Marcela Horvitz-Lennon

The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia.

anagement of behavioral disturbances Mand psychosis associated with dementia is a clinical and, in some cases, a medicolegal and ethical challenge for clinicians, caregivers, and health care settings. These medications are associated with multiple adverse outcomes, including serious adverse effects, such as increased risk for cerebrovascular events and mortality. At the same time, clinicians feel pressure from caregivers, acute inpatient staff, and long-term care settings to safely manage psychotic and aggressive behaviors in this population. The incidence and prevalence of dementia and associated behavioral disturbances in the adult population is on the rise. There is a lack of consistent practices and guidance to manage these behaviors as well as an upto-date review of the existing effectiveness literature, and these are much needed. Thus, the recent publication of the American Psychiatric Associations (APAs) practice guidelines on the use of antipsychotics to treat agitation or psychosis in patients with dementia comes at a most opportune time. Practice guidelines are unique in that they have the potential to positively impact behavior of practicing clinicians. They are also likely to be used as standard of care by insurance companies and in lawsuits or other litigation. It is thus important that practice guidelines provide a thorough, balanced, accurate, and current review of available treatments based on medical and scientific literature. The APAs most recent practice guideline on antipsychotic treatment in patients with dementia appears to have done just that. The practice guideline is organized into two main sections. The first section is broken up into four main categories: an introduction and overview of the guidelines, the guidelines themselves and how they were implemented based on current evidence in literature, quality measurement considerations, and the guideline development process. The second section is an appendix that provides a comprehensive review of available evidence and the results of expert opinion survey data. The authors also included a list of acronyms and abbreviations used in the guidelines, glossary of terms, list

Significance of Endorsement of Psychotic Symptoms by Us Latinos

In US regional studies, Latinos frequently endorse psychotic symptoms associated with impairment and mental health service use, yet do not meet criteria for psychotic disorder. Using a nationally representative Latino sample (N = 2554), we examined the prevalence of psychotic symptoms, their relationship to psychotic disorder, their correlates, and their relationship to mental health outcomes. In this sample, 9.5% (SE = 0.7) endorsed 1 or more lifetime psychotic symptoms, yet 93% of endorsers did not meet Structured Clinical Interview for DSM-IV criteria for psychotic disorders. Endorsement was associated with physical and emotional distress, particularly lifetime anxiety and current substance use disorder. Acculturation to US society and reliance on spiritual/religious help were also associated with psychotic symptom endorsement. These symptoms have substantial clinical significance, being independently associated with suicidal ideation, mental health-related disability, and outpatient mental health service utilization. Endorsed psychotic symptoms in Latinos may constitute a clinically significant marker of general psychiatric vulnerability rather than a sign of psychotic disorder.

Mental health care reforms in Latin America: An overview of mental health care reforms in Latin America and the Caribbean

This new column provides an overview of mental health reforms in Latin America and the Caribbean. Progress has been particularly visible in countries that have implemented policies with strong political support (Brazil, Chile, and Belize, among others). However, lessons may be learned from the collective experience of a region that has faced multiple obstacles to reform. Available resources are still insufficient and inequitably distributed, reform implementation is not complete in most countries, and high levels of unmet need exist. Countries face new challenges related to growing psychosocial problems affecting children and adolescents and increasing violence, which require new responses from mental health services.

Improving Quality And Diffusing Best Practices: The Case Of Schizophrenia

The slow spread of treatments supported by empirical evidence and the rapid diffusion of treatments lacking such support play major roles in the lower quality of mental health care received by people with severe mental illnesses compared with the care of less severely ill people. Further, the rapid spread of treatments that are of low cost-effectiveness limits the systems ability to provide the full gamut of high-value treatments available to treat this vulnerable population. Using the case of schizophrenia, we review the context in which these paradoxical patterns of diffusion have occurred, and we propose policy solutions.

Racial and ethnic disparities in the treatment of a Medicaid population with schizophrenia.

OBJECTIVE To assess health care disparities among black and Latino adults with schizophrenia receiving services during the period July 1994-June 2006, and to evaluate trends in observed disparities. DATA SOURCES Administrative claims data from the Florida Medicaid program. Data sources included membership files (demographic information), medical claims (diagnostic, service, and expenditure information), and pharmacy claims (prescriptions used and expenditures). STUDY DESIGN We identified adults with at least two schizophrenia claims during a fiscal year. We used generalized estimating equation models to estimate disparities in spending on psychotropic drugs, psychiatric inpatient services, all mental health services, and all health services. PRINCIPAL FINDINGS Spending on psychotropic drugs, mental health, and all health was 0.9-70 percent lower for blacks and Latinos than for whites. With the exception of blacks with substance use disorder comorbidity, minorities were less likely than whites to use psychiatric inpatient services. Psychiatric inpatient spending among users did not differ by race/ethnicity. With the exception of psychiatric inpatient utilization/spending, trend analyses showed no change or modest reductions in disparities. CONCLUSIONS Black and Latino Medicaid recipients diagnosed with schizophrenia experience health care disparities. Some but not all disparities narrowed modestly over the study period.

Changes in Physician Antipsychotic Prescribing Preferences, 2002-2007

OBJECTIVE Physician antipsychotic prescribing behavior may be influenced by comparative effectiveness evidence, regulatory warnings, and formulary and other restrictions on these drugs. This study measured changes in the degree to which physicians are able to customize treatment choices and changes in physician preferences for specific agents after these events. METHODS The study used 2002-2007 prescribing data from the IMS Health Xponent database and data on physician characteristics from the American Medical Association for a longitudinal cohort of 7,399 physicians. Descriptive and multivariable regression analyses were conducted of the concentration of prescribing (physician-level Herfindahl index) and preferences for and likelihood of prescribing two first-generation antipsychotics and six second-generation antipsychotics. Analyses adjusted for prescribing volume, specialty, demographic characteristics, practice setting, and education. RESULTS Antipsychotic prescribing was highly concentrated at the physician level, with a mean unadjusted Herfindahl index of .33 in 2002 and .29 in 2007. Psychiatrists reduced the concentration of their prescribing more over time than did other physicians. High-volume psychiatrists had a Herfindahl index that was half that of low-volume physicians in other specialties (.18 versus .36), a difference that remained significant (p<.001) after adjustment for physician characteristics. The share of physicians preferring olanzapine dropped from 29.9% in 2002 to 10.3% in 2007 (p<.001) while the share favoring quetiapine increased from 9.4% to 44.5% (p<.001). Few physicians (<5%) preferred a first-generation antipsychotic in 2002 or 2007. CONCLUSIONS Preferences for specific antipsychotics changed dramatically during this period. Although physician prescribing remained heavily concentrated, the concentration decreased over time, particularly among psychiatrists.

Investigation of Racial and Ethnic Disparities in Service Utilization Among Homeless Adults With Severe Mental Illnesses

OBJECTIVE This study examined whether there are service disparities among homeless adults with severe mental illnesses, a vulnerable population with a high level of unmet need. METHODS Data were collected at baseline for 6,829 black, Latino, and non-Latino white participants in the Access to Community Care and Effective Services and Support study. Outcome variables were measures of utilization of psychiatric outpatient, housing, and case management services in the previous 60 days. The sample was divided into white-black and white-Latino cohorts. Within each cohort, participants were stratified into comparable groups by propensity scores that estimated log-odds of being black or Latino as a function of several confounding variables. White-black and white-Latino differences in mean number of visits (a measure of intensity) and in the mean probability of at least one visit (a measure of access) were subsequently estimated for each of the three services. RESULTS The composition of the sample was 50% black, 6% Latino, and 44% white. Service utilization was low for the three services regardless of race-ethnicity. On multivariate analyses of service utilization in the previous 60 days, blacks made fewer psychiatric outpatient visits than whites (mean difference=.46, 95% confidence interval [CI]=.10 to .81]), yet Latinos had more case management visits than whites (mean difference=-.51, CI=-1.03 to -.05]). Analyses of access did not reveal racial-ethnic disparities. CONCLUSIONS Whereas blacks used psychiatric outpatient services less frequently than whites, hence experiencing a service disparity, Latinos used case management services more than whites did. Possible contributors and clinical and methodological implications of these results are discussed.

Transforming Mental Healthcare in the Veterans Health Administration: A Model for Measuring Performance to Improve Access, Quality, and Outcomes

&NA; In this paper we present the conceptual framework and research design of a national evaluation of the quality of mental healthcare provided to veterans by the Veterans Health Administration, and present results on the reported availability of evidence‐based practices. We used the Donabedian paradigm to design a longitudinal evaluation of the quality of mental healthcare. To evaluate the structure of care we used a combination of survey and administrative data and designed a web‐based facility survey to examine the availability and characteristics of 12 evidence‐based practices and other mental health services. We identified 138 unique facilities that provided mental healthcare to 783,280 veterans. With the exception of opiate substitution therapies, every evidence‐based practice was reported in at least one location in each service network. We use maps to estimate the maximum number of veterans that might benefit from expanding the availability of an evidence‐based practice. We demonstrate the feasibility of overcoming several major challenges typically associated with measuring the quality of healthcare systems. This framework for evaluation of mental healthcare delivery provides a model upon which other stakeholders can continue to build and expand.

Disparities in Quality of Care among Publicly Insured Adults with Schizophrenia in Four Large U.S. States, 2002–2008

OBJECTIVE To examine racial/ethnic disparities in quality of schizophrenia care and assess the size of observed disparities across states and over time. DATA SOURCES Medicaid claims data from CA, FL, NY, and NC. STUDY DESIGN Observational repeated cross-sectional panel cohort study of white, black, and Latino fee-for-service adult beneficiaries with schizophrenia. Main outcome was the relationship of race/ethnicity and year with a composite measure of quality of schizophrenia care derived from 14 evidence-based quality indicators. PRINCIPAL FINDINGS Quality was assessed for 325,373 twelve-month person-episodes between 2002 and 2008, corresponding to 123,496 Medicaid beneficiaries. In 2002, quality was lowest for blacks in all states. With the exception of FL, quality was lower for Latinos than whites. In CA, blacks had about 43 percent of the individual indicators met compared to 58 percent for whites. Quality improved annually for all groups in CA, NY, and NC. While in CA the improvement was slightly larger for Latinos, in FL quality improved for blacks but declined for Latinos and whites. CONCLUSIONS Quality of schizophrenia care is poor and racial/ethnic disparities exist among Medicaid beneficiaries from four states. The size of the disparities varied across the states, and most of the initial disparities were unchanged by 2008.

Salud mental en atención primaria en Chile: aprendizajes para Latinoamérica

This article described the integration of mental health into primary care services in Chile over the past 20 years and analyzed the results of a few evaluations. The purpose was to contribute to the processes of learning how to reduce mental health care gaps throughout Latin America. The return to democracy after the Military Dictatorship and the Caracas Declaration were contributing factors to the integration, as were the high development of the Chilean primary care system and the development of national mental health plans that included primary care services as a central element. The political will of integration should also include the assignment of additional funds for mental health, within the primary care system. Another critical factor for mental health in primary care is the generation of mechanisms for coordination and support between secondary and primary care professionals. The article emphasized that available indicators show that Chile has successfully made mental health a central component of primary care services, possibly for the long term, but there are many remaining questions that require further studies.