JBHSR Recent Issues

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

Volume 40, 2013

Issue 1 / January 2013

Reflection Health Means Hope: 2013 Is the Year of the Children…1– 4
Linda Rosenberg MSW
Abstract: Serious mental illnesses often have their onset before age 20. Early identification and treatment is critical in minimizing the long-term effects of mental illness. We have made great strides in our understanding of children’s behavioral health difficulties and how to treat them. But many challenges remain—from gaps in insurance coverage to inadequate public understanding of children’s behavioral health—and not all youth who need services are able to access them in a timely fashion. The National Council for Behavioral Health offers many programs to address the challenges.
Several articles in this issue of the Journal of Behavioral Health Services and Research (JBHS&R) address issues relating to mental health challenges among children and youth, including Race/Ethnicity, Parent-Identified Emotional Difficulties, and Mental Health Visits among California Children;1 Mental Health Communications Skills Training for Medical Assistants in Pediatric Primary Care;2 Psychopathology as a Predictor of Medical Service Utilization for Youth in Residential Treatment;3 and Antipsychotic Treatment Patterns and Aggressive Behavior Among Adolescents in Residential Facilities.4 Therefore, this Reflection focuses on what the National Council for Behavioral Health (National Council) is doing to provide hope for children and youth.

Race/Ethnicity, Parent-Identified Emotional Difficulties, and Mental Health Visits Among California Children…5–19
Jim E. Banta PhD, MPH,Sigrid James PhD, MSW,Mark G. Haviland PhD, Ronald M. Andersen PhD
Abstract: Variability in mental health services utilization by race/ethnicity was evaluated with a Behavioral Model approach. Subjects were 17,705 children 5 to 11 years of age in the 2005, 2007, and 2009 California Health Interview Surveys. Parents identified minor emotional difficulties in 18.7% of these children (ranging from 14.8% in Asians to 24.4% in African Americans) and definite or severe difficulties in 7.4% (5.5% in Asians to 9.7% in “other race”). Overall, 7.6% of children had at least one mental health visit in the prior year (2.3% in Asians to 11.2% in African Americans). Parent-identified need was the most salient predictor of mental health visits for all racial/ethnic groups. Beyond need, no consistent patterns could be determined across racial/ethnic groups with regard to the relationship between contextual, predisposing, and enabling measures and mental health service utilization. Different factors operated for each racial/ethnic group, suggesting the need for studies to examine mental health need, mental health service use, and determinants by racial/ethnic subgroup. These findings suggest that a “one-size-fits-all approach” with regard to policies and practices aimed at reducing mental health disparities will not be effective for all racial/ethnic groups.

Mental Health Communications Skills Training for Medical Assistants in Pediatric Primary Care…20–35
Jonathan D. Brown PhD, MHS, Lawrence S. Wissow MD, MPH, Benjamin L. Cook PhD, MPH, Shaina Longway BA, Emily Caffery BA, Chris Pefaure BA
Abstract: Paraprofessional medical assistants (MAs) could help to promote pediatric primary care as a source of mental health services, particularly among patient populations who receive disparate mental health care. This project piloted a brief training to enhance the ability of MAs to have therapeutic encounters with Latino families who have mental health concerns in pediatric primary care. The evaluation of the pilot found that MAs were able to master most of the skills taught during the training, which improved their ability to have patient-centered encounters with families during standardized patient visits coded with the Roter Interaction Analysis System. Parents interviewed 1 and 6 months following the training were more than twice as willing as parents interviewed 1 month before the training to discuss mental health concerns with MAs, and they had better perceptions of their interactions with MAs (all p < 0.01) even after controlling for a range of patient and visit characteristics. Before training, 10.2% of parents discussed a mental health concern with the MA but not the physician; this never happened 6 months after training. This pilot provides preliminary evidence that training MAs holds potential to supplement other educational and organizational interventions aimed at improving mental health services in pediatric primary care, but further research is necessary to test this type of training in other settings and among different patient populations.

Psychopathology as a Predictor of Medical Service Utilization for Youth in Residential Treatment...36–45
Timothy D. Nelson PhD, Tori R. Smith BS, Robert Pick MS, Michael H. Epstein EdD, Ronald W. Thompson PhD, Thomas F. Tonniges MD
Abstract: Rising health care costs have led to an emphasis on identifying factors that contribute to medical service utilization. Previous research has suggested an association between youth psychopathology and service utilization; however, prospective studies among high-risk populations are needed. The current study examined youth psychopathology as a predictor of subsequent medical service utilization among a large sample (N = 536) of youth entering residential treatment. Youth psychopathology and medical status were assessed at intake, and medical service utilization was tracked across the duration of the residential placement. Results indicated that higher levels of psychopathology predicted greater youth medical service utilization, even after controlling for the presence of a diagnosed medical condition. Internalizing problems was a significant independent predictor of utilization, but externalizing problems was not. These findings highlight the association between mental health and medical service utilization and suggest that effective behavioral health services may be helpful in reducing costly medical service needs.

Call for Research: Detecting Early Vulnerability for Psychiatric Hospitalization…46– 56
Jonathan D. Prince PhD
Abstract: This study delineated the extent to which a broad set of risk factors in youth, a period well suited to primary prevention strategies, influences the likelihood and timing of first lifetime psychiatric hospitalizations. Logistic regression was used to delineate early risk factors for psychiatric hospitalization among Americans in a nationally representative survey (NCS-R, Part II, 2001–2003: N = 5,692). Results suggest that inpatient stay is more common and happens at earlier ages among Americans who report growing up with versus without: (1) depressed parents or caregivers, (2) family members who victimized them, or (3) one of three child mental illnesses (conduct, oppositional defiant, or separation anxiety disorder). In order to prevent inpatient stay, findings call for longitudinal research on early vulnerability for psychiatric hospitalization among families with: (1) depressed parents of children or adolescents, (2) violence against children, and (3) children that have externalizing or separation anxiety disorders.

Do Client Attributes Moderate the Effectiveness of a Group Cognitive Behavioral Therapy for Depression in Addiction Treatment?…57– 70
Sarah B. Hunter PhD, Susan M. Paddock PhD…
Abstract: The study goal was to determine whether client attributes were associated with outcomes from group cognitive behavioral therapy for depression (GCBT-D) as delivered in community-based addiction treatment settings. Data from 299 depressed residential clients assigned to receive either usual care (N = 159) or usual care plus GCBT-D (N = 140) were examined. Potential moderators included gender, race/ethnicity, education, referral status, and problem substance use. Study outcomes at 6 months post-baseline included changes in depressive symptoms, mental health functioning, negative consequences from substance use, and percentage of days abstinent. Initial examination indicated that non-Hispanic Whites had significantly better outcomes than other racial/ethnic groups on two of the four outcomes. After correcting for multiple testing, none of the examined client attributes moderated the treatment effect. GCBT-D appears effective; however, the magnitude and consistency of treatment effects indicate that it may be less helpful among members of racial/ethnic minority groups and is worthy of future study.

Hard Times and Common Mental Health Disorders in Developing Countries: Insights from Urban Ghana…71–87
Janet Dzator BSc MPhil PhD
Abstract: Over the past century, the world has rapidly become urbanized, meaning more people now live in urban areas and cities than in rural areas. The mass movement of the rural poor to urban centers and cities has also changed the dynamics of poverty. Scarce employment opportunities, lack of assets, and sudden changes in economic conditions have been proposed as increasing the stress level for most urban residents, especially the poorer ones. Using a face-to-face household survey that included a six-item non-specific psychometric instrument, the data revealed how psychological distress may be patterned by socioeconomic status among urban residents in Ghana during difficult times characterized by food and fuel price hikes. The data collected in interviews of 1,158 adults (49% males and 51% females) who were 18 years and above were analyzed using multinomial logit regressions. The results confirmed previous findings and showed negative links between socioeconomic status, adverse life events, and psychological distress. Specifically, low income, low level of education, large household size, undesirable life events and being employed in agriculture was found to be associated with psychological disorders. The outcomes of this research project are consistent with previous findings—that people in lower socioeconomic strata and those who have suffered adverse events are more likely to suffer psychological distress. The implications of these results for behavioral health are discussed.

Tobacco Use Among African-American Youth Receiving Behavioral Healthcare Services... 88–96
Alison B. Breland PhD, Aashir Nasim PhD…
Abstract: African-American youth with behavioral health problems may be particularly vulnerable to tobacco use and dependence; however, little is known about overall prevalence and factors associated with tobacco use in this population. The present study compared rates of tobacco use for African-Americans (aged 13–17) receiving behavioral healthcare services to state and national prevalence rates. In addition, we examined whether tobacco use prevalence was related to treatment characteristics and services rendered. Retrospective chart reviews were conducted at an urban, public behavioral healthcare agency for youth admitted in 2009. Tobacco use rates among African-Americans receiving behavioral healthcare services were similar to, and in some cases, higher than statewide and national prevalence rates. While tobacco users were more likely to be enrolled in a substance abuse program than in a mental health program, only 2 of 55 youth reporting tobacco use had received documented tobacco cessation treatment. Future work should focus on implementing tobacco cessation prevention and treatment for these youth.

Antipsychotic Treatment Patterns and Aggressive Behavior Among Adolescents in Residential Facilities.. 97–110
Leslie Miller MD, Mark A. Riddle MD…
Abstract: This study examined the association between acute aggressive behavior patterns of 145 adolescents in residential treatment facilities with use of and changes in antipsychotic medication for the chronic management of aggression. Seclusion/restraint (S/R) frequency over 12 months was used to categorize youth into none, low, moderate, and high S/R groups. Data were analyzed using longitudinal mixed effects logistic regression models that allowed for intra-subject variability over time. The high and moderate S/R groups were significantly more likely to receive antipsychotics, get higher doses, and have changes in medication compared with the none S/R group. Increases in antipsychotic dose were associated with a lower likelihood of changes in antipsychotic medication over time. Despite persistent antipsychotic use at higher doses, youth in the high and moderate S/R groups continued to be secluded/restrained frequently. The findings question the adequacy of these medications in managing aggressive behavior.

Using Technology in the Delivery of Mental Health and Substance Abuse Treatment in Rural Communities: A Review...111–120
Sandra Benavides-Vaello MPAff, PhD, RN…
Abstract: Rural communities face tremendous challenges in accessing mental health and substance abuse treatment services. Some of the most promising advancements in the delivery of rural health care services have been in the area of telecommunication technology. These applications have the potential to reduce the disparities in the delivery of substance abuse and mental health services between urban and rural communities. The purpose of this inquiry was to explore the advances and uses of telecommunications technology, and related issues, in the delivery of mental health and substance abuse treatment services within rural areas. A review of the academic literature and other relevant works was conducted and the content was organized into four major themes: (a) advantages of telehealth and applications to rural practice, (b) barriers to implementation in rural practice, (c) utilization in rural areas, and (d) areas for further research.

Behavioral Health and Health Care Reform Models: Patient-Centered Medical Home, Health Home, and Accountable Care Organization…121–132
Yuhua Bao PhD, Lawrence P. Casalino MD, PhD…
Abstract: Discussions of health care delivery and payment reforms have largely been silent about how behavioral health could be incorporated into reform initiatives. This paper draws attention to four patient populations defined by the severity of their behavioral health conditions and insurance status. It discusses the potentials and limitations of three prominent models promoted by the Affordable Care Act to serve populations with behavioral health conditions: the Patient-Centered Medical Home, the Health Home initiative within Medicaid, and the Accountable Care Organization. To incorporate behavioral health into health reform, policymakers and practitioners may consider embedding in the reform efforts explicit tools—accountability measures and payment designs—to improve access to and quality of care for patients with behavioral health needs.

Religious Behavior, Sleep Quantity, Sleep Quality, and Sleep Disorders in American Adults...133–134
R. F. Gillum MD, MSPH
This is an excerpt from the letter content: Khalsa and others have reported benefits of spiritual practices in the management of poor sleep quality.1,2 But little is known about the relationship of religious practice and sleep quality in the US general population3. To test the hypothesis that those who frequently attend religious services have better sleep quality than others, data from 3,025 adults, older than 40 years old, in a 2005–2006 national survey4 were examined to relate short sleep duration of less than 7 hours, poor sleep, and diagnosed sleep disorder to frequency of attendance at religious services (FARS) (more than or equal to versus less than weekly). Due to interactions with age, logistic regression was performed within age groups (40–59, 60–89 and older) adjusting for age (years) and gender,5 or age, gender, race (black, nonblack), ethnicity (Hispanic, non-Hispanic), education (less than high school, more than or equal to high school), and self-reported health status (fair/poor, good/very good/excellent).6

Author Response to manuscript: "Religious Behavior, Sleep Quantity, Sleep Quality, and Sleep Disorders in American Adults"...135
Sat Bir Khalsa PhD
This is an excerpt from the content: This letter states, “Khalsa and others have reported benefits of spiritual practices in the management of poor sleep quality reported benefits of spiritual practices in the management of poor sleep quality”, and cites our study as a citation for this statement. Our study did no more than acquire a few anecdotal reports from some students that sleep was improved with yoga practice. I do not believe our paper can be used as a justifying citation for this author's statement. There are other citations that are much more appropriate supporting the contention for yoga-mediated improvements in sleep.

Furthermore, it is a little misleading to indicate that we “reported benefits of spiritual practices” in reference to our yoga intervention study, especially in the context of the authors' subsequent discussion devoted to religious practices. Yoga is a non-religious, mind–body practice, although yoga practice may have some effect on spirituality.

Issue 2 / April 2013

A Shared Struggle with Tobacco Addiction…137-139
Linda Rosenberg MSW
This is an excerpt from the content: An article in this issue of the Journal of Behavioral Health Services & Research discusses “Treatment Desires and Symptomatology among Substance Abusing Homeless Mothers: What I Want versus What I Need.” Other articles discuss how to facilitate consumer change and how to address hard to engage clients receiving both mental health and substance use services. All of these important issues led me to think about another real struggle in behavioral health, tobacco cessation, and to share my story. Smoking is up close and personal for me, and I have been humbled by how difficult it is to stop. I come from a family of smokers and married into a family of smokers. Both my grandfather and father died of lung cancer. Among my earliest childhood memories is being woken each morning by my father’s coughing and the ever-present pack of Camels next to my grandfather’s favorite chair. It was easy to start smoking in high school; in fact, didn’t all the cool kids smoke?

Master Resilience Training and Its Relationship to Individual Well-Being and Stress Buffering Among Army National Guard Soldiers…140-155
James Griffith PhD, Courtney West MA
Abstract: To better enable soldiers to adapt to stressors of military life, Master Resilience Training has been offered to soldiers since 2009. Few studies have examined whether the training achieves its intended effects. To fill this gap, resilience-trained Army National Guard soldiers and civilians (N = 611) completed online questionnaires about their resilience training experience (72% completion rate, N = 441). Respondents (92% or more) indicated the training was helpful and improved resilience competencies that enhanced coping with stressful circumstances. Respondents (97% or more) indicated that these competencies were subsequently used in their military and civilian jobs. A measure of resilience competencies was developed and showed self-reported changes largely pertained to increased self-awareness and strength of character, including improved optimism, mental agility, and connection with others. Self-reported change in resilience competencies was associated with fewer behavioral health symptoms, especially, for those reporting more current stressful events (known as the buffering effect). Findings are discussed in terms of resilience’s potency of training, content of the training, and the need to elaborate on resilience’s relationship to specific stressors.

Treatment Desires and Symptomatology Among Substance-Abusing Homeless Mothers: What I Want Versus What I Need...156–168
Natasha Slesnick PhD, Xiamei Guo MS
Abstract: The current study sought to identify information that may inform treatment providers regarding services for, and engagement of, substance-abusing homeless mothers. Shelter-recruited, substance-abusing homeless mothers' desires for treatment in several commonly reported problem areas including substance use, parenting, depressive symptoms/mood, physical health, and childhood abuse history were assessed. The correspondence between mother's desire for treatment and self-reported problem severity was also examined. The majority of mothers reported at least some desire (versus no desire at all) for assistance with substance use, depressive symptoms/mood, and parenting. A series of independent-sample t tests and chi-square tests showed that mothers indicating any treatment desire in the areas of substance use, depressive symptoms/mood, health problems, and sexual abuse also reported higher levels of severity in the corresponding problem areas. The findings imply that psychosocial treatment should be available to all homeless mothers entering the shelter system, especially given that problem severity appears to be a fair indicator of interest in treatment.

Understanding the Critical Ingredients for Facilitating Consumer Change in Housing First Programming: A Case Study Approach...169–179
Dennis P. Watson PhD, Dana E. Wagner MA, Michael Rivers MA
Abstract: Housing First is a form of permanent supportive housing for chronically homeless consumers with mental health and substance abuse issues. In light of the model’s growing popularity and wide diffusion, researchers and policy makers have identified a need to better understand its critical ingredients and the processes through which they affect consumer outcomes. Researchers used a bottom-up approach to understand the critical ingredients of Housing First within community-based programs. Interviews and focus groups were conducted with 60 informants (staff and consumers) across 4 “successful” Housing First programs. Qualitative analysis demonstrated six program ingredients to be essential: (1) a low-threshold admissions policy, (2) harm reduction, (3) eviction prevention, (4) reduced service requirements, (5) separation of housing and services, and (6) consumer education.

Caregiver Participation in Community-Based Mental Health Services for Children Receiving Outpatient Care...180–190
Kya Fawley-King PhD
Abstract: Caregiver participation in child mental health treatment has been associated with better youth outcomes, but little is known about the amount and type of caregiver participation in usual care services for children. This study examined 1,255 caregivers’ reports of their participation in the outpatient services their children received through a large, public mental health system in the Southwest. The majority of the caregivers reported that they participated in their child’s services. Extent of participation was associated with several factors including children’s physical health and caregivers’ primary language, satisfaction with the services, feelings of support, and perceptions of barriers to participation. The findings offer some encouragement for the contextual fit for many evidence-based interventions that focus on caregiver involvement, and highlight which caregivers may need greater encouragement to participate in their child’s care.

Balancing Accessibility and Selectivity in 21st Century Public Mental Health Services: Implications for Hard to Engage Clients…191–206
Amy Blank Wilson PhD, LSW, Stacey Barrenger MSW, Casey Bohrman LSW, Jeffrey Draine PhD, MSW
Abstract: This research highlights the importance of expanding examinations of service accessibility for hard to engage client populations to include assessments of individuals’ ability to gain entrance to services and the system’s ability to meet the service needs of particular client populations. The results of this research provide a framework to support these examinations. The increasing levels of selectivity and targeting of mental health services to particular client populations found in this study raise fundamental questions about the goals of service accessibility in 21st century public mental health services generally, and for hard-to-engage clients particularly. These findings also point to the need for examinations of the eligibility criteria and gatekeeping mechanism that are used to target services to particular client populations to determine if they are working as intended and to assess what impact these mechanisms have on hard to engage clients’ ability to gain entrance to needed services.

Hospital Readmission Among Medicaid Patients with an Index Hospitalization for Mental and/or Substance Use Disorder…207–221
Tami Mark PhD, MBA, Karen Smoyer Tomic PhD, Niranjana Kowlessar PhD, Bong Chul Chu PhD, Rita Vandivort-Warren MSW, Shelagh Smith MPH, CHES
Abstract: Hospital readmission rates are increasingly used as a performance indicator. Whether they are a valid, reliable, and actionable measure for behavioral health is unknown. Using the MarketScan Multistate Medicaid Claims Database, this study examined hospital- and patient-level predictors of behavioral health readmission rates. Among hospitals with at least 25 annual admissions, the median behavioral health readmission rate was 11% (10th percentile, 3%; 90th percentile, 18%). Increased follow-up at community mental health centers was associated with lower probabilities of readmission, although follow-up with other types of providers was not significantly associated with hospital readmissions. Hospital average length of stay was positively associated with lower readmission rates; however, the effect size was small. Patients with a prior inpatient stay, a substance use disorder, psychotic illness, and medical comorbidities were more likely to be readmitted. Additional research is needed to further understand how the provision of inpatient services and post-discharge follow-up influence readmissions.

A Medicaid and Commercial Insured Claims-Based Study to Estimate Improved Antipsychotic Medication Adherence Among Patients with Schizophrenia…222–233
Bruce Pyenson FSA, MAAA, Sara Goldberg FSA, MAAA, Kosuke Iwasaki FIAJ, MAAA, Victoria Boyarsky FSA, MAAA, Riad Dirani PhD
Abstract: Compliance with antipsychotic medication is clinically important but challenging for schizophrenia patients. Clinical trials and epidemiological studies strongly suggest that improved compliance results in reduced hospitalizations and other adverse outcomes. Examination of Medicaid and commercial claim data suggests that a significant portion of schizophrenia patients have a regular pattern of visits with one outpatient professional, yet are noncompliant with their medication. For many of these patients, results show that the administration of once-monthly verifiable therapy would improve compliance.

Assessing the Co-occurring Capability of Mental Health Treatment Programs: the Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) Index…234–241
Heather J. Gotham PhD, Jessica L. Brown PhD, Joseph E. Comaty PhD, MP, Mark P. McGovern PhD, Ronald E. Claus PhD
Abstract: The Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) Index was developed to assess the capability of mental health programs to provide substance abuse and co-occurring treatment services. The DDCMHT is an objective scale rated following a site visit that includes semi-structured interviews with staff at all levels, review of program documents and client charts, and ethnographic observation of the milieu and setting. Using data from 67 mental health programs across six states, this study found that the DDCMHT had excellent total score reliability, variable subscale reliability, high inter-rater reliability (n = 18), and moderate construct validity (n = 22). Results also suggest that many mental health programs are at a relatively low level of capability for the delivery of care to individuals with co-occurring disorders. Results from this important new benchmark measure, the DDCMHT, can be used with programs in implementation planning and with treatment systems, states, or national organizations to guide policy change.

Could Comprehensive Soldier Fitness Have Iatrogenic Consequences? A Commentary…24–246
Stephanie L. Smith MD
Abstract: Comprehensive Soldier Fitness (CSF) is a public health program intended to improve US Army service personnels’ resilience to military stressors including combat and operational experiences. The program uses psychological and behavioral strategies that have been shown to enhance resilience in children and adolescents. CSF has many modules that target a variety of dimensions of wellness. One of the core themes to CSF is the promotion of optimism and positive reframing of challenging situations. To date, the CSF program has not been critically and independently evaluated. This commentary argues that an emphasis on positive emotions and optimism could be maladaptive for post-combat recovery. Clinical and public behavioral health practitioners and researchers can play an important role in evaluating CSF psychological strategies.

Issue 3 / July 2013

Improving Implementation of Mental Health Services for Trauma in Multicultural Elementary Schools: Stakeholder Perspectives on Parent and Educator Engagement…247–262
Audra Langley PhD, Catherine DeCarlo Santiago PhD, Adriana Rodríguez MS, Jennifer Zelaya BA
Abstract: Although more schools are offering mental health programs, few studies have involved the school community in research to improve their successful implementation. In this community-partnered study, focus groups were conducted with school staff and parents to explore issues related to community engagement and feasibility of a mental health intervention for elementary school students exposed to trauma. Four educator focus groups, including 23 participants, and 2 parent focus groups, consisting of 9 Spanish-speaking and 7 English-speaking parents were conducted. Participants discussed facilitators and barriers to successful implementation of the program. Participants identified the importance of pre-implementation parent education, raising awareness of the impact of student mental health among educators, maintaining ongoing communication during the intervention, and addressing logistical concerns. Participants described clear considerations for parent and educator engagement, both at the pre-implementation phase and during implementation of the program. Implications for next steps of this community-partnered approach are described.

Parents Served by Assertive Community Treatment: Prevalence, Treatment Services, and Provider Attitudes…263–278
Laura M. White MS, John H. McGrew PhD
Abstract: Assertive Community Treatment (ACT) is an evidence-based practice for individuals with severe mental illness. Although studies estimate at least half of all people with severe mental illness are parents, little is known about ACT policies and services for consumers who are parents. ACT providers from 67 teams completed a survey assessing policies for identifying parent consumers of ACT, estimated prevalence of parent consumers, available treatment services, and attitudes about parent consumers. Participants estimated that 18% of ACT consumers are parents. However, less than half of participants (47.8%) reported formally asking about parental status during intake and only 22.4% reported providing programs or services designed for parent consumers. Most participants (about 80%) reported negative or mixed attitudes about parenting with severe mental illness. Findings suggest the need for more attention and focus on parent consumers, including the formal identification of consumers’ parental status and availability of parent-related treatment services.

The Characteristics and Severity of Psychological Distress After Abortion Among University Students…279–293
Maureen Curley PhD, PMHCNS, BC, Celeste Johnston N Ed D
Abstract: Controversy over abortion inhibits recognition and treatment for women who experience psychological distress after abortion (PAD). This study identified the characteristics, severity, and treatment preferences of university students who experienced PAD. Of 151 females, 89 experienced an abortion. Psychological outcomes were compared among those who preferred or did not prefer psychological services after abortion to those who were never pregnant. All who had abortions reported symptoms of post-traumatic stress disorder (PTSD) and grief lasting on average 3 years. Yet, those who preferred services experienced heightened psychological trauma indicative of partial or full PTSD (Impact of Event Scale, M = 26.86 versus 16.84, p < .05), perinatal grief (Perinatal Grief Scale, M 62.54 versus 50.89, p < 0.05), dysthymia (BDI M = 11.01 versus 9.28, p < 0.05), (M = 41.86 versus 39.36, p < 0.05), and co-existing mental health problems. PAD appeared multi-factorial, associated with the abortion and overall emotional health. Thus, psychological interventions for PAD need to be developed as a public health priority.

The Impact of System Level Factors on Treatment Timeliness: Utilizing the Toyota Production System to Implement Direct Intake Scheduling in a Semi-rural Community Mental Health Clinic…294–305
Addie Weaver PhD, Catherine G. Greeno PhD, Donald H. Goughler MSW, Kathleen Yarzebinski BA, Tina Zimmerman LCSW, Carol Anderson PhD
Abstract: This study examined the effect of using the Toyota Production System (TPS) to change intake procedures on treatment timeliness within a semi-rural community mental health clinic. One hundred randomly selected cases opened the year before the change and 100 randomly selected cases opened the year after the change were reviewed. An analysis of covariance demonstrated that changing intake procedures significantly decreased the number of days consumers waited for appointments (F(1,160) = 4.9; p = .03) from an average of 11 to 8 days. The pattern of difference on treatment timeliness was significantly different between adult and child programs (F(1,160) = 4.2; p = .04), with children waiting an average of 4 days longer than adults for appointments. Findings suggest that small system level changes may elicit important changes and that TPS offers a valuable model to improve processes within community mental health settings. Results also indicate that different factors drive adult and children’s treatment timeliness.

Factor Structure of the Mental Health Statistics Improvement Program (MHSIP) Family and Youth Satisfaction Surveys…306–316
Alan B. Shafer PhD, Judith M. Temple MSW
Abstract: Two studies of the Mental Health Statics Improvement Project (MHSIP) Family and Youth consumer satisfaction surveys factor structure and psychometrics were conducted. In study 1, the 2002–2006 Youth Services Survey for Families (N = 6,007) was administered to parents of children receiving services, and in study 2, the 2002–2004 Youth Services Survey (N = 1,718) was administered to children age 12–18 receiving services. Factor analyses across both studies found five factors that strongly supported the hypothesized scale domains of outcomes, satisfaction, cultural sensitivity, participation, and access. Scales based on these factors had good reliability with an average coefficient alpha of 0.85. The average convergent validity correlation between scale scores from the parent and child surveys was r = 0.62. Overall, the results supported the structure, reliability, and validity of the surveys.

Revolutionizing Child Welfare with Outcomes Management…317–329
Linda L. Toche-Manley PhD, Laura Dietzen MS, Jesse Nankin MA, Astrid Beigel PhD
Abstract: Outcomes management technology holds great promise for improving the quality of services provided to youth in the child welfare system. Advantages include better detection of behavioral health and trauma-related issues, early indicators of case progress or risk of failure, and program- and system-level learning. Yet organizational barriers to implementation persist. Attention is spent in this paper on addressing these barriers so the use of outcomes management technology becomes a common practice. A model for predicting resiliency is presented, along with case examples demonstrating its potential use for treatment planning and monitoring progress.

Determinants of Successful Treatment Outcomes Among a Sample of Urban American Indians/Alaska Natives: the Role of Social Environments…330–341
Suzanne E. Spear PhD, Desiree Crevecoeur-MacPhail PhD, Loretta Denering MS, Daniel Dickerson DO, MPH, Mary-Lynn Brecht PhD
Abstract: Very few studies have analyzed the role of social environments on substance abuse treatment outcomes among urban American Indians/Alaska Natives (AI/ANs). This study examined a measure of positive treatment response—abstinence from substance use at treatment discharge—among urban AI/ANs in Los Angeles County. The sample included all AI/ANs in outpatient drug-free (e.g., no methadone) treatment and residential treatment from 2004 to 2008 (N = 811). Predictors of abstinence at discharge were (a) having recovery-oriented social support and (b) not having a difficult living situation (i.e., experiencing family conflict and/or living with someone who uses alcohol and/or drugs). Higher levels of recovery-oriented social support in the past 30 days predicted abstinence during outpatient treatment. In residential treatment, retention of 90 days or more, high recovery-oriented social support, and not experiencing difficult living situations predicted abstinence. Suggestions for optimizing treatment outcomes among AI/ANs and areas of further research are provided.

A Pilot Study Examining Trainee Treatment Session Fidelity when Parent–Child Interaction Therapy (PCIT) Is Implemented in Community Settings…342–354
Jamie K. Travis MS, Elizabeth Brestan-Knight PhD
Abstract: Research supports the impact of empirically based treatments, such as Parent–Child Interaction Therapy (PCIT), on producing positive treatment outcomes for clients. However, achieving outcomes in community settings that are similar to those found in research settings can be challenging, and little research has been conducted on how to best train community providers to implement PCIT with fidelity. This study assessed trainee implementation fidelity to the PCIT protocol in community settings. Session fidelity was reviewed for trainees using pre-established session integrity checklists and post hoc video review of key sessions. Analyses revealed that trainees maintained strong overall session fidelity, although fidelity percentages varied by session type and treatment phase. Results also highlight those session content items that are frequently left out by trainees during implementation. Implications of these findings, limitations, and future directions for research and PCIT workshops and consultation are discussed.

Healthcare Cost Reductions Associated with the Use of LAI Formulations of Antipsychotic Medications Versus Oral Among Patients with Schizophrenia…355–366
Jay Lin PhD, MBA, Bruce Wong MD, Steve Offord PhD, Dario Mirski MD
Abstract: Real-world medication adherence and healthcare costs of patients with schizophrenia initiating long-acting injectable (LAI) vs. oral antipsychotics were compared. Patients with schizophrenia initiating LAI or oral antipsychotics (index event) were identified from MarketScan Commercial and Medicare claims databases and their medication possession ratios (MPR), pre- and post-index costs for inpatient/outpatient care were compared. Of 3,004 patients, 394 initiated LAI antipsychotics and 2,610 oral antipsychotics. Post-index, the mean MPR was greater for the LAI cohort (0.67 ± 0.34 vs. 0.56 ± 0.35; p < 0.001). Schizophrenia-related hospital costs for LAI users were reduced during the follow-up period in comparison to the pre-index period, but were increased for patients using oral antipsychotics (-$5,981 ± $16,554 vs. 758 ± 14,328, p < 0.001). The change in costs of outpatient care also favored LAI medications ($134 ± 8,280 vs. 658 ± 3,260, p = 0.023). Drug costs of LAI antipsychotics were higher ($4,132 ± 4,533 vs. 2,562 ± 2,714, p < 0.001). Schizophrenia patients initiating LAI antipsychotics incur less healthcare costs in comparison to patients initiating oral antipsychotics.

Variation in Use of Buprenorphine and Methadone Treatment by Racial, Ethnic, and Income Characteristics of Residential Social Areas in New York City…367–377
Helena B. Hansen MD, PhD, Carole E. Siegel PhD, Brady G. Case MD, David N. Bertollo BA, Danae DiRocco MPH, Marc Galanter MD
This is an excerpt from the content: Introduction:Opiate agonist therapies for opiate dependence lower HIV incidence and arrest rates among injection drug users,1–3 thus enhancing access to these treatments is a major public health priority. Buprenorphine, a partial opiate receptor agonist approved by the US FDA in 2002 for treatment of opiate dependence, offers important advantages over methadone maintenance. Buprenorphine is less lethal in overdose than methadone.4 The most commonly prescribed formulation of buprenorphine, in which it is combined with the opiate antagonist naloxone, produces opiate withdrawal when injected, limiting its abuse potential.5 Because of these lower risks, buprenorphine can be prescribed by office-based generalist physicians, potentially increasing treatment access and reducing stigma in comparison to methadone,6 which is restricted to federally regulated methadone clinics.

The Status of Billing and Reimbursement in Pediatric Obesity Treatment Programs…378–385
Jane Simpson Gray PhD, Stephanie Spear Filigno PhD, Melissa Santos PhD, Wendy L. Ward PhD, Ann M. Davis PhD, MPH, ABPP
Abstract: Pediatric psychologists provide behavioral health services to children and adolescents diagnosed with medical conditions. Billing and reimbursement have been problematic throughout the history of pediatric psychology, and pediatric obesity is no exception. The challenges and practices of pediatric psychologists working with obesity are not well understood. Health and behavior codes were developed as one potential solution to aid in the reimbursement of pediatric psychologists who treat the behavioral health needs of children with medical conditions. This commentary discusses the current state of billing and reimbursement in pediatric obesity treatment programs and presents themes that have emerged from discussions with colleagues. These themes include variability in billing practices from program to program, challenges with specific billing codes, variability in reimbursement from state to state and insurance plan to insurance plan, and a general lack of practitioner awareness of code issues or reimbursement rates. Implications and future directions are discussed in terms of research, training, and clinical service.

Issue 4 / October 2013

Statewide Implementation of Recovery Support Groups for People with Serious Mental Illness: A Multidimensional Evaluation…391–403
Michael A. Mancini PhD, Donald M. Linhorst PhD, Anthony A. Menditto PhD, James Coleman PhD
Abstract: This study evaluated a statewide demonstration project to implement a group-based intervention called Procovery in selected inpatient and community mental health centers. Procovery is a facilitated mutual support group designed to build hope and a sense of social inclusion by raising consciousness and helping people develop an understanding of the ways one can move toward recovery in their own lives. This evaluation sought to determine both consumer outcomes and perceptions of the program and implementation efforts held by consumers and the facilitators of the intervention. A multidimensional approach was used, including a quasi-experimental design with consumers, questionnaires and focus groups with the intervention facilitators, and individual interviews with administrators. The Procovery model was shown to have a positive impact on consumers’ recoveries and was viewed favorably by consumers, facilitators, and administrators. Several barriers to effective implementation were identified. These findings and their implications for future practice and research are discussed.

Children’s Behavioral Health System Transformation: One State’s Context and Strategies for Sustained Change…404–415Deborah S. Harburger MSW, Sharon H. Stephan PhD, Sarah Kaye PhD
Abstract: The purpose of this paper was to examine the State of Maryland as a case study of sustained change efforts in the service delivery system for children with significant behavioral health needs and their families. A punctuated equilibrium paradigm is introduced to describe Maryland’s behavioral health system transformation over the course of three decades. The context and specific strategies that characterized Maryland’s execution of its recent Mental Health Transformation State Incentive Grant are highlighted. There is a discussion of one of the pinnacle achievements of Maryland’s transformation efforts, the recent statewide establishment of care management entities for children with behavioral health challenges, and its implications for behavioral health in the context of health care reform changes. This case study illustrates how a state can systematically and incrementally develop systems of care for children and families that are values-based, sustainable, and flexible.

Healthcare Utilization and Symptom Variation Among Veterans Using Behavioral Telehealth Center Services…416–426
Kyle Possemato PhD, Todd M. Bishop MS, Matthew A. Willis MA, Larry J. Lantinga PhD
Abstract: Substance use and mental health problems are often underdiagnosed and undertreated in primary care. Veterans affairs facilities are using the Behavioral Telehealth Center (BTC) to provide evidence-based assessments for primary care patients via telephone. Whether participation in BTC services is associated with (1) increases in healthcare utilization and (2) decreases in symptoms based on behavioral health screening instruments, post-BTC services compared with pre-BTC services were investigated. Retrospective data were extracted for 1,820 patients who were referred to the BTC. Differences in utilization rates and symptom scores pre- and post-BTC services were tested using repeated measures analysis of covariance while controlling for relevant sociodemographic variables. Participants (1) utilized significantly more substance use and mental health treatment services and (2) had significantly lower alcohol and depression screening scores post-BTC services compared with pre-BTC services. This initial evaluation provides support that BTC services are associated with increased healthcare utilization and decreased alcohol and depressive symptoms.

Low-Income Cancer Patients in Depression Treatment: Dropouts and Completers…427–441
Anjanette A. Wells PhD, MSW, Lawrence A. Palinkas PhD, En-Jung Shon MA, MSW, Kathleen Ell DSW
Abstract: This study aims to explore reasons for depression treatment dropout among low-income, minority women with depression and cancer. Semi-structured telephone interviews are conducted with 20, predominately Latina, patients who dropped out of depression treatment and 10 who completed. Transcripts analyzed using techniques rooted in grounded theory. Treatment completion barriers cluster according to Meichenbaum and Turk's (Facilitating treatment adherence: A practitioner's guidebook, Plenum Press, New York, 1987) five adherence dimensions: (a) Barriers to Treatment (informational, instrumental, cultural [language, discrimination]); (b) Disease Features (emotional burden of cancer/depression); (c) Cancer/Depression Treatment Regimens; (d) Provider–Patient Relationship (depression treatment dissatisfaction); and (e) Clinical Setting (hospital organizational issues). Although both groups describe multiple overlapping dimensions of barriers, completers seem more motivated and satisfied with treatment, possibly due to completers experiencing the positive treatment effects after the first several sessions. More research should be conducted to determine the most effective clinical treatment methods for this population.

Community Context and Healthcare Quality: The Impact of Community Resources on Licensing and Accreditation of Substance Abuse Treatment Agencies…442–456
Matthew E. Archibald PhD, Caddie Putnam Rankin PhD
Abstract: This study examines variation in healthcare quality among substance abuse treatment agencies. Using an organizations framework, the authors predict that resource advantages benefit certain types of healthcare organizations, especially those located in affluent communities. As a result, levels of licensing and accreditation of substance abuse treatment agencies will differ across United States counties. The authors model these resources at both the organizational and community levels in an effort to understand the variability of licensing and accreditation between agencies and their local contexts. In multivariate models, the findings confirm that organizational characteristics such as private ownership (compared to public ownership), managed care contracts, inpatient and residential programs (compared to outpatient settings), as well as socioeconomic, racial/ethnic, and healthcare system advantage promote higher levels of licensing and accreditation. Public ownership and outpatient settings, as well as socioeconomic, racial/ethnic, and healthcare system disadvantage, are associated with lower levels of licensing and accreditation.

Health Risks, Race, and Adolescents’ Use of School-Based Health Centers: Policy and Service Recommendations…457–468
Yolanda Anyon MSW, PhD, Megan Moore MSW, PhD, Elizabeth Horevitz MSW, PhD, Kelly Whitaker MPA, Susan Stone MSW, PhD, John P. Shields PhD
This is an excerpt from the content:Introduction: School-based health centers (SBHCs) offering health and behavioral health services in educational settings are an increasingly popular strategy to improve adolescents’ access to care, particularly in low-income communities of color where youth experience social, economic, and geographic barriers to care that result in high rates of unmet behavioral and physical health needs.1 Recent studies of SBHCs in high school settings indicate that, relative to their proportion in the general school population, Black and Latino students tend to be overrepresented in these programs, whereas White and Asian youth are underrepresented.2,3 One possible explanation is that these patterns reflect differential need for services resulting from higher health risks (e.g., depression, substance use, asthma, or unprotected sexual activity) among Black and Latino youth because of their disadvantaged social location.

Perceptions of Health Intervene in the Relationship Between Psychiatric Symptoms and Quality of Life for Individuals in Supportive Housing...469–475
Jason Matejkowski PhD, Sungkyu Lee PhD, Benjamin Henwood PhD, Jonathon Lukens PhD, Lara Carson Weinstein MD
This is an excerpt from the content/Introduction: Psychiatric symptoms and quality of life (QOL) are important domains for mental health services and research. Findings from studies examining the relationship between psychiatric symptoms and quality of life have been mixed, prompting researchers to test moderating variables that identify for whom and under what circumstances psychiatric symptoms may or may not be particularly influential on individuals’ quality of life.1,2 However, in addition to knowing when or for whom symptoms influence QOL, it is also important to understand how symptoms may be influencing quality of life. Identification of factors that intervene between psychiatric symptoms and QOL can assist in addressing this question and inform the development of services to improve QOL among individuals with serious mental illness (SMI).

Social Network Members’ Roles and Use of Mental Health Services Among Drug Users in New York City…476–487
Katherine J. Sapra MPH, Natalie D. Crawford PhD, Abby E. Rudolph PhD, Kandice C. Jones MPH, Ebele O. Benjamin MPH, Crystal M. Fuller PhD
Abstract: Depression is more common among drug users (15–63 %) than the general population (5–16 %). Lack of social support network members may be associated with low mental health service (MHS) use rates observed among drug users. We investigated the relationship between social network members’ roles and MHS use among frequent drug users using Social Ties Associated with Risk of Transition into Injection Drug Use data (NYC 2006–2009). Surveys assessed depression, MHS use, demographics, drug use and treatment, and social network members’ roles. Participants reporting lifetime depressive episode with start/end dates and information on social/risk network members were included (n = 152). Adjusting for emotional support and HIV status, having one or more informational support network members remained associated with MHS use at last depressive episode (adjusted odds ratio (AOR) 3.37, 95 % confidence interval (CI) 1.38–8.19), as did history of drug treatment (AOR 2.75, 95 % CI 1.02–7.41) and no legal income (AOR 0.23, 95 % CI 0.08–0.64). These data suggest that informational support is associated with MHS utilization among depressed drug users.

The Role of Community Health Centers in Providing Behavioral Health Care…488–496
Peter Shin PhD, MPH, Jessica Sharac MSc MPH, D. Richard Mauery MS, MPH
Abstract: The prevalence of behavioral health problems is higher for low-income individuals, yet this population is less likely to receive behavioral health treatment. Community health centers have their advantages as behavioral health-care providers because they serve a majority low-income population and are located in medically underserved areas. Their role in providing behavioral health care is expected to expand under health reform as they are expected to double their patient capacity, and due to increased insurance coverage for individuals with behavioral health problems. However, the ability of community health centers to provide behavioral health care is compromised by provider shortages and funding shortfalls.