Joyce C. West

Sleep problems, psychiatric hospitalization, and emergency department use among psychiatric patients with Medicaid.

OBJECTIVE This study examined the prevalence of sleep problems and their association with the use of inpatient and emergency department services by Medicaid recipients with serious mental illness. METHODS The sample consisted of 1,560 psychiatric patients with Medicaid coverage who were identified in a ten-state random survey of psychiatrists. Sleep problems were assessed by clinician ratings. RESULTS Over 75% of the patients experienced a sleep problem, and approximately 50% of these patients had problems that were moderate to severe. Greater sleep problem severity was associated with an increased risk of psychiatric hospitalization and emergency department visits for mental health reasons. CONCLUSIONS Sleep problems were highly prevalent among Medicaid patients with serious mental illness and were associated with greater inpatient and emergency mental health service use. More careful monitoring and management of sleep problems in this patient population could address a common clinical need and might help to reduce costly service use.

Clinically unintended medication switches and inability to prescribe preferred medications under Medicare Part D

Medicare Part D has expanded medication access; however, there is some evidence that dually eligible psychiatric patients have experienced medication access problems. The aim of this study was to characterize medication switches and access problems for dually eligible psychiatric patients and associations with adverse events, including emergency department visits, hospitalizations, homelessness, and incarceration. Reports on 986 systematically sampled, dually eligible patients were obtained from a random sample of practicing psychiatrists. A total of 27.6% of previously stable patients had to switch medications because clinically indicated and preferred refills were not covered or approved. An additional 14.0% were unable to have clinically indicated/preferred medications prescribed because of drug coverage/approval. Adjusting for case-mix, switched patients (p = 0.0009) and patients with problems obtaining clinically indicated medications (p = 0.0004) had significantly higher adverse event rates. Patients at greatest risk were prescribed a medication in a different class or could not be prescribed clinically-indicated atypical antipsychotics, other antidepressants, mood stabilizers, or stimulants. Patients with problems obtaining clinically preferred/indicated antipsychotics had a 17.6 times increased odds (p = 0.0039) of adverse events. These findings call for caution in medication switches for stable patients and support prescription drug policies promoting access to clinically indicated medications and continuity for clinically stable patients.

Assessment and Evidence-Based Treatments for Patients with Alcohol Use Disorders Treated in Army Behavioral Health Care Settings

ABSTRACT This study examines patterns and quality of care for alcohol use disorders (AUDs) provided by U.S. Army behavioral health clinicians (BHCs). Army BHCs (N = 399) completed a clinically detailed Web-based questionnaire on one systematically selected service member patient. Of 399 service member patients, 18% (n = 68) were diagnosed with AUD. Nearly two-thirds received evidence-based (EB) psychopharmacotherapy and/or any psychotherapy. Only 40%, however, received AUD-targeted psychotherapy (e.g., motivational interviewing/enhancement, 12-Step facilitation) and/or psychopharmacotherapy. Army BHCs commonly provide EB care for AUD. However, AUD-targeted psychotherapies are less common. Selected opportunities for improvement in provision of EB care for AUD have been identified.