Francisca Azocar

Distressed women's clinic patients: Preferences for mental health treatments and perceived obstacles.

Women seen in public gynecology settings are at very high risk of developing psychiatric disorders. Because low-income and ethnic minority women seen in such settings underutilize mental health services, it is important to better understand treatment preferences and obstacles among this high-risk patient population. Public womens clinic patients (N = 105) who reported psychological or emotional distress were asked about their interest in medication, psychotherapy, and psychoeducational classes, as well as perceived obstacles to using these services. The vast majority were interested in receiving some form of mental health treatment, with the most interest shown for individual therapy and general psychoeducational classes about health and stress. Less interest was expressed in group therapy and medication. Women anticipated more instrumental barriers to using services, such as lack of money, transportation, and childcare, than stigma-related barriers, such as fear of embarrassment or rejection. However, Latinas, women with less education, and those with a current mood or anxiety disorder were more likely to anticipate stigma-related barriers to treatment than other women. Implications of these findings for referral and treatment of mental health problems among public womens clinic patients are discussed.

Unmet mental health needs of women in public-sector gynecologic clinics

OBJECTIVE We examined the mental health needs of poor young women seen in public-sector gynecologic settings. STUDY DESIGN Participants were 205 ethnically diverse women, mean age 29 years, seen by gynecologists at San Francisco General Hospital, all either uninsured or receiving public medical assistance. An interview with an instrument designed to diagnose mood, anxiety, alcohol, and eating disorders in medical patients, the Prime-MD, was used to assess current mental disorders. Any history of sexual or other physical assault was recorded. Receipt of primary care was scored for comprehensiveness. RESULTS The rates of current psychiatric disorders were extremely high; 21.5% had current major depression. The prevalence of anxiety disorders was also elevated among these women. Many had a history of sexual trauma, and 28% had been the victims of unwanted intercourse. Finally, many reported behaviors that pose serious health risks. For example, 32% smoked and 2% used illicit drugs. Fewer than half had access to comprehensive primary medical care. CONCLUSIONS Young, poor women who seek care in public-sector gynecologic clinics would benefit from comprehensive medical care addressing their psychosocial needs.

The impact of evidence-based guideline dissemination for the assessment and treatment of major depression in a managed behavioral health care organization

This study tests whether a managed behavioral health care organization can influence adherence to practice guidelines for the treatment of major depression in a randomized trial of guideline dissemination. Guidelines were disseminated to mental health clinicians (N=443) under one of three conditions: (1) a general mailing of guidelines to clinicians, (2) a mailing in which guidelines were targeted to a patient starting treatment with the clinician, and (3) no mailing of guidelines. The results showed no effects of guideline dissemination as measured by self-report of patients and clinicians and through episode characteristics derived from claims data, despite sentinel effects. Results also showed high rates of clinician-reported guideline adherence that were not detected in the claims data, indicating significant undertreatment of depression. Results suggest that mental health systems must look to other dissemination strategies to improve adherence to standards of care and raise the performance of independent practicing clinicians

Usual Care Psychotherapy for Depression in a Large Managed Behavioral Health Organization

Evidence-based psychotherapies to treat depression are available, yet it remains unknown the extent to which these practices are used in routine care for depression. Using survey and administrative data, we sought to describe usual care psychotherapy for depression for adult patients receiving care through a large, managed behavioral health care organization. Data from 420 patients receiving psychotherapy for depression and 159 of their therapists provide evidence that some practitioners are using evidence-based psychotherapy techniques for depression, but also demonstrate the need for improved tools to monitor and improve quality of psychotherapy in usual care.

Monitoring patient improvement and treatment outcomes in managed behavioral health.

&NA; This study examined the use of outcome reports sent to clinicians by a managed behavioral healthcare organization to monitor patient progress and its relation to treatment outcome. Results showed that clinicians who reported using outcome information had patients who also reported greater improvement at 6 months from baseline. Improvement per session was greatest among patients whose clinicians reported reading the outcome report and using outcome measures in their clinical practice. Using baseline and ongoing measures to assess patient improvement can provide clinicians with feedback during treatment, which may lead to better clinical outcomes and enable quality management systems in managed care to flag high‐risk cases and identify failure of adequate improvement.

Development of a Clinician Report Measure to Assess Psychotherapy for Depression in Usual Care Settings

Although mental health policy initiatives have called for quality improvement in depression care, practical tools to describe the quality of psychotherapy for depression are not available. We developed a clinician-report measure of adherence to three types of psychotherapy for depression—cognitive behavioral therapy, interpersonal therapy, and psychodynamic therapy. A total of 727 clinicians from a large, national managed behavioral health care organization responded to a mail survey. The measure demonstrated good psychometric properties, including appropriate item-scale correlations, internal consistency reliability, and a three-factor structure. Our results suggest that this questionnaire may be a promising approach to describing psychotherapy for depression in usual care.

Effect of medicare part D benzodiazepine exclusion on psychotropic use in benzodiazepine users.

To evaluate the effect of the Medicare benzodiazepine coverage exclusion on psychotropic use of benzodiazepine users.

A Randomized Clinical Trial of a Telephone Depression Intervention to Reduce Employee Presenteeism and Absenteeism

OBJECTIVES The study tested an intervention aimed at improving work functioning among middle-aged and older adults with depression and work limitations. METHODS A randomized clinical trial allocated an initial sample of 431 eligible employed adults (age ≥45) to a work-focused intervention (WFI) or usual care. Inclusion criteria were depression as measured by the Patient Health Questionnaire-9 (PHQ-9) and at-work limitations indicated by a productivity loss score ≥5% on the Work Limitations Questionnaire (WLQ). Study sites included 19 employers and five related organizations. Telephone-based counseling provided three integrated modalities: care coordination, cognitive-behavioral therapy strategy development, and work coaching and modification. Effectiveness (change in productivity loss scores from preintervention to four months postintervention) was tested with mixed models adjusted for confounders. Secondary outcomes included change in WLQ work performance scales, self-reported absences, and depression. RESULTS Of 1,227 eligible employees (7% of screened), 431 (35%) enrolled and 380 completed the study (12% attrition). At-work productivity loss improved 44% in the WFI group versus 13% in usual care (difference in change, p<.001). WFI group scores on the four WLQ scales improved 44% to 47%, significantly better than in usual care (p<.001 for each scale). Absence days declined by 53% in the WFI group versus 13% in usual care (difference in change, p<.001). Mean PHQ-9 depression symptom severity scores declined 51% for WFI versus 26% for usual care (difference in change, p<.001). CONCLUSIONS The WFI was more effective than usual care at four-month follow-up. Given increasing efforts to provide more patient-centered, value-based care, the WFI could be an important resource.

Assessment of Evidence-Based Psychotherapy Practices in Usual Care: Challenges, Promising Approaches, and Future Directions

In this special issue of Administration and Policy in Mental Health and Mental Health Services Research, we focus on measuring evidence-based practices in psychotherapy within usual care practice. Measuring evidence-based practices in usual care settings is important for at least three reasons. First, such measurement would help identify practices within usual care settings that are promising. For example, patients in usual care psychotherapy settings tend to have co-morbid mental disorders; whereas, our evidence base for psychotherapy is largely based on single disorders. Mixing strategies from more than one evidence-base may be effective in practice. Second, measuring evidence-based practices is essential for quality improvement interventions. Such measures could provide a baseline, as well as a comparative measure of change following quality improvement interventions that attempt to introduce more evidence-based care to patients. Third, understanding what clinical practices in usual care works best individually or in combination can help tailor graduate training programs to improve the pool of new professionals currently in training. Overall, developing measures of and understanding psychotherapy as it happens in the community is important for improving our mental health service delivery system. National policy forums focused on improving the mental health delivery system are all noting the need for improved measurement of quality care. The Institute of Medicine Report, Improving The Quality of Health Care for Mental and Substance-Use Conditions (2006), notes, “Measuring the quality of care provided by individuals, organizations, and health plans and reporting back the results is linked both conceptually and empirically to reductions in variations in care and increases in delivery of effective care.” Recommendation 4–3 of this Report focuses on developing better measures of quality. Similarly, The President’s Advisory Commission on consumer Protection and Quality in the Health Care Industry (1998) identified mental health care as an area where quality measures, such as measures of evidence-based practices, are not well addressed. Managed behavioral health organizations have the clinical and fiduciary responsibility over the quality of care provided to their members; therefore it is in their own interest to have tools that measure quality of care for psychotherapy. Most mental health practitioners belong to multiple managed care organization provider panels where current measures of quality of care for behavioral health care are based on population-level metrics. The Health Plan Employer Data and Information Set (HEDIS) developed by National Committee on Quality Assurance (NCQA) is designed to measure access to care, enrollee satisfaction, use of services and the effectiveness of care. Within behavioral health the metrics for effectiveness, for example, include follow-up after hospitalization rates (FUH), anti-depressant medication management (AMM), and follow-up for children prescribed attention-deficit/hyperactivity medications (ADD). However, these metrics are poor measures of actual quality of care, and primarily apply to health plans rather than managed behavioral health organization. Most individuals receiving outpatient care through managed behavioral health organization provider panels are receiving psychotherapy, yet HEDIS metrics are based on medication management and inpatient care. There are no measures currently available that can provide individual-level metrics of the use of evidence–based psychotherapy to measure overall quality of care. As a proxy, managed behavioral health organizations may measure the quality of care provided by their provider panels by assessing the use of clinical-practice guidelines (Azocar et al. 2001, 2003) or by monitoring outcomes and in some circumstances, providing feedback reports (Lambert et al. 2005; Brodey et al. 2005; Brown et al. 2005); neither of which look at the actual use of evidence-based practices and how that relates to quality of care. The use of outcomes-informed care is growing but still a rarity among behavioral health providers and difficult to implement within managed behavioral health organizations because of its association to pay-for-performance issues. The development of measures of evidence-based practices in outpatient psychotherapy will help engage the provider and the consumer at the individual level as a stakeholder in improving quality of care. The need for measuring evidence-based psychotherapy practices have also been called for by those individuals developing policies to improve our mental health workforce. The Annapolis Coalition on Workforce Development, in their report “An Action Plan for Behavioral Health Workforce Development (DHHS 2007)” discuss the recurrent finding of lack of reliable and valid data on the status of workforce development strategies, including evaluation of the sustained adoption of newly learned skills in real-world service settings. In this special issue, we begin to answer these important policy recommendations by presenting new evidence in this seminal study of evidence-based practices in clinical settings. In this special issue, four papers help develop methods for moving ahead in this important field of measuring evidence-based practices in clinical settings. Garland et al. (2010) offer an important overview of the methodological issues to be considered when measuring usual care as practiced in clinical settings. Hepner et al. (2010a) provide data on a short, efficient measure of evidene-based practices for depression care completed by providers of adult services and Kelley et al. (2010) provide data on a similar measure for youth services. Hurlburt et al. (2010) then present compelling data regarding therapists self-rating of psychotherapy techniques and goals as compared with ratings by observers. Finally, Miranda et al. (2010) present initial data on a self-report measure of psychotherapy techniques completed by patients following usual care therapy in managed health care settings. Following these initial papers addressing important methods issues in measuring psychotherapy practice, four papers present state-of-the-art data on psychotherapy in clinical settings. Brookman-Frazee et al. (2010) discuss characteristics that predict the likelihood of evidence-based practices occurring in child therapy sessions. Hepner et al. (2010b) present data on evidence-based practices in psychotherapy among practitioners in a large, cross-national managed behavioral healthcare organization. Finally, Landry et al. (2010) present data on evidence-based practices in a nationally representative sample of patients receiving mental health care services. Together, these articles define the state of the art for measuring psychotherapy practices in clinical settings. This series provides a clear overview of this seminal work and helps shape new efforts to carefully understand the care we provide to our nations vulnerable populations with mental health care needs.

Medicare Part D Benzodiazepine Exclusion and Use of Psychotropic Medication by Patients With New Anxiety Disorders

OBJECTIVE The Medicare Modernization Act (MMA) specifically excluded benzodiazepines from Medicare Part D coverage starting in 2006; however, benzodiazepines are an effective, low-cost treatment for anxiety. This study evaluated the effect of the Medicare Part D benzodiazepine coverage exclusion among patients with new anxiety disorders. METHODS The authors used a quasi-experimental cohort design to study patients with new anxiety diagnoses from a large national health plan during the first six months of 2005, 2006, and 2007. Logistic and zero-truncated negative-binomial regression models using covered claims for behavioral, medical, and pharmaceutical care linked with eligibility files were used to estimate utilization and costs of psychotropic medication and health care utilization among elderly Medicare Advantage enrollees (N=8,397) subject to the MMA benzodiazepine exclusion and a comparison group of near-elderly (ages 60–64) enrollees (N=1,657) of a managed care plan. RESULTS Medicare Advantage enrollees diagnosed in 2005 had significantly (p<.05) higher rates of covered claims for benzodiazepines and all psychotropic drugs, lower rates of covered claims for nonbenzodiazepines, and lower expenditures for psychotropic drugs than enrollees diagnosed in 2006 and 2007. There were no significant differences over time in utilization or expenditures related to psychotropic medication among the comparison group. There also were no significant changes over time in outpatient visits for behavioral care by either cohort. CONCLUSIONS Among elderly patients with new anxiety diagnoses, the MMA benzodiazepine exclusion increased use of nonbenzodiazepine psychotropic drugs without substitution of increased behavioral care. Overall, the exclusion was associated with a modest increase in covered claims for psychotropic medication.