JBHSR Recent Issues

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

Volume 39, 2012

Issue 1 / January 2012

Behavioral Disorders: The New Public Health Crisis...1–2
Linda Rosenberg
Abstract: Behavioral health has become a public health crisis. No other public health crises are as widespread or contribute as much to the burden of illness in the U.S. as do behavioral health disorders. By 2020, mental and substance use disorders will surpass all physical diseases worldwide as major causes of disability. Yet state and federal governments continue to make steep cuts to funding for public behavioral health services. We cannot afford to wait for the next national tragedy to recognize that behavioral health disorders are a public health crisis deserving of our nation's attention and support.

Universal Screening for Alcohol and Drug Use and Racial Disparities in Child Protective Services Reporting...3–16
Sarah C. M. Roberts and Amani Nuru-Jeter
Abstract: This study examines racial disparities in Child Protective Services (CPS) reporting at delivery in a county with universal screening for alcohol/drug use in prenatal care. It also explores two mechanisms through which universal screening could reduce reporting disparities: Equitable Surveillance and Effective Treatment. Equitable Surveillance is premised on the assumptions that identification of drug use through screening in prenatal care leads to CPS reporting at delivery and that Black women are screened more than White women, which leads to disproportionate reporting of Black newborns. Universal screening would correct this by ensuring that prenatal providers screen and therefore also report White women to CPS, thereby reducing disparities. Effective Treatment is premised on the idea that identification of drug use through screening in prenatal care leads women to receive treatment during pregnancy, which thereby reduces CPS reporting at delivery. Universal screening would lead to prenatal providers screening more Black women and thereby to more Black women receiving treatment prenatally. The increase in treatment receipt during pregnancy would then decrease the number of Black newborns reported to CPS at delivery, thereby reducing disparities. County data were used to compare the racial/ethnic distribution of women and newborns in three points in the system (identification in prenatal care, treatment entry during pregnancy, and reporting to CPS at delivery related to maternal alcohol/drug use) and explore pathways to treatment. Despite Black women having alcohol/drug use identified by prenatal care providers at similar rates to White women and entering treatment more than expected, Black newborns were four times more likely than White newborns to be reported to CPS at delivery. This contradicts the premise of Effective Treatment. By default, findings were more consistent with Equitable Surveillance than Effective Treatment. Providers and policy makers should not assume that universal screening in prenatal care reduces CPS reporting disparities.

The Availability of Integrated Care in a National Sample of Therapeutic Communities---17–27
Meredith Huey Dye, Paul M. Roman, Hannah K. Knudsen and J. Aaron Johnson
Abstract: Therapeutic communities (TCs) for substance abusers are oriented toward changing the entire person as a means for facilitating a drug-free future. This vision parallels ideas such as integrated care for the treatment of co-occurring substance abuse and psychiatric conditions. The extent to which integrated services are available in TCs has not been documented. Using data from a national sample of 345 TCs, this paper examines the availability of integrated care in TCs and the structural and cultural characteristics of TCs that offer integrated care. The results indicate that a substantial portion of TCs in this sample admit clients with co-occurring disorders (70.7%), and as many as half of the TCs offer integrated care. TCs that offer integrated care show increased use of professional staff, individual psychotherapy, and a less confrontational milieu, but notably, retain many of the “essential elements” of the traditional TC model.

The Implementation of Smoking Cessation Counseling in Substance Abuse Treatment...28–41
Hannah K. Knudsen, Christina R. Studts and Jamie L. Studts
Abstract: Research on the implementation of smoking cessation counseling within substance abuse treatment organizations is limited. This study examines associations among counselors’ implementation of therapy sessions dedicated to smoking cessation, organizational factors, and counselor-level variables. A two-level hierarchical linear model including organization- and counselor-level variables was estimated using survey data collected from 1,794 counselors working in 359 treatment organizations. Overall implementation of smoking cessation counseling was low. In the final model, implementation was positively associated with counselors’ knowledge of the Public Health Service’s clinical practice guideline, perceived managerial support, and belief that smoking cessation had a positive impact on recovery. Private versus public funding and presence of a formal smoking cessation program were organization-level variables which interacted with these counselor-level effects. These results highlight the importance of organizational contexts as well as counselors’ knowledge and attitudes for effective implementation of smoking cessation counseling in substance abuse treatment organizations.

Improving Satisfaction in Patients Receiving Mental Health Care: A Case Study...42–54
Yin-Ling Irene Wong, Jason Matejkowski and Sungkyu Lee
Abstract: Patient satisfaction is increasingly becoming an important component of quality for behavioral health care systems. The following report describes Group Health Cooperative’s Behavioral Health Services department experiences over a 5-year period in moving from uncertainty about the value of patient satisfaction and the ability to positively impact patient ratings to achieving a significant improvement in patient ratings of satisfaction with mental health care. In this process, the Behavioral Health Department developed a deeper understanding of patient requirements and improvement strategies which could impact these requirements. A description of the results achieved along with the role of quality improvement processes in understanding and improving patient satisfaction in mental health care is presented.

The Cost of Screening and Brief Intervention in Employee Assistance Programs...55–67
Alexander J. Cowell, Jeremy W. Bray and Jesse M. Hinde
Abstract: Few studies examine the costs of conducting screening and brief intervention (SBI) in settings outside health care. This study addresses this gap in knowledge by examining the employer-incurred costs of SBI in an employee assistance program (EAP) when delivered by counselors. Screening was self-administered as part of the intake paperwork, and the brief intervention (BI) was delivered during a regular counseling session. Training costs were 83 per counselor. The cost of a screen to the employer was0.64; most of this cost comprised the cost of the time the client spent completing the screen. The cost of a BI was $2.52. The cost of SBI is lower than cost estimates of SBI conducted in a health care setting. The low costs for the current study suggest that only modest gains in outcomes would likely be needed to justify delivering SBI in an EAP setting.

Longer Length of Stay Is Not Associated with Better Outcomes in VHA’s Substance Abuse Residential Rehabilitation Treatment Programs...68–79
Alex H. S. Harris, Daniel Kivlahan, Paul G. Barnett and John W. Finney
Abstract: Are longer stays in Veterans Health Administration (VHA) substance abuse residential rehabilitation treatment programs (SARRTPs) associated with better substance-related outcomes? To investigate, up to 50 new patients were randomly selected from each of 28 randomly selected programs (1,307 patients). The goal was to examine if patient and program average length of stay (ALOS) were associated with improvement on Addiction Severity Index (ASI) Alcohol and Drug composite scores in covariate-adjusted, multi-level regression models. Patients in programs with ALOS greater than 90 days tended to have more mental health treatment prior to the index episode and less severe substance-related symptoms, but more homelessness. At follow-up, programs longer than 90 days had the least improvement in the ASI Alcohol composite and significantly less improvement than programs with ALOSs of 15 to 30 and 31 to 45 days (both p < 0.05). Therefore, in VHA SARRTPs, ALOS greater than 90 days cannot be justified by the substance use disorder severity of the patients served or the magnitude of the clinical improvement observed.

Evaluation of the Mental Health Benefits of Yoga in a Secondary School: A Preliminary Randomized Controlled Trial...80–90
Sat Bir S. Khalsa, Lynn Hickey-Schultz, Deborah Cohen, Naomi Steiner and Stephen Cope
Abstract: The goal of this study was to evaluate potential mental health benefits of yoga for adolescents in secondary school. Students were randomly assigned to either regular physical education classes or to 11 weeks of yoga sessions based upon the Yoga Ed program over a single semester. Students completed baseline and end-program self-report measures of mood, anxiety, perceived stress, resilience, and other mental health variables. Independent evaluation of individual outcome measures revealed that yoga participants showed statistically significant differences over time relative to controls on measures of anger control and fatigue/inertia. Most outcome measures exhibited a pattern of worsening in the control group over time, whereas changes in the yoga group over time were either minimal or showed slight improvements. These preliminary results suggest that implementation of yoga is acceptable and feasible in a secondary school setting and has the potential of playing a protective or preventive role in maintaining mental health.

A Business Case for Quality Improvement in Addiction Treatment: Evidence from the NIATx Collaborative...91–100
Sarann Bielavitz, Jennifer Wisdom and David A. Pollack
Abstract: The Network for the Improvement of Addiction Treatment (NIATx) promotes treatment access and retention through a customer-focused quality improvement model. This paper explores the issue of the “business case” for quality improvement in addiction treatment from the provider’s perspective. The business case model developed in this paper is based on case examples of early NIATx participants coupled with a review of the literature. Process inefficiencies indicated by long waiting times, high no-show rates, and low continuation rates cause underutilization of capacity and prevent optimal financial performance. By adopting customer-focused practices aimed at removing barriers to treatment access and retention, providers may be able to improve financial performance, increase staff retention, and gain long-term strategic advantage.

Issue 2 / April 2012

Primary and Behavioral Healthcare Integration: Threat or Opportunity for Addiction Treatment Organizations?...101–102
Linda Rosenberg
Without Abstract

Predictors of Primary Care Physicians’ Self-reported Intention to Conduct Suicide Risk Assessments...103–115
Lisa M. Hooper, Steven A. Epstein, Kevin P. Weinfurt, Jamie DeCoster and Lixin Qu, et al.
Abstract: Primary care physicians play a significant role in depression care, suicide assessment, and suicide prevention. However, little is known about what factors relate to and predict quality of depression care (assessment, diagnosis, and treatment), including suicide assessment. The authors explored the extent to which select patient and physician factors increase the probability of one element of quality of care: namely, intention to conduct suicide assessment. Data were collected from 404 randomly selected primary care physicians after their interaction with CD-ROM vignettes of actors portraying major depression with moderate levels of severity. The authors examined which patient factors and physician factors increase the likelihood of physicians’ intention to conduct a suicide assessment. Data from the study revealed that physician-participants inquired about suicide 36% of the time. A random effects logistic model indicated that several factors were predictive of physicians’ intention to conduct a suicide assessment: patient’s comorbidity status (odds ratio (OR) = 0.61; 95% confidence interval (CI) = 0.37–1.00), physicians’ age (OR = 0.67; 95% CI = 0.49–0.92), physicians’ race (OR = 1.84; 95% CI = 1.08–3.13), and how depressed the physician perceived the virtual patient to be (OR = 0.58; 95% CI = 0.39–0.87). A substantial number of primary care physicians in this study indicated they would not assess for suicide, even though most physicians perceived the virtual patient to be depressed or very depressed. Further study is needed to establish factors that may be modified and targeted to increase the likelihood of physicians’ providing one element of quality of care—suicide assessment—for depressed patients.
This study was supported by a grant from the National Institute of Mental Health and the National Center for Minority Health and Health Disparities of the National Institutes of Health (R01 MH 6096) to Steven A. Epstein.

Racial and Ethnic Disparities in the Continuation of Community-Based Children’s Mental Health Services...116–129
Yumiko Aratani and Janice L. Cooper
Abstract: This paper examines racial and ethnic disparities in continuation of mental health services for children and youth in California and how English language proficiency moderates the effect of race/ethnicity on the continuation of service. While previous research indicated racial/ethnic or geographic disparities in accessing mental health services among children and youth, few studies specifically focused on the continuation of mental health care. The authors used administrative data from California county mental health services users under age 25. Applying logistic regression, English language proficiency was found to be the major determinant of continuation of mental health services in this age group. With the exception of children of Asian descent, non-English speaking children and youth of diverse racial/ethnic background were significantly less likely to continue receiving mental health services compared with White English-speaking peers, even after controlling for sociodemographic, clinical and county characteristics.

Outcomes Management: Incorporating and Sustaining Processes Critical to Using Outcome Data to Guide Practice Improvement...130–143
Kay Hodges and James R. Wotring
Abstract: An outcomes management system (OMS) greatly facilitates an organization or state achieving requirements regarding accountability and use of empirically based interventions. A case example of the authors’ experience with a successful and enduring OMS is presented, followed by a review of the literature and a proposed model delineating the key components and benefits of an OMS. Building capacity to measure performance requires embedding utilization of youth-specific, clinically meaningful outcome data into the organization’s processes and structures. An OMS measures outcomes associated with services, facilitates implementation of evidence-based practices, informs case decision making, enables better and more efficient clinical management, and provides aggregated information used to improve services. A case-specific supervisory model based on instantaneously available information, including progress to date, helps maximize consumer outcomes. Continuous quality improvement activities, which are databased and goal-oriented, become a positive change management tool. This paper describes organizational processes that facilitate the development of a highly functional OMS.

Social Integration of People with Severe Mental Illness: Relationships Between Symptom Severity, Professional Assistance, and Natural Supporty...144–157
Jack Tsai, Rani A. Desai and Robert A. Rosenheck
Abstract: Reducing dependency on professionals and social integration has been a major goal of recovery-oriented mental health services. This cross-sectional study examined 531 male outpatients at three public mental health centers in Southern Connecticut. Hierarchical multiple regression analyses were conducted to answer: (1) Do clients who have more severe clinical problems rely more on professional support and mental health services, and rely less on natural supports? (2) Do clients who have greater natural supports rely less on professional support and mental health services? Results found clients with more severe clinical problems do not rely more on professional support and report less natural social support. Natural support was also found to be a complement, rather than a substitute for professional support. These findings suggest the social integration of male clients with severe mental illness may include being more connected to mental health providers even as they develop increasing natural supports.

Outcomes Associated with a Cognitive-Behavioral Chronic Pain Management Program Implemented in Three Public HIV Primary Care Clinics...158–173
Jodie A. Trafton, John T. Sorrell, Mark Holodniy, Heather Pierson and Percy Link, et al.
Abstract: In patients with HIV/AIDS, chronic pain is common and analgesics pose serious risks. Cognitive-behavioral therapies (CBT) provide an alternative. This study evaluated feasibility and impact of a CBT-based pain management program in three public primary care clinics for HIV patients. The program included a workbook and 12-weeks of group CBT sessions. HIV-positive patients with chronic moderate to severe pain were invited to participate in the program and were assessed at enrollment, 6, 12, and 24 weeks. Despite only moderate group attendance, program enrollment was associated with significant improvements in pain intensity, pain-related functioning, anxiety and acceptance, and mental health. At 24 weeks, effect sizes for pain outcomes were −0.83 for pain intensity and −0.43 for functioning. The pattern of change in outcomes was consistent with predictions based on cognitive-behavioral theory. Effects were observed at all clinics. Adding CBT-based pain management into primary care may provide important benefits for patients with HIV/AIDS.

The Relationship Between Neighborhood Characteristics and Recruitment into Adolescent Family-Based Substance Use Prevention Programs...174–189
Hilary F. Byrnes, Brenda A. Miller, Annette E. Aalborg and Carolyn D. Keagy
Abstract: Youth in disadvantaged neighborhoods are at risk for poor health outcomes. Characteristics of these neighborhoods may translate into intensified risk due to barriers utilizing preventive care such as substance use prevention programs. While family-level risks affect recruitment into prevention programs, few studies have addressed the influence of neighborhood risks. This study consists of 744 families with an 11- to 12-year-old child recruited for a family-based substance use prevention program. Using US Census data, logistic regressions showed neighborhoods were related to recruitment, beyond individual characteristics. Greater neighborhood unemployment was related to decreased agreement to participate in the study and lower rates of high school graduation were related to lower levels of actual enrolment. Conversely, higher rates of single-female-headed households were related to increased agreement. Recruitment procedures may need to recognize the variety of barriers and enabling forces within the neighborhood in developing different strategies for the recruitment of youth and their families.

Discrepancy in Diagnosis and Treatment of Post-traumatic Stress Disorder (PTSD): Treatment for the Wrong Reason...190–201
Ellen C. Meltzer, Tali Averbuch, Jeffrey H. Samet, Richard Saitz and Khelda Jabbar, et al.
Abstract: In primary care (PC), patients with post-traumatic stress disorder (PTSD) are often undiagnosed. To determine variables associated with treatment, this cross-sectional study assessed 592 adult patients for PTSD. Electronic medical record (EMR) review of the prior 12 months assessed mental health (MH) diagnoses and MH treatments [selective serotonin reuptake inhibitor (SSRI) and/or ≥1 visit with MH professional]. Of 133 adults with PTSD, half (49%; 66/133) received an SSRI (18%), a visit with MH professional (14%), or both (17%). Of those treated, 88% (58/66) had an EMR MH diagnosis, the majority (71%; 47/66) depression and (18%; 12/66) PTSD. The odds of receiving MH treatment were increased 8.2 times (95% CI 3.1–21.5) for patients with an EMR MH diagnosis. Nearly 50% of patients with PTSD received MH treatment, yet few had this diagnosis documented. Treatment was likely due to overlap in the management of PTSD and other mental illnesses.

The Receipt and Utilization of Effective Clinical Smoking Cessation Services in Subgroups of the Insured and Uninsured Populations in the USA...202–213
Priti Bandi, Vilma E. Cokkinides, Katherine S. Virgo and Elizabeth M. Ward
Abstract: Subgroups among the uninsured and even the insured may be at increased risk for not receiving and utilizing effective clinical smoking cessation services. Data for this study came from 18 to 64 year old smokers in the 2005 National Health Interview Survey. Long-term uninsured (greater than or equal to one year) smokers were less likely to receive physician advice to quit than those continuously-insured in the past year. Being long-term and short-term uninsured (less than one year) was negatively associated with dependence treatments’ use in quit attempts compared to the continuously-insured, even though the prevalence of quit attempts were similar between these groups. Intermittent-uninsurance (spell of uninsurance in past year) did not influence cessation services delivery or use. Even though Medicaid-insured smokers were more likely to be advised to quit than those privately-insured, they were less likely to use dependence treatments, especially if they had a spell of uninsurance in the past year. Provisions in the Affordable Care Act of 2009 that ensure coverage of effective cessation services for previously-uninsured individuals and Medicaid-insured smokers may increase access and potentially improve population cessation rates.

Issue 3 / July 2012

Are Healthcare Leaders Ready for the Real Revolution?...215–219
Linda Rosenberg
Abstract: The current revolution, that could pass us by if we are not prepared to join it, is a consumer-directed, technologically driven revolution in the way we receive, process, and use information. Today, the knowledge we need—as business owners, healthcare consumers, and informed citizens—is literally in the palm of our hands. The future has arrived and we cannot be late to the dance. Citizen science, integration, and data-driven care will shape our future. Healthcare leaders must be comfortable with complexity and eager to embrace fast-paced, revolutionary changes. We must be prepared to lead in integrated health care environments that harness technology and value data.

Utilization and Intensity of Outpatient Care Related to Military Sexual Trauma for Veterans from Afghanistan and Iraq...220–233
Jessica A. Turchik PhD, Joanne Pavao MPH, Jenny Hyun MPH, PhD, Hanna Mark BA, Rachel Kimerling PhD
Abstract: Little research has examined factors associated with the utilization of outpatient health care services related to sexual assault experiences. The Veterans Health Administration provides free outpatient treatment services to veterans who report military sexual trauma (MST); this system provides a unique opportunity to examine factors related to the utilization of mental health and non-mental health outpatient services by patients with sexual trauma. The current study examined sociodemographic, military service factors, and primary diagnoses related to utilization and utilization intensity of MST-related care among 4,458 Operation Enduring Freedom/Operation Iraqi Freedom Veterans in a 1-year period after reporting an experience of MST. Of the veterans who reported MST, 75.9% received MST-related care. The most notable factor that influenced receipt and intensity of MST-related care was gender, where male veterans used less care than female veterans. These results have important treatment implications for both veteran and civilian sexual trauma survivors.

Improving Quality of Care in Substance Abuse Treatment Using Five key Process Improvement Principles...234–244
Kim A. Hoffman PhD, Carla A. Green PhD, James H. Ford II PhD, Jennifer P. Wisdom PhD, MPH, David H. Gustafson PhD, Dennis McCarty PhD
Abstract: Process and quality improvement techniques have been successfully applied in health care arenas, but efforts to institute these strategies in alcohol and drug treatment are underdeveloped. The Network for the Improvement of Addiction Treatment (NIATx) teaches participating substance abuse treatment agencies to use process improvement strategies to increase client access to, and retention in, treatment. NIATx recommends five principles to promote organizational change: (1) understand and involve the customer, (2) fix key problems, (3) pick a powerful change leader, (4) get ideas from outside the organization, and (5) use rapid cycle testing. Using case studies, supplemented with cross-agency analyses of interview data, this paper profiles participating NIATx treatment agencies that illustrate successful applications of each principle. Results suggest that organizations can successfully integrate and apply the five principles as they develop and test change strategies, improving access and retention in treatment, and agencies’ financial status. Upcoming changes requiring increased provision of behavioral health care will result in greater demand for services. Treatment organizations, already struggling to meet demand and client needs, will need strategies that improve the quality of care they provide without significantly increasing costs. The five NIATx principles have potential for helping agencies achieve these goals.

Impact of Family Caregiving by Youth on Their Psychological Well-Being: A Latent Trait Analysis...245–256
Donna Cohen PhD, Jennifer A. Greene BA, Peter A. Toyinbo PhD, MB, ChB, Constance T. Siskowski RN, PhD
Abstract: Secondary data analyses were conducted on a survey dataset from 1,281 middle school students to analyze the impact of family caregiving on self-reports of psychological well-being using the Multiple Indicators, Multiple Causes (MIMIC) model. Factor analysis resulted in four latent factors underlying psychological functioning, and the MIMIC model revealed significant caregiver effects on three factors: anxiety/depression, engaged coping, and disengaged coping, but not life satisfaction. Youth caregivers, especially those living with the care recipient, reported significantly higher anxiety/depression and a greater use of both coping styles compared to non-caregivers. Caregiving has a negative influence on the emotional well-being of youth with dual student–caregiver roles. The utilization of more coping strategies may reflect needing to try many approaches to school/family stressors because supports and experience are limited. Research to clarify how caregiving mediates the behavioral health and academic success of youth and also impacts care recipients and the family is warranted.

Applying Social and Cultural Capital Frameworks: Understanding Employment Perspectives of Transition Age Youth with Serious Mental Health Conditions...257–270
Vanessa Vorhies MSSW, Kristin E. Davis PhD, Rochelle L. Frounfelker MPH, MSSW, Susan M. Kaiser MPH
Abstract: Vulnerable transition age youth, such as those in foster care and with serious mental health conditions, are at increased risk for lower rates of employment. Social capital is empirically linked to employment in the general population, yet little is known about the role of social capital in employment for at-risk transition age youth. Focus groups were conducted with young people with serious mental health conditions and their vocational specialists. Discussions reveal that both social and cultural capital influence employment processes. Those with employment experience value the motivation to work provided through others compared to those with no employment experience. Consistently employed describe strong working relationships with vocational specialists and possession of self-awareness, professionalism, and work-place knowledge as critical for employment success, while inconsistently employed describe worries about controlling emotions or behaviors on the job. Building social and cultural capital are explored as potential service provider goals.

Arrest Types and Co-occurring Disorders in Persons with Schizophrenia or Related Psychoses...271–284
Patrick J. McCabe MPH, Paul P. Christopher MD, Nicholas Druhn PsyD, Kristen M. Roy-Bujnowski MA, Albert J. Grudzinskas Jr. JD, William H. Fisher PhD
Abstract: This study examined the patterns of criminal arrest and co-occurring psychiatric disorders among individuals with schizophrenia or related psychosis that were receiving public mental health services and had an arrest history. Within a 10-year period, 65% of subjects were arrested for crimes against public order, 50% for serious violent crimes, and 45% for property crimes. The presence of any co-occurring disorder increased the risk of arrest for all offense categories. For nearly all offense types, antisocial personality disorder and substance use disorders conferred the greatest increase in risk for arrest. Among anxiety disorders, post-traumatic stress disorder was associated with a greater risk of arrest for serious violent crimes but not other offense types. Criminal risk assessments and clinical management in this population should focus on co-occurring antisocial personality disorder and substance use disorders in addition to other clinical and non-clinical factors.

Supervision in Behavioral Health: Implications for Students, Interns, and New Professionals...285–294
Keeley J. Pratt PhD, LMFT; Angela L. Lamson PhD, LMFT, CFLE
Abstract: Behavioral health providers (BHPs) are trained by their respective programs and professions on the importance of communicating with other professionals around patient care, yet few are trained on how to provide collaborative care and work as part of a team. New clinical innovation models, such as integrated care, punctuate the need to further develop training methods to best equip the next generation of BHPs to work in collaborative settings. Supervision is a tool that students, interns, and new professionals can use to help them navigate new and unfamiliar territory in health care settings. This manuscript will describe the steps of choosing a supervisor, provide elements that must be considered when developing a supervision contract, offer a template for crafting a document that will assist with assessing fidelity to one’s practice and maximize consistency and productivity in the supervision process, and detail the potential supervision dynamics in different levels of clinical collaboration. Supervision that is tailored to the BHPs level of clinical collaboration in their given practice setting can provide a structure for the supervision process.

A Pilot Evaluation of Associations Between Displayed Depression References on Facebook and Self-reported Depression Using a Clinical Scale...295–304
Megan Andreas Moreno MD, MSEd, MPH, Dimitri A. Christakis MD, MPH, Katie G. Egan BSN, Lauren A. Jelenchick BS, Elizabeth Cox MD, PhD, Henry Young PhD, Hope Villiard, Tara Becker PhD
Abstract: The objective of this study was to determine associations between displayed depression symptoms on Facebook and self-reported depression symptoms using a clinical screen. Public Facebook profiles of undergraduates from two universities were examined for displayed depression references. Profiles were categorized as depression symptom displayers or non-displayers. Participants completed an online PHQ-9 depression scale. Analyses examined associations between PHQ-9 score and depression symptom displayers versus non-displayers. The mean PHQ-9 score for non-displayers was 4.7 (SD = 4.0), the mean PHQ-9 score for depression symptom displayers was 6.4 (SD = 5.1; p = 0.018). A trend approaching significance was noted that participants who scored into a depression category by their PHQ-9 score were more likely to display depression symptom references. Displayed references to depression symptoms were associated with self-reported depression symptoms.

Report: The Use of a “Mystery Shopper” Methodology to Evaluate Children’s Access to Psychiatric Services...305–313
Kenneth J. Steinman PhD, MPH, Kelly Kelleher MD, Allard E. Dembe ScD, Thomas M. Wickizer PhD, MPH, Traci Hemming
The study was conducted by the Center for Innovation in Pediatric Practice at Nationwide Children’s Hospital (700 Children’s Drive, Columbus, OH 43205) in conjunction with the Center for Health Policy, Outcomes and Evaluation Studies in the College of Public Health at The Ohio State University (1841 Neil Avenue, 202 Cunz Hall, Columbus, OH 43210), in collaboration with the Ohio Department of Mental Health (30 East Broad Street, 8th Floor, Columbus, OH 43215). The study was approved by the Institutional Review Board of the Ohio State University.

Report: Becoming an Evidence-Based Service Provider: Staff Perceptions and Experiences of Organizational Change...314–332
Melissa Kimber MSW, Melanie Barwick PhD, C.Psych, Gwendolyn Fearing BA, BSW

Issue 4 / October 2012

Appreciation to Reviewers...333–335

HIT: Time to End Behavioral Health Discrimination...336–338
Linda Rosenberg MSW
Abstract: While the Health Information Technology for Economic and Clinical Health Act, enacted as part of the American Recovery and Reinvestment Act of 2009, provided $20.6 billion for incentive payments to support the adoption and meaningful use of health information technology (HIT), behavioral health organizations were not eligible to receive facility payments. The consequences of excluding behavioral health from HIT incentive payments are found in the results of the "HIT Adoption and Meaningful Use Readiness in Community Behavioral Health" survey. The survey found that only 2% of community behavioral health organizations are able to meet federal meaningful use (MU) requirements—compare this to the 27% of Federally Qualified Health Centers and 20% of hospitals that already meet some level of MU requirements. Behavioral health organizations, serving more than eight million adults, children, and families with mental illnesses and addiction disorders, are ready and eager to adopt HIT to meet the goals of better healthcare, better health, and lower costs. But reaching these goals may prove impossible unless behavioral health achieves "parity" within healthcare and receives resources for the adoption of HIT.

Directions in Implementation Research Methods for Behavioral and Social Science...339–342
Molly Irwin PhD, MPH, Lauren H. Supplee PhD
Abstract: There is a growing interest, by researchers, policymakers, and practitioners, in evidence-based policy and practice. As a result, more dollars are being invested in program evaluation in order to establish “what works,” and in some cases, funding is specifically tied to those programs found to be effective. However, reproducing positive effects found in research requires more than simply adopting an evidence-based program. Implementation research can provide guidance on which components of an intervention matter most for program impacts and how implementation components can best be implemented. However, while the body of rigorous research on effective practices continues to grow, research on implementation lags behind. To address these issues, the Administration for Children and Families and federal partners convened a roundtable meeting entitled, Improving Implementation Research Methods for Behavioral and Social Science, in the fall of 2010. This special section of the Journal of Behavioral Health Services & Research includes papers from the roundtable and highlights the role implementation science can play in shedding light on the difficult task of taking evidence-based practices to scale.

Measuring Enactment of Innovations and the Factors that Affect Implementation and Sustainability: Moving Toward Common Language and Shared Conceptual Understanding...343–361
Jeanne Century EdD, Amy Cassata PhD, Mollie Rudnick MS Ed, Cassie Freeman
Abstract: This article describes research that focuses on the concern that researchers are unable to fully realize the potential value of their collective efforts because they do not have shared conceptual or operational tools for communicating assumptions, ideas, research strategies, or findings with others outside, or even within their disciplines. This research, through the lens of measuring implementation of educational programs, has taken steps toward bringing researchers’ varied pictures of understanding into a coherent landscape. This article describes a conceptual framework for describing aspects of implementation, a conceptual framework for describing the factors that affect implementation, and tools for measuring each. It describes the challenges addressed in the development of these approaches, and the application of these approaches to current studies in education and other fields in the social sciences. In doing so, it demonstrates that meaningful communication between researchers and accumulation of knowledge across fields is possible, and necessary.

A Concept Mapping Approach to Guide and Understand Dissemination and Implementation...362–373
Amy E. Green PhD, Danielle L. Fettes PhD, Gregory A. Aarons PhD
Abstract: Many efforts to implement evidence-based programs do not reach their full potential or fail due to the variety of challenges inherent in dissemination and implementation. This article describes the use of concept mapping—a mixed method strategy—to study implementation of behavioral health innovations and evidence‐based practice (EBP). The application of concept mapping to implementation research represents a practical and concise way to identify and quantify factors affecting implementation, develop conceptual models of implementation, target areas to address as part of implementation readiness and active implementation, and foster communication among stakeholders. Concept mapping is described and a case example is provided to illustrate its use in an implementation study. Implications for the use of concept mapping methods in both research and applied settings towards the dissemination and implementation of behavioral health services are discussed.

A Procedure for Assessing Intervention Fidelity in Experiments Testing Educational and Behavioral Interventions...37–396
Michael C. Nelson BS, David S. Cordray PhD, Chris S. Hulleman PhD, Catherine L. Darrow PhD, Evan C. Sommer BS, BA
Abstract: An intervention's effectiveness is judged by whether it produces positive outcomes for participants, with the randomized experiment being the gold standard for determining intervention effects. However, the intervention-as-implemented in an experiment frequently differs from the intervention-as-designed, making it unclear whether unfavorable results are due to an ineffective intervention model or the failure to implement the model fully. It is therefore vital to accurately and systematically assess intervention fidelity and, where possible, incorporate fidelity data in the analysis of outcomes. This paper elaborates a five-step procedure for systematically assessing intervention fidelity in the context of randomized controlled trials (RCTs), describes the advantages of assessing fidelity with this approach, and uses examples to illustrate how this procedure can be applied.
*An earlier version of this paper was presented at the Society for Research on Educational Effectiveness 2010 Conference.

The Assimilation of Evidence-Based Healthcare Innovations: A Management-Based Perspective...397–416
Phyllis C. Panzano PhD, Helen Anne Sweeney MS, Beverly Seffrin PhD, Richard Massatti MSW, Kraig J. Knudsen PhD
Abstract: In order to reap the benefits of the nation’s vast investments in healthcare discoveries, evidence-based healthcare innovations (EBHI) must be assimilated by the organizations that adopt them. Data from a naturalistic field study are used to test a management-based model of implementation success which hypothesizes strategic fit, climate for EBHI implementation, and fidelity will explain variability in the assimilation of EBHIs by organizations that adopted them under ordinary circumstances approximately 6 years earlier. Data gathered from top managers and external consultants directly involved with these long-term EBHI implementation efforts provide preliminary support for predicted positive linkages between strategic fit and climate; climate and fidelity; and fidelity and assimilation. Mediated regression analyses also suggest that climate and fidelity may be important mediators. Findings raise important questions about the meaning of assimilation, top managers’ roles as agents of assimilation, and the extent to which results represent real-world versus implicit models of assimilation.

Examining the Association Between Implementation and Outcomes...417–433
Elise T. Pas PhD, Catherine P. Bradshaw PhD
Abstract: Although there is an established literature supporting the efficacy of a variety of prevention programs, there has been less empirical work on the translation of such research to everyday practice or when scaled-up state-wide. There is a considerable need for more research on factors that enhance implementation of programs and optimize outcomes, particularly in school settings. The current paper examines how the implementation fidelity of an increasingly popular and widely disseminated prevention model called, School-wide Positive Behavioral Interventions and Supports (SW-PBIS), relates to student outcomes within the context of a state-wide scale-up effort. Data come from a scale-up effort of SW-PBIS in Maryland; the sample included 421 elementary and middle schools trained in SW-PBIS. SW-PBIS fidelity, as measured by one of three fidelity measures, was found to be associated with higher math achievement, higher reading achievement, and lower truancy. School contextual factors were related to implementation levels and outcomes. Implications for scale-up efforts of behavioral and mental health interventions and measurement considerations are discussed.

Evidence-Based Practices in Community Mental Health: Outcome Evaluation...434–444
Kirstin Painter PhD, LCSW
Abstract: In 2003, questions were being raised relating to the lack of evidence-based treatments available in public mental health and whether the use of treatments found effective in research settings would be equally effective in real world situations. In response, one state passed a bill mandating a disease management model of service delivery and the use of evidence-based practices designed to obtain better clinical and functional outcomes, and to maximize the possibility for recovery for adults experiencing a serious mental illness. The purpose of this article is to provide an overview of the re-engineered public mental health system and report on findings of a longitudinal time-series study of the redesigned community mental health system. Findings of the study suggest using evidence-based practices and following a disease management model of mental health service delivery can be effective in real world settings for adults experiencing serious mental health symptoms and functional impairment.

Quality of Communication Between Primary Health Care and Mental Health Care: An Examination of Referral and Discharge Letters...445–461
Janet Durbin PhD, Jan Barnsley PhD, Brenda Finlayson RW, MSW, RSW, Liisa Jaakkimainen MD, CCFP, Elizabeth Lin PhD, Whitney Berta PhD, Josephine McMurray PhD (candidate)
Abstract: In managing treatment for persons with mental illness, the primary care physician (PCP) needs to communicate with mental health (MH) professionals in various settings over time to provide appropriate management and continuity of care. However, effective communication between PCPs and MH specialists is often poor. The present study reviewed evidence on the quality of information transfer between PCPs and specialist MH providers for referral requests and after inpatient discharge. Twenty-three audit studies were identified that assessed the quality of content and nine that assessed strategies to improve quality. Results indicated that rates of item reporting were variable. Within the limited evidence on interventions to improve quality, use of structured forms showed positive results. Follow-up work can identify a minimum set of items to include in information transfers, along with item definitions and structures for holding this information. Then, methodologies for measuring data quality, including electronically generated performance metrics, can be developed.

Tobacco Use and Substance Use Disorders as Predictors of Postoperative Weight Loss 2 Years After Bariatric Surgery...462–471
Claire E. Adams PhD, Jeanne M. Gabriele PhD, Lauren E. Baillie PhD, Patricia M. Dubbert PhD
Abstract: Although evaluations of tobacco and substance use disorders (SUDs) are required before bariatric surgery, the impact of these factors on postsurgical outcomes is unclear. This study describes (1) the prevalence of tobacco and SUDs in 61 veterans undergoing bariatric surgery, (2) associations between presurgical tobacco use and postsurgical weight loss, and (3) relationships between presurgical SUDs and postsurgical weight loss. Height, weight, tobacco, and SUDs were assessed from medical charts at presurgery and 6, 12, and 24 months postsurgery. Thirty-three patients (55%) were former or recent tobacco users; eight (13%) had history of SUDs. All patients who quit smoking within 6 months before surgery resumed after surgery, which was associated with increased weight loss at 6 and 12 months. Presurgical SUDs were related to marginally worse weight loss at 12 and 24 months. Bariatric surgery candidates with history of smoking and/or SUDs might benefit from additional services to improve postsurgical outcomes.

Predicting Inpatient Aggression Using the InterRAI Risk of Harm to Others Clinical Assessment Protocol...472–480
Eva Neufeld MA, Christopher M. Perlman PhD, John P. Hirdes PhD
Abstract: This study examined the ability of a risk assessment algorithm, the Risk of Harm to Others Clinical Assessment Protocol (RHO CAP) to predict inpatient aggression within a mental health and addictions treatment facility in Ontario, Canada. Anonymized patient records were retrospectively reviewed from April 1, 2004 to July 31, 2009 (N = 6,425). Survival analysis using Cox’s regression was used to predict time to inpatient aggression using the RHO CAP. Approximately 10% of inpatients were at moderate risk of harm to others, and 2% were considered high risk. The pattern of survival curves revealed that within the first month of admission, approximately 10% of inpatients at high risk of harm to others displayed physical aggression. Patients at high risk were also two times more likely to display physical aggression. Clinical teams can use the RHO CAP to implement preventive safety measures, reduce the incidence of inpatient aggression and improve quality of care.
*Results from this manuscript were presented at the annual meeting of the International Network for Excellence in Mental Health (iNEMH), in Reykjavik, Iceland: October 12–18, 2009.

Addressing Challenges to Providing Peer-Based Recovery Support...481–491
Anthony J. Alberta PhD, Richard R. Ploski, Scott L. Carlson
Abstract: As more systems of care deploy peer-based recovery support (P-BRS) programs, challenges to the effective use of P-BRS have emerged. These include external challenges, embedded in the organization and culture of traditionally organized services, and individual challenges, associated with the nonprofessional status of individual peer support staff members. The Living Centers, recovery resource centers providing P-BRS, have developed methods for addressing these challenges. These include organizing the P-BRS as stand-alone programs, having peer support staff and clients organize the P-BRS, emphasizing organizational values and culture as the basis for staff training, and implementing measures designed to encourage accountability among peer support staff. In the future, research into the types of barriers to P-BRS that may exist in traditionally organized behavioral health services and the types and content of training that contribute to the provision of P-BRS will facilitate the use of these services.