aging out of child mental health systems, as well as for those who experience their first episodes of mental disorder in early adulthood.

Transition Age Youth in Publicly Funded Systems: Identifying High-Risk Youth for Policy Planning and Improved Service Delivery...390-401
Craig Anne Heflinger and Cheri Hoffman
Abstract: Youth with Serious Emotional Disturbances (SED) face many challenges as they approach the transition to adulthood and adult services. This study examines publicly funded transition-age youth in order to describe the numbers and type of youth in need of policy and service planning in one state. Using Medicaid enrollment and claims/encounter data, youth with high risk of transition difficulties were identified in the following groups: SED, state custody/foster care or risk of custody, users of intensive or frequent mental health services, or having diagnoses of major mental disorders, conduct disorders, or developmental disabilities. Almost one quarter of all enrolled 14 to 17-year olds met criteria for at least one of the high risk groups, and three-quarters of these were youth with SED. High risk youth are described, with greater detail on those with SED, and implications for policy, services, and research are discussed.

Community Integration of Transition-Age Individuals: Views of Young with Mental Health Disorders...402-418
Pauline Jivanjee, Jean Kruzich and Lynwood J. Gordon
Abstract: This qualitative study examines the perceptions of young adults with mental health disorders of community integration. Fifty-nine young men and women participated in 12 focus groups whose aim was to gain understanding of what community integration means to them. Focus group questions also explored barriers and supports for their community integration, as well as their goals for the future and advice to others facing similar challenges. Themes that emerged were reported within the multiple domains that participants used to describe their experiences of community integration (or the lack thereof). This study highlights the desires of these young people to achieve goals in education and employment and to have friendships. Participants identified a pervasive lack of understanding of mental health and prevalent stigmatizing attitudes as resulting in challenges to their community integration. Implications of the study discuss roles for behavioral health services in encouraging empowerment, choices, and connections so that young people with mental health disorders may achieve their preferred levels of community integration.

Alcohol and Drug Use among Alumni of Foster Care: Decreasing Dependency Through Improvement of Foster Care Experiences...419-434
Catherine Roller White, Kirk O’Brien, James White, Peter J. Pecora and Chereese M. Phillips
Abstract: The Northwest Foster Care Alumni Study examined the effects of family foster care on adult substance dependencies. The study focused on young adults (N = 479) who were served by a private (Casey Family Programs) or public foster care agency in Washington and Oregon states. This paper describes (1) prevalence rates of alcohol dependence and drug dependence, (2) the relation between risk factors and experiences in foster care and adult substance dependencies, and (3) statistical simulations showing how adult substance dependency rates may be reduced through improvement of the foster care experience. The rate of alcohol dependence within the past 12 months (3.6%) among alumni was not significantly different from that of the general population; the rate of drug dependence within the past 12 months (8.0%) was significantly higher among alumni. Optimization of foster care experiences (i.e., improving care) was associated with significant reductions in the estimated prevalence of these two dependencies.

Predictors of Emotional Well-Being in At-Risk Adolescent Girls: Developing Preventive Intervention Strategies...435-453
Mary I. Armstrong and Roger A. Boothroyd
Abstract: This article examines the degree to which various demographic characteristics, personality traits, and environmental factors are associated with overall emotional well-being of 125 adolescent girls whose mothers were involved in welfare reform. Daughters participated in a 4-year, mixed method study and annually completed a structured interview protocol and a sub-group also completed a qualitative interview. The quantitative findings from the study suggest that daughters having an internal locus of control, experiencing fewer negative life events, and reporting stronger parental and teacher social support had enhanced emotional well-being over the 4-year study compared to daughters without these factors. The findings were further elaborated with examples from qualitative interviews conducted with the daughters. The findings were used to propose prevention activities using a tertiary mental health preventive intervention framework.

Nonkin Natural Mentors in the Lives of Older Youths in Foster Care...454-468
Michelle R. Munson and J. Curtis McMillen
Abstract: This study explored the nonkin natural mentoring relationships among older youths in foster care. Three hundred thirty-nine youths nearing their exit from one state’s alternative care system were interviewed. Those that reported the presence of a natural mentor, 62% (n=211), were subsequently asked about how they met their mentor, how long they have known their mentor, how frequently they have contact with their mentor, and the quality of the relationship. Seventy percent of the youth with mentors reported having known their mentors for over 1 year. Youth reported high levels of contact and relationship quality. Ethnic group membership, gender, where youth were living, and clinical characteristics were associated with individual mentoring characteristics. Child and adult service delivery systems might benefit from considering ways to support the continuation of these relationships during the transition period.

SPECIAL ISSUE
Characteristics, Service Experiences, and Outcomes of Transition-Aged Youth in Systems of Care: Programmatic and Policy Implications...469-487
Brigitte Manteuffel, Robert L. Stephens, Diane L. Sondheimer and Sylvia K. Fisher
Abstract: This article examines data for 8,484 transition-aged youth (TAY) in different age groups who received services in 45 federally funded systems of care between 1997 and 2006. Data from the national evaluation of these systems of care were used to compare descriptive and clinical characteristics at intake of TAY aged 14–15, 16–17, and 18 years, and service use and outcomes of TAY aged 14–15 and 16–17 at 6 and 12 months after system of care intake. Few studies have examined outcomes of TAY. The large national evaluation database provides a unique opportunity to examine outcomes for TAY in relation to increases in age. Results revealed differences in severity and type of behavioral and emotional problems, living situations, access to Medicaid, service use, and outcomes among younger and older youth. Findings support the need to enhance access to services for older TAY and to customize services to the unique needs of each age group.

SPECIAL ISSUE
Predicting Improvement of Transitioning Young People in the Partnerships for Youth Transition Initiative: Findings from a Multisite Demonstration...488-513
Mason G. Haber, Arun Karpur, Nicole Deschênes and Hewitt B. Clark
Abstract: Prior research has indicated that young people with serious mental health conditions show poorer progress and greater challenges in the transition to adulthood, as reflected by lower rates of employment and postsecondary education, higher rates of criminal justice involvement, and greater interference in daily activities from mental health and substance use disorders. Little knowledge exists, however, regarding improvement on these indicators among young people enrolled in community-based transition support programs and individual characteristics that might moderate this improvement. This study describes rates of improvement on indicators of transition progress and challenges among young people enrolled in a multisite demonstration of transition support programs. Young people in the study showed increased rates of progress and decreased rates of challenges over four quarters of enrollment. Moderation of these changes by individual characteristics including demographic, historical, and diagnostic variables suggested ways of improving transition support programs and avenues for future research.