Marisa Sklar

Integrated Care Increases Treatment and Improves Outcomes of Patients With Chronic Hepatitis C Virus Infection and Psychiatric Illness or Substance Abuse

BACKGROUND & AIMS Patients with hepatitis C virus (HCV) infection with psychiatric disorders and/or substance abuse face significant barriers to antiviral treatment. New strategies are needed to improve treatment rates and outcomes. We investigated whether an integrated care (IC) protocol, which includes multidisciplinary care coordination and patient case management, could increase the proportion of patients with chronic HCV infection who receive antiviral treatment (a combination of interferon-based and direct-acting antiviral agents) and achieve a sustained virologic response (SVR). METHODS We performed a prospective randomized trial at 3 medical centers in the United States. Participants (n = 363 patients attending HCV clinics) had been screened and tested positive for depression, post-traumatic stress disorder, and/or substance use; they were assigned randomly to groups that received IC or usual care (controls) from March 2009 through February 2011. A midlevel mental health practitioner was placed at each HCV clinic to provide IC with brief mental health interventions and case management, according to formal protocol. The primary end point was SVR. RESULTS Of the study participants, 63% were non-white, 51% were homeless in the past 5 years, 64% had psychiatric illness, 65% were substance abusers within 1 year before enrollment, 57% were at risk for post-traumatic stress disorder, 71% had active depression, 80% were infected with HCV genotype 1, and 23% had advanced fibrosis. Over a mean follow-up period of 28 months, a greater proportion of patients in the IC group began receiving antiviral therapy (31.9% vs 18.8% for controls; P = .005) and achieved a SVR (15.9% vs 7.7% of controls; odds ratio, 2.26; 95% confidence interval, 1.15-4.44; P = .018). There were no differences in serious adverse events between groups. CONCLUSIONS Integrated care increases the proportion of patients with HCV infection and psychiatric illness and/or substance abuse who begin antiviral therapy and achieve SVRs, without serious adverse events. ClinicalTrials.gov # NCT00722423.

Development and Validation of a Housing First Fidelity Survey

OBJECTIVES Programs that use the Housing First model are being implemented throughout the United States and internationally. The authors describe the development and validation of a Housing First fidelity survey. METHODS A 46-item survey was developed to measure fidelity across five domains: housing process and structure, separation of housing and services, service philosophy, service array, and team structure. The survey was administered to staff and clients of 93 supported-housing programs in California. Exploratory and confirmatory factor analyses were used to identify the items and model structure that best fit the data. RESULTS Sixteen items were retained in a two-factor model, one related to approach to housing, separation of housing and services, and service philosophy and one related to service array and team structure. CONCLUSIONS Our survey mapped program practices by using a common metric that captured variation in fidelity to Housing First across a large-scale implementation of supported-housing programs.

Instruments for measuring mental health recovery: A systematic review

Persons in recovery, providers, and policymakers alike are advocating for recovery-oriented mental health care, with the promotion of recovery becoming a prominent feature of mental health policy in the United States and internationally. One step toward creating a recovery-oriented system of care is to use recovery-oriented outcome measures. Numerous instruments have been developed to assess progress towards mental health recovery. This review identifies instruments of mental health recovery and evaluates the appropriateness of their use including their psychometric properties, ease of administration, and service-user involvement in their development. A literature search using the Medline and Psych-INFO databases was conducted, identifying 21 instruments for potential inclusion in this review, of which thirteen met inclusion criteria. Results suggest only three instruments (25%) have had their psychometric properties assessed in three or more unique samples of participants. Ease of administration varied between instruments, and for the majority of instruments, development included service user involvement. This review updates and expands previous reviews of instruments to assess mental health recovery. As mental health care continues to transform to a recovery-oriented model of service delivery, this review may facilitate selection of appropriate assessments of mental health recovery for systems to use in evaluating and improving the care they provide.

Measuring the impact of cataract surgery on generic and vision-specific quality of life

PurposeCataracts are the leading cause of blindness worldwide and cause visual impairment for millions of adults in the United States. We compared the sensitivity of a vision-specific health-related quality of life (HRQOL) measure to that of multiple generic measures of HRQOL before and at 2 time points after cataract surgery.MethodsParticipants completed 1 vision-specific and 5 generic quality of life measures before cataract surgery, and again 1 and 6 months after surgery. Random effects modeling was used to measure changes over the three assessment points.ResultsThe NEI-VFQ25 total score and all 11 subscales showed significant improvements during the first interval (baseline and 1 month). During the second interval (1–6 months post-surgery), significant improvements were observed on the total score and 5 of 11 NEI-VFQ25 subscales. There were significant increases in HRQOL during the first interval on some preference-based generic HRQOL measures, though changes during the second interval were mostly non-significant. None of the SF-36v2™ or SF6D scales changed significantly between any of the assessment periods.ConclusionsThe NEI-VFQ25 was sensitive to changes in vision-specific domains of QOL. Some preference-based generic HRQOL measures were also sensitive to change and showed convergence with the NEI-VFQ25, but the effects were small. The SF-36v2™ and SF-6D did not change in a similar manner, possibly reflecting a lack of vision-related content. Studies seeking to document both the vision-specific and generic HRQOL improvements of cataract surgery should consider these results when selecting measures.

The psychometric properties of the Illness Management and Recovery scale in a large American public mental health system.

The Illness Management and Recovery (IMR) scale was created to measure recovery outcomes produced by the IMR program. However, many other mental health care programs are now designed to impact recovery-oriented outcomes, and the IMR has been identified as a potentially valuable measure of recovery-oriented mental health outcomes. The purpose of this study was to examine the psychometric properties and structural validity of the IMR clinician scale within a variety of therapeutic modalities other than IMR in a large multiethnic sample (N=10,659) of clients with mental illness from a large U.S. county mental health system. Clients completed the IMR on a single occasion. Our estimates of internal consistency were stronger than those found in previous studies (α=0.82). The scale also related to other measures of theoretically similar constructs, supporting construct and criterion validity claims. Additionally, confirmatory factor analyses supported the multidimensional representation of the IMR clinician scale. The three-factor model of illness self-management and recovery was represented by dimensions of recovery, management, and substance use. These reliable psychometric properties support the use of both the original one-factor and revised three-factor models to assess illness self-management and recovery among a broad spectrum of clients with mental illness.

“Scaling-out” evidence-based interventions to new populations or new health care delivery systems

BackgroundImplementing treatments and interventions with demonstrated effectiveness is critical for improving patient health outcomes at a reduced cost. When an evidence-based intervention (EBI) is implemented with fidelity in a setting that is very similar to the setting wherein it was previously found to be effective, it is reasonable to anticipate similar benefits of that EBI. However, one goal of implementation science is to expand the use of EBIs as broadly as is feasible and appropriate in order to foster the greatest public health impact. When implementing an EBI in a novel setting, or targeting novel populations, one must consider whether there is sufficient justification that the EBI would have similar benefits to those found in earlier trials.DiscussionIn this paper, we introduce a new concept for implementation called “scaling-out” when EBIs are adapted either to new populations or new delivery systems, or both. Using existing external validity theories and multilevel mediation modeling, we provide a logical framework for determining what new empirical evidence is required for an intervention to retain its evidence-based standard in this new context. The motivating questions are whether scale-out can reasonably be expected to produce population-level effectiveness as found in previous studies, and what additional empirical evaluations would be necessary to test for this short of an entirely new effectiveness trial. We present evaluation options for assessing whether scaling-out results in the ultimate health outcome of interest.ConclusionIn scaling to health or service delivery systems or population/community contexts that are different from the setting where the EBI was originally tested, there are situations where a shorter timeframe of translation is possible. We argue that implementation of an EBI in a moderately different setting or with a different population can sometimes “borrow strength” from evidence of impact in a prior effectiveness trial. The collection of additional empirical data is deemed necessary by the nature and degree of adaptations to the EBI and the context. Our argument in this paper is conceptual, and we propose formal empirical tests of mediational equivalence in a follow-up paper.

Evaluating a Measure of Social Health Derived from Two Mental Health Recovery Measures: The California Quality of Life (CA-QOL) and Mental Health Statistics Improvement Program Consumer Survey (MHSIP)

Social health is important to measure when assessing outcomes in community mental health. Our objective was to validate social health scales using items from two broader commonly used measures that assess mental health outcomes. Participants were 609 adults receiving psychological treatment services. Items were identified from the California Quality of Life (CA-QOL) and Mental Health Statistics Improvement Program (MHSIP) outcome measures by their conceptual correspondence with social health and compared to the Social Functioning Questionnaire (SFQ) using correlational analyses. Pearson correlations for the identified CA-QOL and MSHIP items with the SFQ ranged from .42 to .62, and the identified scale scores produced Pearson correlation coefficients of .56, .70, and, .70 with the SFQ. Concurrent validity with social health was supported for the identified scales. The current inclusion of these assessment tools allows community mental health programs to include social health in their assessments.

The Role of Leadership in Creating a Strategic Climate for Evidence-Based Practice Implementation and Sustainment in Systems and Organizations

There is a growing impetus to effectively implement evidence-based practices (EBPs) in health and allied health settings in order to improve the public health impact of such practices. To support implementation and sustainment of EBPs, it is important to consider that health care is delivered within the outer context of public health systems and the inner context of health care organizations and work groups (3). This article identifies two relevant types of leadership for implementation and recommends steps that leaders can take in developing a strategic climate for EBP implementation and sustainment within the outer and inner contexts of health and allied health care systems and organizations.

Gender Congruence Moderates Beliefs About the Causes of Alcohol Dependence and Major Depression

Lay beliefs about the causes of common mental health conditions may perpetuate stigmatizing attitudes toward individuals with mental illness. Furthermore, some of these beliefs may be subject to intergroup membership bias based on gender congruence, as depression is more prevalent in women and alcohol dependence is more prevalent in men. Respondents listened to a vignette portraying an individual with depression or alcohol dependence and were asked how likely the vignette character’s (X’s) symptoms were due to the following causes: X’s bad character, genetics, stress, the way X was raised, and the normal ups and downs of life. Respondents endorsed bad character as a more likely cause of alcohol dependence compared to depression, but this was stronger for women respondents. Men, on the other hand, were more likely to endorse bad character as a cause of depression compared to women. A trend suggested that the overall tendency for alcohol to be attributed to genetics more than depression was stronger for men, whereas women endorsed genetics as a more likely cause of depression than men. Finally, men were significantly more likely to attribute characters’ symptoms to the normal ups and downs of life compared to women. Overall, these patterns suggest gender differences in attitudes about the underlying causes of alcohol dependence and depression that may be consistent with intergroup membership bias. Anti-stigma interventions aimed at reducing bias toward individuals with these common, gender-typical disorders should consider adapting strategies to target intergroup membership bias.

Yoga as a Treatment for Low Back Pain: A Review of the Literature"

Chronic low back pain (CLBP) affects millions of people worldwide. In addition to chronic pain, CLBP is associated with increased disability and psychological symptoms, and reduced health-related quality of life (HRQOL). There are many treatment options for chronic low back pain, although no single therapy stands out as being the most effective. In the past 10 years, yoga interventions have been studied as an additional approach for treating CLBP. The objective of this chapter is to provide an introduction to yoga as a treatment for CLBP before reviewing the published literature to date supporting the efficacy of yoga for CLBP. Two large randomized controlled trials (RCTs) published late in 2011 provide the most conclusive evidence to date in this area. With few exceptions, previous studies and the recent RCTs indicate that yoga can reduce pain and disability, can be practiced safely, and is well received by participants. Some studies also indicate that yoga can reduce pain medication use and improve psychological symptoms, but these effects are currently not as well established. We summarize these results, discuss their implications, and examine caveats and limitations of the current research evidence. Finally, we provide suggestions for future avenues of research.