Lorna J. Simon

Community mental health services and the prevalence of severe mental illness in local jails: are they related?

The excessive prevalence of severe mental illness noted in correctional settings has sometimes been attributed to the inadequacy of community based mental health services. This study examines the prevalence of severe mental illness in two jails situated within catchment areas featuring markedly different levels of community mental health services. We use these settings to test the hypothesis that greater levels of services in a community are associated with lower prevalence of severe mental illness in the communitys jail. An epidemiologic approach, using standardized field instruments, was used to estimate the prevalence of major mental illness in detainees arriving at the two sites over a 6-month period. The hypothesis that greater levels of mental health resources in a community would be associated with lower prevalence of mental illness in the communitys jail was not supported. These findings suggest that community-based mental health services by themselves do not affect the prevalence of mental illness in jail.

How Closely Do Institutional Review Boards Follow the Common Rule

Purpose To determine how closely institutional review board (IRB) discussions reflect the ethical criteria specified in the Common Rule federal regulations. Method Between November 2006 and July 2009, the authors observed, audio-recorded, transcribed, and coded protocol reviews from 20 IRB meetings at 10 leading academic medical centers. They also reviewed each of the applications discussed to identify the Common Rule criteria—(1) risk minimization, (2) risk/benefit comparison, (3) equitable subject selection, (4) informed consent, (5) data monitoring to ensure safety, (6) privacy protection and confidentiality, and (7) protection of vulnerable subjects—that were both relevant to the study and not adequately addressed in the application. They then determined if the IRB addressed each of the relevant and not-discussed Common Rule criteria in their discussions. Results IRBs made no mention of many of the Common Rule criteria that required their discussion—In 17/82 (21%) reviews, they failed to address risk minimization; in 52/91 (57%), risk/benefit comparison; in 31/52 (60%), equitable subject selection; in 32/59 (54%), data monitoring; in 13/52 (25%), privacy and confidentiality; and in 7/55 (13%), protection of vulnerable populations. However, they discussed informed consent in 102/104 (98%) reviews and raised questions about, or requested changes about, informed consent for 92/104 (88%) protocols. Conclusions These findings suggest that essential elements of human subjects protection are not implemented uniformly across IRBs. Although not directly addressing this issue, the current proposed changes to the Common Rule offer an opportunity to improve, in general, the effectiveness of IRBs to protect human subjects.

Self-reported lifetime psychiatric hospitalization histories of jail detainees with mental disorders: Comparison with a non-incarcerated national sample

Lack of access to hospitalization is an often-cited risk factor for incarceration among persons with severe mental illness. This proposition is examined by comparing self-reports of lifetime psychiatric hospitalization histories of mentally ill jail inmates with data from a national sample of non-incarcerated mentally ill. Roughly 52% of mentally ill jail detainees reported at least one psychiatric hospitalization, a rate nearly three times that of the comparison group. The data call into question the notion that mentally ill jail inmates have reduced access to psychiatric inpatient treatment, without addressing the adequacy of the treatment received. Longitudinal studies are needed to explore temporal relationships to better understand the relationship between mental health treatment and criminal justice involvement.

Insurance status and length of stay for involuntarily hospitalized patients

General and private psychiatric hospitals are becoming increasingly common as sites for involuntary hospitalization. Unlike the public facilities that these settings are supplanting, these hospitals must pay strict attention to issues associated with reimbursement, insurance status, and managed care. This article examines the effects of insurance status on length of stay for involuntarily hospitalized patients in general and private hospitals in Massachusetts. Using a two-stage sampling procedure, data on episodes of involuntary hospitalization were gathered and assessed using multiple regression. The primary effect was found between patients with Medicare, who had the longest stays, and individuals who were uninsured, who had the shortest. The data raise concerns that warrant closer scrutiny on the part of administrators and clinicians.

The participation of community members on medical institutional review boards

The goal of this study was to describe the contributions of community members (unaffiliated members) who serve on institutional review boards (IRBs) at large medical research centers and to compare their contributions to those of other IRB members. We observed and audiotaped 17 panel meetings attended by community members and interviewed 15 community members, as well as 152 other members and staff. The authors coded transcripts of the panel meetings and reviewed the interviews of the community members. Community members played a lesser role as designated reviewers than other members. They were infrequently primary reviewers and expressed hesitation about the role. As secondary or tertiary reviewers, they were less active participants than other members in those roles. Community members were more likely to focus on issues related to confidentiality when reviewing an application than other reviewers. When they were not designated reviewers, however, they played a markedly greater role and their discussion focused more on consent disclosures than other reviewers. They did not appear to represent the community so much as to provide a nonscientific view of the protocol and the consent form.

Privatized Medicaid managed care in Massachusetts: disposition in child and adolescent mental health emergencies

Data from child and adolescent emergency mental health screening episodes prior and subsequent to privatized Medicaid managed care in Massachusetts are used to investigate the relationship between payer source and disposition and to compare the match between clinical need and disposition level of care. Having Medicaid as the payer in the post-Medicaid managed care period decreased the odds of hospitalization by nearly 60%. None of the clinical need variables that contributed to hospitalization for Medicaid episodes in the pre-Medicaid managed care period were significant in the post-Medicaid managed care period. Multiple forces shaping professional standards, decision making, and quality of care are described. Public sector agencies must lay the groundwork for comprehensive evaluation prior to the implementation of privatized Medicaid managed care initiatives.

A continuum of services for the deinstitutionalized, chronically mentally ill elderly

Under a 1978 federal court consent decree, Massachusetts developed a comprehensive system of community based residential and non-residential services to minimize the utilization of one of its state hospitals. This paper describes the service system and its impact on the use of the state hospital by the chronically mentally ill elderly. The findings show that the development of a continuum of services can all but eliminate the use of the state hospital by psychiogeriatric patients. The authors suggest consideration be given to many of the systems elements in planning future services for this population.

Disparities in opioid prescribing for patients with psychiatric diagnoses presenting with pain to the emergency department

Background The goal of this investigation is to discover whether or not patients with psychiatric diagnoses are less likely to be prescribed opioids for pain in emergency departments compared with other patients. Methods Pain-related visits to US emergency departments were identified using reason-for-visit and physician diagnosis codes for 13 years (1993–2005) of the National Hospital Ambulatory Medical Care Survey. The outcome measure was the prescription or administration of an opioid analgesic. Results Roughly 10 million pain-related visits were made by persons with psychiatric diagnoses in the USA between 1993 and 2005. Across all years, only 18% (95% CI 16 to 20) of pain-related visits by patients with psychiatric diagnoses resulted in an opioid prescription, whereas 33% (95% CI 32 to 34) of visits by other patients did. Lower prescription rates for patients with psychiatric diagnoses were seen for every year of the survey and this difference occurred at every level of pain severity. Controlling for confounding factors did not attenuate this difference. In a multivariate model, patients with psychiatric diagnoses were about half as likely as other patients to be prescribed opiates (adjusted OR 0.49; 95% CI 0.44 to 0.56). Major limitations of the study include the uncertain precision of psychiatric and drug/alcohol diagnoses and the lack of detail about each patient visit. Conclusion Having a psychiatric diagnosis was associated with a lower likelihood of receiving an opioid among persons presenting with pain to the ED.

Factors Influencing IACUC Decision Making: Who Leads the Discussions?

Decisions about the appropriate use of animals in research are largely made by Institutional Animal Care and Use Committees (IACUCs). Several commentators claim that scientists exert excessive influence on IACUC decisions. We studied 87 protocol reviews from 10 IACUCs to assess whether any group of participants appeared to dominate the protocol discussions. Audio recordings of the meetings were coded to capture the topics of the discussions. We found that animal research scientists made the largest total number of topic mentions while community members made the fewest. On a per person basis, chairpersons and attending veterinarians made the most mentions. Scientists presented the largest number of protocols, and the subsequent discussions tended to contain the same topics mentioned in the presentations. The large number of protocols presented by scientists and their total number of comments made during protocol discussions suggest that scientists may significantly influence IACUC decision making.

Capsule Commentary on Joynt et al., The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States

This study used data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) between 2006 and 2009 to examine the prescription of opioids for moderate to severe pain in emergency departments across the United States.1 Patients from poorer neighborhoods and African-Americans and Latinos were less likely to be prescribed opioids. The effects for race and ethnicity persisted even when neighborhood factors were controlled. This study is the first to examine the effect of socio-economic status (SES) on the prescription of opioids, and is thus an important addition to the literature on inequities in health care. As the authors note, however, the study is limited in that individual patient characteristics for SES were unavailable and neighborhood characteristics were used as proxies for patient SES. Inequities in the delivery of health care for minority groups generally,2 and in the prescription of opioids specifically,3,4 has been well documented and reflect inequities in society as a whole. However, emergency department physicians typically see patients for a short period of time, and often have little personal knowledge about their patients. As a consequence, ED physicians may be more likely to make decisions about opiate prescriptions based on cultural stereotypes, specifically the perception that racial and ethnic minorities are more likely to abuse drugs of all sorts. Health care is delivered in the context of a relationship between the provider and the patient,5 and many factors may influence prescribing practices, including how patients report their symptoms, how these reports are interpreted by clinicians and whether or not pain medications are requested.3 While likely an important component, current inequities in the quality of care delivered to minorities is unlikely to be determined by cultural stereotypes alone.3 Future research needs to move beyond documenting inequities. We need to determine the sources of these disparities and test interventions to reduce disparate care.T his study used data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) between 2006 and 2009 to examine the prescription of opioids for moderate to severe pain in emergency departments across the United States. Patients from poorer neighborhoods and African-Americans and Latinos were less likely to be prescribed opioids. The effects for race and ethnicity persisted even when neighborhood factors were controlled. This study is the first to examine the effect of socioeconomic status (SES) on the prescription of opioids, and is thus an important addition to the literature on inequities in health care. As the authors note, however, the study is limited in that individual patient characteristics for SES were unavailable and neighborhood characteristics were used as proxies for patient SES. Inequities in the delivery of health care for minority groups generally, and in the prescription of opioids specifically, has been well documented and reflect inequities in society as a whole. However, emergency department physicians typically see patients for a short period of time, and often have little personal knowledge about their patients. As a consequence, ED physicians may be more likely to make decisions about opiate prescriptions based on cultural stereotypes, specifically the perception that racial and ethnic minorities are more likely to abuse drugs of all sorts. Health care is delivered in the context of a relationship between the provider and the patient, and many factors may influence prescribing practices, including how patients report their symptoms, how these reports are interpreted by clinicians and whether or not pain medications are requested. While likely an important component, current inequities in the quality of care delivered to minorities is unlikely to be determined by cultural stereotypes alone. Future research needs to move beyond documenting inequities. We need to determine the sources of these disparities and test interventions to reduce disparate care.