Alisa B. Busch

Seclusion and Restraint: A Review of Recent Literature

&NA; An October 1998 Hartford Courant investigative series highlighted alleged cases of brutality and death suffered by involuntarily secluded, restrained, and/or emergently medicated patients. The resulting public and professional furor prompted a spate of new federal regulations and legislative initiatives setting national standards for reporting and clinical oversight. These events provide stimulus for this literature review.

New Jersey’s Efforts To Improve Postpartum Depression Care Did Not Change Treatment Patterns For Women On Medicaid

Identification and treatment of postpartum depression are the increasing focus of state and national legislation, including portions of the Affordable Care Act. Some state policies and proposals are modeled directly on programs in New Jersey, the first state to require universal screening for postpartum depression among mothers who recently delivered babies. We examined the impact of these policies on a particularly vulnerable population, Medicaid recipients, and found that neither the required screening nor the educational campaign that preceded it was associated with improved treatment initiation, follow-up, or continued care. We argue that New Jerseys policies, although well intentioned, were predicated on an inadequate base of evidence and that efforts should now be undertaken to build that base. We also argue that to improve detection and treatment, policy makers contemplating or implementing postpartum depression mandates should consider additional measures. These could include requiring mechanisms to monitor and enforce the screening requirement; paying providers to execute screening and follow-up; and preliminary testing of interventions before policy changes are enacted.

Does exposure to conflict of interest policies in psychiatry residency affect antidepressant prescribing

Background:Academic medical institutions have instituted conflict of interest (COI) policies in response to concerns about pharmaceutical industry influence. Objective:To determine whether exposure to COI policies during psychiatry residency training affects psychiatrists’ antidepressant prescribing patterns after graduation. Research Design:We used 2009 physician-level national administrative prescribing data from IMS Health for 1652 psychiatrists from 162 residency programs. We used difference-in-differences estimation to compare antidepressant prescribing based on graduation before (2001) or after (2008) COI policy adoption across residency program groups with maximally, moderately, and minimally restrictive COI policies. The primary outcomes were shares of psychiatrists’ prescribing of heavily promoted, brand reformulated, and brand antidepressants. Results:Rates of prescribing heavily promoted, brand reformulated, and brand antidepressants in 2009 were lower among post-COI graduates than pre-COI graduates at all levels of COI restrictiveness. However, differences between pre-COI and post-COI graduates’ prescribing of heavily promoted medications were larger for maximally restrictive programs than both minimally restrictive programs [−4.3 percentage points; 95% confidence interval (CI), −7.0, −1.6] and moderately restrictive programs (−3.6 percentage points; 95% CI, −6.2, −1.1). The difference in prescribing reformulations was larger for maximally restrictive programs than minimally restrictive programs (−3.0 percentage points; 95% CI, −5.3, −0.7). Results were consistent for prescribing of brand drugs. Conclusions:This study provides the first empirical evidence of the effects of COI policies. Our results suggest that COI policies can help inoculate physicians against persuasive aspects of pharmaceutical promotion. Further research should assess whether these policies affect other drug classes and physician specialties similarly.

Changes over Time and Disparities in Schizophrenia Treatment Quality

Background:Schizophrenia medication and psychosocial treatment options have expanded since the Schizophrenia PORT was conducted. However, there also have been considerable changes in the delivery of mental health care in the public sector, as well as increasing state concerns about Medicaid cost containment. Objectives:To examine trends and patient characteristics associated with differences in schizophrenia medication and visit treatment quality in a Medicaid population. Research Design:Observational study of claims data from July 1, 1996 to June 30, 2001. Subjects:Florida Medicaid enrollees diagnosed with schizophrenia (N = 23,619). Measures:We examined the likelihood of meeting any 1 and all 4 of the following quality standards: (1) receiving antipsychotic medication, (2) antipsychotic continuity, (3) dosing consistent with PORT recommendations, and (4) mental health visit continuity. Separate models were fit for acute and maintenance phases of treatment. Results:Approximately 18% of acute and 7% of maintenance phases met all 4 quality standards. Antipsychotic quality improved (largely driven by an increasingly likelihood of receiving any antipsychotic), while visit continuity declined. The greatest disparities were seen for persons with co-occurring substance use disorders and of black race. Quality differences were often phase specific and at times in opposite directions across treatment phases. Conclusions:The improvement in antipsychotic treatment quality is encouraging. However, visit continuity declined. This study highlights the importance of quality measurement that includes focus on different treatment modalities and phases of care, as well as for potentially vulnerable populations (such as persons with co-occurring substance use disorders and racial/ethnic minorities).

Impact of full mental health and substance abuse parity for children in the Federal Employees Health Benefits Program.

OBJECTIVE. The Federal Employees Health Benefits Program implemented full mental health and substance abuse parity in January 2001. Evaluation of this policy revealed that parity increased adult beneficiaries’ financial protection by lowering mental health and substance abuse out-of-pocket costs for service users in most plans studied but did not increase rates of service use or spending among adult service users. This study examined the effects of full mental health and substance abuse parity for children. METHODS. Employing a quasiexperimental design, we compared children in 7 Federal Employees Health Benefits plans from 1999 to 2002 with children in a matched set of plans that did not have a comparable change in mental health and substance abuse coverage. Using a difference-in-differences analysis, we examined the likelihood of child mental health and substance abuse service use, total spending among child service users, and out-of-pocket spending. RESULTS. The apparent increase in the rate of children’s mental health and substance abuse service use after implementation of parity was almost entirely due to secular trends of increased service utilization. Estimates for children’s mental health and substance abuse spending conditional on this service use showed significant decreases in spending per user attributable to parity for 2 plans; spending estimates for the other plans were not statistically significant. Children using these services in 3 of 7 plans experienced statistically significant reductions in out-of-pocket spending attributable to the parity policy, and the average dollar savings was sizeable for users in those 3 plans. In the remaining 4 plans, out-of-pocket spending also decreased, but these decreases were not statistically significant. CONCLUSIONS. Full mental health and substance abuse parity for children, within the context of managed care, can achieve equivalence of benefits in health insurance coverage and improve financial protection without adversely affecting health care costs but may not expand access for children who need these services.

The impact of parity on major depression treatment quality in the Federal Employees' Health Benefits Program after parity implementation.

Background:Since the 1990s, parity laws have been implemented to reduce inequities in mental health coverage compared with that for general medical conditions. It is unclear if parity under managed care is associated with improvements in mental health treatment quality. Major depressive disorder (MDD) is a prevalent but often undetected and undertreated and thus could potentially benefit from parity implementation. Objective:The objective of this study was to examine the association between parity implementation and changes in MDD treatment quality in the Federal Employees’ Health Benefits (FEHB) Program. Methods:We conducted retrospective analyses of insurance claims data. Logistic regression models estimated quality changes for MDD-diagnosed enrollees from pre- to postparity. Subjects:Subjects included MDD-diagnosed FEHB insured enrollees, aged 18–64, across multiple states and 6 FEHB plans before (1999–2000) and after (2001–2002) parity implementation. Measures:Measures included receipt of any antidepressant or psychotherapy within a given calendar year of diagnosis; receipt of appropriate psychotherapy frequency/intensity and duration; and pharmacotherapy duration during acute-phase treatment episodes. Results:Postparity, several plans improved significantly in the likelihood of receiving antidepressant medication. In the acute-phase episodes, the greatest improvement was seen in the likelihood of follow up ≥4 months. Few or no other changes were observed in the acute-phase treatment intensity or duration quality measures. Conclusions:Parity under managed care was associated with modest improvements. The observed improvements were consistent with secular trends in MDD treatment. Whereas mental health parity is an important policy goal, these results highlight its limitations: improving the financing of care may not be sufficient to improve quality.

Validation of the PHQ-9 in a psychiatric sample.

BACKGROUND The PHQ-9 was originally developed as a screener for depression in primary care and is commonly used in medical settings. However, surprisingly little is known about its psychometric properties and utility as a severity measure in psychiatric populations. We examined the full range of psychometric properties of the PHQ-9 in patients with a range of psychiatric disorders (i.e., mood, anxiety, personality, psychotic). METHODS Patients (n=1023) completed the PHQ-9 upon admission and discharge from a partial hospital, as well as other self-report measures of depression, anxiety, well-being, and a structured diagnostic interview. RESULTS Internal consistency was good (α=.87). The PHQ-9 demonstrated a strong correlation with a well-established measure of depression, moderate correlations with related constructs, a weak correlation with a theoretically unrelated construct (i.e., disgust sensitivity), and good sensitivity to change, with a large pre- to post-treatment effect size. Using a cut-off of ≥13, the PHQ-9 demonstrated good sensitivity (.83) and specificity (.72). A split-half exploratory factor analysis/confirmatory factor analysis suggested a two-factor solution with one factor capturing cognitive and affective symptoms and a second factor reflecting somatic symptoms. Psychometric properties did not differ between male and female participants. LIMITATIONS No clinician-rated measure of improvement, and the sample lacked ethnoracial diversity. CONCLUSIONS This first comprehensive validation of the PHQ-9 in a large, psychiatric sample supported its use as a severity measure and as a measure of treatment outcome. It also performed well as a screener for a current depressive episode using a higher cut-off than previously recommended for primary care samples.

The Effects of Mental Health Parity on Spending and Utilization for Bipolar, Major Depression, and Adjustment Disorders

OBJECTIVE The Mental Health Parity and Addiction Equity Act requires insurance parity for mental health/substance use disorder and general medical services. Previous research found that parity did not increase mental health/substance use disorder spending and lowered out-of-pocket spending. Whether paritys effects differ by diagnosis is unknown. The authors examined this question in the context of parity implementation in the Federal Employees Health Benefits (FEHB) Program. METHOD The authors compared mental health/substance use disorder treatment use and spending before and after parity (2000 and 2002, respectively) for two groups: FEHB enrollees diagnosed in 1999 with bipolar disorder, major depression, or adjustment disorder (N=19,094) and privately insured enrollees unaffected by the policy in a comparison national sample (N=10,521). Separate models were fitted for each diagnostic group. A difference-in-difference design was used to control for secular time trends and to better reflect the specific impact of parity on spending and utilization. RESULTS Total spending was unchanged among enrollees with bipolar disorder and major depression but decreased for those with adjustment disorder (-

The rise and fall of gabapentin for bipolar disorder: a case study on off-label pharmaceutical diffusion.

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Changes in the Quality of Care for Bipolar I Disorder During the 1990s

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