Alexis A. Giese

Antidepressant treatment and risk of suicide attempt by adolescents with major depressive disorder: a propensity-adjusted retrospective cohort study.

AbstractContext: The US FDA has issued an advisory warning of a possible link between antidepressant treatment for paediatric patients with major depressive disorder (MDD) and an increased risk of suicidal behaviour. A large database of paid health insurance claims for adolescents with MDD provided the opportunity to examine this possible relationship. Objective: To examine the potential empirical link between antidepressant treatment and suicide attempts among adolescents aged 12–18 years using a community sample of managed care enrollees across the US. Design: A retrospective longitudinal cohort using paid insurance claims for all healthcare and prescription fills for adolescents who were newly diagnosed with MDD and had at least 6 months of follow-up data. A multivariate Cox proportional hazards regression analysis was used to test the hypothesis that antidepressant use increased the risk of suicide attempt, adjusting for propensity for allocation to each treatment group and for demographic and clinical characteristics. Setting: Managed care plans including both commercial and Medicaid plans in the east, midwest, south and western regions of the US from January 1997 to March 2003. Participants: All adolescent insurance members aged 12–18 years at first diagnosis of MDD. Main outcome measures: Suicide attempts as indicated by medical utilisation with International Classification of Diseases (9th edition) [ICD-9] or 10th edition (ICD-10) codes in any healthcare setting or by any covered provider. Results: 24 119 adolescents met inclusion criteria (63% female). Crude suicide attempt rates ranged from 0.0-2.3% by index treatment group. Treatment with SSRIs (hazard ratio) [HR] = 1.59; CI 0.89, 2.82), other antidepressants (HR = 1.03; CI 0.43, 2.44), or multiple antidepressants (HR = 1.43; CI 0.70, 2.89) after index MDD diagnosis resulted in no statistically increased risk of suicide attempt. Treatment with antidepressant medication for at least 180 days (6 months) reduced the likelihood of suicide attempt compared with antidepressant treatment for <55 days (8 weeks) [HR = 0.34; CI 0.21, 0.55]. Other variables that were independently associated with greater risk of suicide attempts included female gender, severity of illness indicators, younger age at time of MDD diagnosis, and living in the midwest or west. Conclusions: Antidepressant medication use had no statistically significant effect on the likelihood of suicide attempt in a large cohort of adolescents across the US after propensity adjustment for treatment allocation and controlling for other factors. The relationship between suicidal behaviour and antidepressant medication use is complex and requires further investigation.

What Do Persons with Mental Illnesses Need to Quit Smoking? Mental Health Consumer and Provider Perspectives

OBJECTIVES Forty-one percent (41%) of persons in the U.S. who reported having recent mental illnesses also smoke cigarettes. Tobacco use among this population is associated with up to 25 less years of life and excess medical comorbidity compared to the general population. While research demonstrates that tobacco interventions can be effective for persons with mental illnesses, they are not commonly utilized in clinical practice. The current study explored how to adapt evidence-based tobacco cessation interventions to meet the unique physiological, psychological, and social challenges facing persons with mental illnesses. METHODS Ten focus groups were conducted utilizing a semi-structured discussion; 5 for adult mental health consumers (n = 62) and 5 with mental health clinicians and administrators (n = 22). Content analysis was used to organize themes into categories. RESULTS Five thematic categories were found: (1) Barriers to treatment, (2) Resources and infrastructure, (3) Negative influences on smoking behavior, (4) Knowledge deficits, and (5) Treatment needs. CONCLUSIONS These findings are instructive in developing appropriate tobacco cessation services for this population. Specifically, these data have been incorporated into a mental health provider toolkit for smoking cessation and have informed the development of a tobacco cessation intervention study.

Smoking reduction for persons with mental illnesses: 6-month results from community-based interventions.

Persons with mental illnesses use tobacco at significantly higher and heavier rates than the general population, and suffer greater tobacco- related morbidity and mortality. However, there are few existing tobacco cessation interventions for these individuals. This study examined two tobacco cessation interventions, a telephonic quitline intervention (counseling and nicotine replacement therapy) and a community-based group counseling intervention with adults currently receiving community mental health services. At 6-month follow-up, both groups demonstrated significantly reduced tobacco use, but participants who received both quitline services and the group counseling intervention were significantly more likely to have a 50% tobacco use reduction. Across groups, the overall intent-to-treat cessation rate was 7%. Tobacco dependence, depression symptoms, and psychotic symptoms decreased significantly for all treatment groups, while health and mental health functioning increased. Findings suggest that common community tobacco cessation services are effective for this population.

Findings from mental health screening of newly arrived refugees in colorado

States are required to provide a public health screening for all newly arrived refugees in the United States. In 1997, a comprehensive program was created to include both a physical examination and a mental health screening. This article provides a complete description of the mental health screening process, including two illustrative cases, and reports information about the refugees who participated in the program. Ten percent of screened refugees were offered mental health referrals; of those, 37% followed up. Refugees who presented for treatment reported a higher number of symptoms upon screening compared with those who were offered referrals but did not follow up. Psychiatric evaluation confirmed that those who screened positive and presented for treatment were experiencing a high level of suffering and qualified for mental health diagnoses. The findings support inclusion of a mental health screening as part of the public health screening.

Dissociative symptoms in psychotic mood disorders: an example of symptom nonspecificity.

Dissociative symptoms have been the subject of psychiatric inquiry since the beginning of this century (Putnam 1992; Sanders 1986; van der Kolk and van der Hart 1989). Although recent investigations have focused on the four specific dissociative disorders (American Psychiatric Association 1994) and their relationship to early traumatic experiences (Chu and Dill 1990; Putnam 1985; Terr 1991), dissociative symptoms have been reported in virtually every major psychiatric disorder (Bremner et al. 1992; Goff et al. 1992; Steinberg 1992), and, in less severe forms, even in nonpatient populations (Briere 1988; Putnam 1992; Ross and Joshi 1992). These observations raise questions about the clinical significance of dissociative symptoms that occur when other mental disorders are also present (Coons 1984; Fahy 1988).

Selection bias in an inpatient outcomes monitoring project

Managed care organizations increasingly tout clinical outcomes assessment as the mechanism by which we will ensure quality and compare providers. The authors report on their experience with a multisite inpatient outcomes monitoring project by comparing patients who accepted (N = 51), refused (N = 36), or were not asked (N = 110) to participate in the project. The patients who were asked to participate had significantly longer inpatient stays compared with the unasked group (11.2 vs 6.9 days). Patients who agreed to participate in the project were more likely to have a bipolar (43.1% vs 19.2%) or any affective disorder (94.1% vs 79.5%), and less likely to have a schizophrenic disorder (2.0% vs 11.6%) than the refused and unasked groups. The project participants also had higher 90-day readmit rates (27.5% vs 9.6%), more readmissions (0.51 vs 0.16), and more education (14.59 vs 13.51 years) than nonparticipating patients. In this preliminary study, patient-related variables were found to influence who the staff asked and who consented to participate in this clinical outcomes monitoring project. The authors distinguish clinical outcomes monitoring from treatment effectiveness research and discuss the need to develop methodologies that deal with nonrepresentative patient sampling and intersite variability in recruitment practices.

Colorado access' enhanced care management for high-cost, high-need Medicaid members: preliminary outcomes and lessons learned.

Colorado Access, a nonprofit health plan, collaborated with the Center for Health Care Strategies and the State of Colorado Department of Health Care Policy Financing, to develop, implement, and evaluate a care management services pilot program focused on improving the quality of care and decreasing the cost of care for the highest cost, highest need Medicaid recipients. Colorado Access’ preliminary internal evaluation demonstrated decreases in hospitalizations and emergency department utilization and increases in primary care ambulatory visits and member satisfaction. Qualitative analyses informed program implementation. Implementation lessons learned are discussed.

Model Curriculum for Academic Child and Adolescent Psychiatry Training

ObjectiveThe United States is facing a severe shortage of academic child and adolescent psychiatrists. This article reviews a model integrated pathway to improve recruitment.MethodsThe authors review training portals for research in child and adolescent psychiatry. There is a summary of a focus group discussion of the advantages and disadvantages of the Integrated Research Pathway in Child and Adolescent Psychiatry (IRPCAP).ResultsThe University of Colorado and Yale University have initiated integrated pathways. These pathways integrate research into a 5 or 6-year residency to train the next generation of physician-scientists.ConclusionThe innovative Integrated Research Pathway in Child and Adolescent Psychiatry training model has enhanced recruitment of talented physician-scientists. Challenges include long-term financial viability and incorporating all training requirements. Novel pilot models of training are encouraged.

Evaluating Depression Care Management in a Community Setting: Main Outcomes for a Medicaid HMO Population with Multiple Medical and Psychiatric Comorbidities

The authors describe the implementation of a depression care management (DCM) program at Colorado Access, a public sector health plan, and describe the programs clinical and system outcomes for members with chronic medical conditions. High medical risk, high cost Medicaid health plan members were identified and systematically screened for depression. A total of 370 members enrolled in the DCM program. Longitudinal analyses revealed significantly reduced depression severity scores at 3, 6, and 12 months after intervention as compared to baseline depression scores. At 12 months, 56% of enrollees in the DCM program had either a 50% reduction in PHQ-9 scores or a PHQ-9 score < 10. Longitudinal economic analyses comparing 12 months before and after intervention revealed a significant but modest increase in ER visits, outpatient office visits, and overall medical and pharmacy costs when adjusted for months enrolled in DCM. Limitations and recommendations for the integrated depression care management are discussed.

Impact of Shorter Lengths of Stay on Status at Discharge in Bipolar Mania

This study assesses the impact of shortening the inpatient length of stay on status at discharge in patients with mania. Methods: The authors performed a chart review on 131 patients with discharge diagnoses of bipolar disorder, current episode manic type, admitted to the private attending service at Colorado Psychiatric Hospital between 1985 and 1995. In 1990, a new program (the alternatives program) that provides a continuum of acute care services and shorter inpatient lengths of stay was instituted. Retrospectively assessed GAF, CGI, treatment outcome rating scores, and length of stay (LOS) were compared for the prealternatives (1985–1989), early alternatives (1990–1992), and recent alternatives (1993–1995) program treatment eras. A progressive decrease in inpatient LOS, duration of the acute care episodes, and total service utilization was seen across eras. Despite the more recent shortening in LOS, no significant differences were seen in GAF and treatment outcome rating scores at discharge. GAF and treatment outcome rating scores on hospital days 3 and 7, however, suggested that patients were improving more rapidly in the more recent eras. Inpatient LOS and duration of the acute care episodes have significantly decreased over the last 10 years, but patients appear no more ill at discharge. The authors postulate that changes in psycho-pharmacologic practice and the inpatient treatment model may have facilitated the more rapid clinical improvement seen in the more recent eras. The authors caution that we need prospective studies that include postdischarge follow-up to assess further the impact of shorter inpatient stays on the posthospital course of manic patients.