Jane N. Kogan

Use of a computerized medication shared decision making tool in community mental health settings: Impact on psychotropic medication adherence.

Healthcare reform emphasizes patient-centered care and shared decision-making. This study examined the impact on psychotropic adherence of a decision support center and computerized tool designed to empower and activate consumers prior to an outpatient medication management visit. Administrative data were used to identify 1,122 Medicaid-enrolled adults receiving psychotropic medication from community mental health centers over a two-year period from community mental health centers. Multivariate linear regression models were used to examine if tool users had higher rates of 180-day medication adherence than non-users. Older clients, Caucasian clients, those without recent hospitalizations, and those who were Medicaid-eligible due to disability had higher rates of 180-day medication adherence. After controlling for sociodemographics, clinical characteristics, baseline adherence, and secular changes over time, using the computerized tool did not affect adherence to psychotropic medications. The computerized decision tool did not affect medication adherence among clients in outpatient mental health clinics. Additional research should clarify the impact of decision-making tools on other important outcomes such as engagement, patient-prescriber communication, quality of care, self-management, and long-term clinical and functional outcomes.

Predictors of adequate depression treatment among Medicaid-enrolled adults.

OBJECTIVE To determine whether Medicaid-enrolled depressed adults receive adequate treatment for depression and to identify the characteristics of those receiving inadequate treatment. DATA SOURCE Claims data from a Medicaid-enrolled population in a large mid-Atlantic state between July 2006 and January 2008. STUDY DESIGN We examined rates and predictors of minimally adequate psychotherapy and pharmacotherapy among adults with a new depression treatment episode during the study period (N=1,098). PRINCIPAL FINDINGS Many depressed adults received either minimally adequate psychotherapy or pharmacotherapy. Black individuals and individuals who began their depression treatment episode with an inpatient psychiatric stay for depression were markedly less likely to receive minimally adequate psychotherapy and more likely to receive inadequate treatment. CONCLUSIONS Racial minorities and individuals discharged from inpatient treatment for depression are at risk for receiving inadequate depression treatment.

Measuring client perceptions of motivational interviewing: factor analysis of the Client Evaluation of Motivational Interviewing scale

Motivational interviewing (MI) is an intervention approach that has solid evidence of efficacy with substance use disorders. Research and training have benefitted from the development of observational measures to assess MI fidelity and competence. However, one untapped area of assessment is the client perception of the clinician use of MI. Client perceptions of MI have been found through qualitative interviews to relate to motivation to change, view of the therapist and safety of therapy. The Client Evaluation of MI (CEMI) scale was developed to assess client perception of clinician MI use. This study further evaluated the CEMI through exploratory and confirmatory factor analysis with a sample of 500 individuals with dual diagnosis pre-discharge from an inpatient unit. Participants completed an MI based session prior to completing CEMIs. A two factor (relational and technical) model explained 51.1% of the cumulative variance and was supported through confirmatory factor analysis. Suggestions for revisions are provided as well as potential uses of the CEMI and future directions for research.

Evaluation of an Implementation Initiative for Embedding Dialectical Behavior Therapy in Community Settings

We examined the effectiveness of Dialectical Behavior Therapy (DBT) training in community-based agencies. Data were gathered at four time points over a 2-year period from front-line mental health therapists (N=64) from 10 community-based agencies that participated in a DBT implementation initiative. We examined change on therapist attitudes toward consumers with Borderline Personality Disorder (BPD), confidence in the effectiveness of DBT, and use of DBT model components. All measures were self-report. Participating in DBT training was associated with positive changes over time, including improved therapist attitudes toward consumers with BPD, improved confidence in the effectiveness of DBT, and increased use of DBT components. Therapists who had the lowest baseline scores on the study outcomes had the greatest self-reported positive change in outcomes over time. Moreover, there were notable positive correlations in therapist characteristics; therapists who had the lowest baseline attitudes toward individuals with BPD, confidence in the effectiveness of DBT, or who were least likely to use DBT modes and components were the therapists who had the greatest reported increase over time in each respective area. DBT training with ongoing support resulted in changes not commonly observed in standard training approaches typically used in community settings. It is encouraging to observe positive outcomes in therapist self-reported skill, perceived self-efficacy and DBT component use, all of which are important to evidence-based treatment (EBT) implementation. Our results underscore the importance to recognize and target therapist diversity of learning levels, experience, and expertise in EBT implementation.

Facilitators and Barriers Associated With Implementation of Evidence-Based Psychotherapy in Community Settings

OBJECTIVE Despite widespread use of individual outpatient psychotherapies among community mental health centers (CMHCs), few studies have examined implementation of these psychotherapies. This exploratory qualitative study identified key themes associated with the implementation of an empirically supported psychotherapy in CMHCs. METHODS The authors conducted semistructured interviews with 12 key informants from four CMHCs that had implemented interpersonal and social rhythm therapy (IPSRT). Their responses were categorized into key themes. RESULTS Five major themes were identified: pretraining familiarity with IPSRT, administrative support for implementation, IPSRT fit with usual practice and clinic culture, implementation team and plan, and supervision and consultation. Discussion of these themes varied among participants from clinics considered successful or unsuccessful implementers. CONCLUSIONS Participants identified both key themes and several strategies for facilitating implementation. The findings suggest that when these key factors are present, outcome-enhancing treatments can be implemented and sustained, even in clinics with limited resources.

Treatment of attention-deficit hyperactivity disorder: patterns of evolving care during the first treatment episode.

OBJECTIVE This study sought to better understand factors associated with different patterns of treatment among children starting treatment for attention-deficit hyperactivity disorder (ADHD). METHODS Factors associated with service utilization and pharmacy claims data for 2,077 Medicaid-enrolled children aged six to 12 who started treatment for ADHD between October 2006 and December 2007 in a large mid-Atlantic state were investigated by using logistic regressions and Cox proportional hazard models. RESULTS A total of 45% of children started ADHD treatment with a psychosocial intervention alone, 41% of children started treatment with medication alone, and 14% of children started treatment with a combination of both treatments. By the end of the treatment episode, 42% of children who initiated treatment with psychosocial interventions alone had added medication. Within six months of starting treatment, approximately 40% of children had discontinued treatment. Among those who continued receiving treatment, a majority received medication, either alone or with a psychosocial intervention. Treatment with a psychosocial intervention was significantly more likely to be initiated among nonwhite versus white children and among younger versus older children. Younger versus older children and African-American versus Caucasian children were significantly more likely to drop out of treatment sooner. CONCLUSIONS During the first episode of treatment for ADHD, the interventions children received frequently changed, suggesting dissatisfaction with initial treatment. Further research is needed to better understand what underlies the patterns of evolving care so that all families seeking care for children with ADHD may receive preferred and effective treatment.

Treatment contracting in cognitive-behavior therapy

Consistent with the goal of providing reviews of core strategies and principles used in cognitive-behavior therapy ( Albano, 2003 ), this article is devoted to a discussion of the philosophy, elements, and potential benefits of treatment contracting. Treatment contracting is discussed as a way of formalizing the goals, responsibilities, and strategies to be employed in treatment by therapists, patients, and the patients support network. In particular, we discuss the potential value of contracts for enhancing motivation and eliciting adaptive behaviors from patients, particularly at moments of high stress or high risk when these behaviors are most needed. In addition, we comment on how contracts can serve as an agreement of advocacy for patients who may fail to take appropriate action for themselves during acute distress. We provide an example of a treatment contract for use with adults with posttraumatic stress disorder (PTSD). This contract most directly focuses on enhancing motivation for treatment and engendering self-care, and is embedded in the context of an informational worksheet detailing common patterns in PTSD.

Concurrent Mental Health Therapy Among Medicaid-Enrolled Youths Starting Antipsychotic Medications

OBJECTIVE The use of antipsychotic medications among children and adolescents has increased substantially in recent years, predominantly in disorders for which effective psychosocial interventions exist. The authors of this study examined the extent to which youths being prescribed antipsychotic medications were receiving concurrent mental health therapy. METHODS Using administrative data, the authors identified 6,110 Medicaid-enrolled youths starting antipsychotic medications from November 1, 2006, through October 31, 2009, and identified youths who had received any concurrent mental health therapy. Multivariate regression models were used to examine the relationship between concurrent therapy and sociodemographic and clinical variables. RESULTS Sixty-eight percent (N=4,155) of youths starting antipsychotic medications received concurrent therapy. Multivariate regression findings are that concurrent therapy was more common with younger children, recently hospitalized youths, children from urban communities, youths from racial-ethnic minority groups, children with an antipsychotic-indicated diagnosis, and youths eligible for Medicaid because of family income. CONCLUSIONS The finding that 68% of youths starting antipsychotic medications received concurrent therapy suggests that for a majority of children, these medications complemented rather than substituted for nonpharmacologic interventions. However, with almost one-third of youths not receiving concurrent therapy, a better understanding of the factors contributing to the lack of concurrent therapy for youths starting antipsychotic medications is needed. Children and families should be aware of and have access to effective psychosocial treatments for disorders such as attention-deficit hyperactivity disorder and depression that are common among children receiving antipsychotic medications.

Mental Health Services for Children of Substance Abusing Parents: Voices from the Community

This qualitative study explores how to improve services for children of parents with Substance Use Disorders (SUD) with unmet mental health needs. Focus groups were conducted with parents and caregivers to identify perceived barriers to services, including: (1) attitudes and beliefs about mental health care, (2) inadequacies in mental health services, (3) children’s ambivalence about treatment, and (4) parental disagreement and lack of involvement. Peer support, afterschool activities, and family counseling were identified as potential improvements. This information can serve as a foundation and guide to develop services for the underserved population of children and adolescents of substance abusing parents.

Increasing minority research participation through collaboration with community outpatient clinics: the STEP-BD Community Partners Experience

Background Minority populations have been under-represented in mental health research studies. The systematic treatment enhancement program for bipolar disorder developed the Community Partners Program (CPP) to address this issue in a large, prospective treatment study of persons with bipolar disorder. Purpose The primary goal of CPP was to develop a community-based infrastructure for studying bipolar disorder that would enhance the ethnic/racial and socioeconomic diversity of participants. Methods Selected academic sites partnered with local clinics (n = 6 partnerships in five cities). This report describes the conceptualization, implementation, and qualitative evaluation of CPP, as well as quantitative analysis of clinical and sociodemographic differences between the samples recruited at academic versus community sites. Results Quantitative analysis of the 155 participants from the six partnerships revealed enrollment of 45% from minority populations (vs. 15% in academic sites). Significant sociodemographic differences were evident not only between academic and community sites, but within minority and non-minority groups across site types. Notably, clinical differences were not evident between participants from academic and community sites. Review of qualitative data suggests that certain factors around implementation of research protocols may enhance community participation. Conclusions Moving research recruitment and participation into community sites was more successful in increasing minority enrollment than efforts to attract such individuals to academic sites. Recommendations for creating and maintaining academic/community partnerships are given. Limitations Several important variables were not considered including mood severity, hospitalization, or treatment differences. Minority participants were grouped by combining African American and Hispanics, which may have obscured subgroup differences. A derivation of standard qualitative methods was used in this study. Clinical Trials 2009; 6: 344—354. http://ctj.sagepub.com