Paul R. Falzer

Violence Risk and Race in a Sample of Youth in Juvenile Detention The Potential to Reduce Disproportionate Minority Confinement

Overrepresentation of minorities and their disproportionate confinement in the U.S. justice system are pernicious, unyielding problems. The authors used the Structured Assessment of Violence Risk in Youth to examine risk and protective factors of 757 juveniles admitted to detention centers. A chi-square analysis revealed that significantly more African American youth were rated low risk for violence compared to White counterparts. African American and Hispanic youth initiated violent behavior earlier and frequently lived in violent, disorganized neighborhoods. However, they had more prosocial involvement, stronger attachments and bonds, and more resilient personality traits. Ideas for targeted release and intervention with minority youth are described.

Physical fitness training: outcomes for adult oncology patients.

Physical activity and exercise participation are important considerations in the study and management of acute and long-term care for cancer patients. Although excessive rest and lack of physical activity are related to diminished physical fitness, reduced functional status, impaired cognition, and diminished quality of life, exercise prescription is not a standard treatment support for patients or survivors of cancer. In this retrospective study, it was hypothesized that routine participation in exercise could improve physical fitness for adults recently completing months of cancer treatment. Forty-five cancer patients were able to make considerable fitness gains over an 8-week period. A fitness program coordinated by an exercise physiologist, certified trainers, and an advanced practice cancer nurse was an effective method of organizing referral, monitoring individual patient concerns, and avoiding unnecessary risks.

Mental Illness, Violence Risk, and Race in Juvenile Detention: Implications for Disproportionate Minority Contact

Disproportionate minority contact (DMC) is a pervasive problem throughout the juvenile justice system. This article explored whether mental illness may be an explanatory factor in DMC. Data such as measures of violence risk and symptoms of mental illness were taken from intake interviews with 482 detained youth in Connecticut. Results indicated that racial minorities in detention have significantly lower violence risk than Caucasians but are disproportionately represented among detention populations relative to their proportions in the general population. In addition, DMC in these data was not explained by mental illness, seriousness of charges, violence risk, age, or gender. We suggest that mandated efforts to reduce DMC will need to address more than improving behavior or reducing symptoms of mental illness among detained minority youth. Instead, efforts should be focused on reducing the racial disparity evident in decisions made within the juvenile justice system.

Contextual decision making and the implementation of clinical guidelines: an example from mental health.

Purpose Clinical decision making plays a crucial role in the transformation of science to service. Treatment decisions typically are evaluated by comparing them against norms, such as practice guidelines. An adherence standard has been criticized as inappropriate, but no measurable alternative has been proposed to date. This study develops a new standard of incorporation and a companion matching test, and addresses two questions: (1) Do clinicians incorporate a treatment guideline even when they do not endorse it? (2) If so, do they incorporate the guideline consistently? Method The study uses the clinical paradigm of treatment-resistant schizophrenia and a published guideline developed at the Yale University Department of Psychiatry that has been soundly rejected in clinical practice. A vignette study was developed, using a four-factor, fully crossed and within-subject design, then administered to 21 volunteer paid psychiatry residents. Results The endorsement pattern showed a low concurrence rate and significant apparent inconsistency within subjects. However, the matching test showed a clear relationship between endorsement of the guideline and features of individual vignettes. The matching test demonstrated significant within-subject consistency and accounted for 65% of the endorsement variance. Conclusions Implications are preliminary, given limitations that pertain to the subject population and use of vignettes, the clinical paradigm, and treatment guideline. However, the studys concepts, procedures, and findings may play a valuable role in future transformative initiatives, including training clinicians in the use of clinical guidelines and evaluating the appropriateness of guidelines before their implementation.

Developing and Using Social Capital In Public Mental Health

Social capital has played a prominent role in recent initiatives to improve mental health and enhance the quality of services. However, efforts to substantiate a link between social capital and mental health have been daunted by equivocal findings and conceptual confusion. These consequences are in part due to having two prominent approaches that offer disparate and inconsistent accounts about what comprises social capital, how to increase it and how to use it to benefit mental health policy and practice. This paper lays the groundwork for a rapprochement.

Representation of the governed: leadership building for people with behavioral health disorders who are homeless or were formerly homeless.

Many organizations that provide services to individuals with behavioral health disorders are required to include people with psychiatric disabilities on their boards and action groups, yet this requirement rarely results in successful, ongoing representation. We report on a pilot project that trained people who were homeless and formerly homeless, most of whom were diagnosed with behavioral health disorders, for internships on boards and action groups that provide services to people who are homeless. We relate the projects goals to the theme of empowerment, present our findings, discuss key implementation issues, and offer recommendation for future program efforts and research.

Evidence-Based Decision-Making as a Practice-Based Learning Skill: A Pilot Study

ObjectivesAs physicians are being trained to adapt their practices to the needs and experience of patients, initiatives to standardize care have been gaining momentum. The resulting conflict can be addressed through a practice-based learning and improvement (PBL) program that develops competency in using treatment guidelines as decision aids and incorporating patient-specific information into treatment recommendations. This article describes and tests a program that is consistent with the ACGME’s multilevel competency-based approach, targets students at four levels of training, and features progressive learning objectives and assessments.MethodsThe program was pilot-tested with 22 paid volunteer psychiatric residents and fellows. They were introduced to a schizophrenia treatment guideline and reviewed six case vignettes of varying complexity. PBL assessments were based on how treatment recommendations were influenced by clinical and patient-specific factors. The task permitted separate assessments of learning objectives all four training levels.ResultsAmong the key findings at each level, most participants found the treatment guideline helpful in making treatment decisions. Recommendations were influenced by guideline-based assessment criteria and other clinical features. They were also influenced by patients’ perceptions of their illness, patient-based progress assessments, and complications such as stressors and coping patterns. Recommendations were strongly influenced by incongruence between clinical facts and patient experience.ConclusionPractical understanding of how patient experience joins with clinical knowledge can enhance the use of treatment guidelines as decision tools and enable clinicians to appreciate more fully how and why patients’ perceptions of their illness should influence treatment recommendations. This PBL program can assist training facilities in preparing students to cope with contradictory demands to both standardize and adapt their practice. The program can be modified to accommodate various disorders and a range of clinical factors and patient-specific complications.

Incorporating clinical guidelines through clinician decision-making

BackgroundIt is generally acknowledged that a disparity between knowledge and its implementation is adversely affecting quality of care. An example commonly cited is the failure of clinicians to follow clinical guidelines. A guiding assumption of this view is that adherence should be gauged by a standard of conformance. At least some guideline developers dispute this assumption and claim that their efforts are intended to inform and assist clinical practice, not to function as standards of performance. However, their ability to assist and inform will remain limited until an alternative to the conformance criterion is proposed that gauges how evidence-based guidelines are incorporated into clinical decisions.MethodsThe proposed investigation has two specific aims to identify the processes that affect decisions about incorporating clinical guidelines, and then to develop ad test a strategy that promotes the utilization of evidence-based practices. This paper focuses on the first aim. It presents the rationale, introduces the clinical paradigm of treatment-resistant schizophrenia, and discusses an exemplar of clinician non-conformance to a clinical guideline. A modification of the original study is proposed that targets psychiatric trainees and draws on a cognitively rich theory of decision-making to formulate hypotheses about how the guideline is incorporated into treatment decisions. Twenty volunteer subjects recruited from an accredited psychiatry training program will respond to sixty-four vignettes that represent a fully crossed 2 × 2 × 2 × 4 within-subjects design. The variables consist of criteria contained in the clinical guideline and other relevant factors. Subjects will also respond to a subset of eight vignettes that assesses their overall impression of the guideline. Generalization estimating equation models will be used to test the studys principal hypothesis and perform secondary analyses.ImplicationsThe original design of phase two of the proposed investigation will be changed in recognition of newly published literature on the relative effectiveness of treatments for schizophrenia. It is suggested that this literature supports the notion that guidelines serve a valuable function as decision tools, and substantiates the importance of decision-making as the means by which general principles are incorporated into clinical practice.

New Forms of Outreach in Community Psychiatry: A Report from the Field

Alternatives to office-based practice, such vere mental illnesses in their own communities became apparent; and (2) in the 1980s, as assertive community treatment (Stein & Test, 1985; McGrew & Bond, 1995) and ashomelessness among persons with mental illness reached a crisis point. A form of outsertive outreach to homeless persons (Cohen & Marcos, 1992; Rowe, Hoge, & Fisk, reach in community psychiatry that is less often discussed and evaluated is outreach 1996) were implemented in some community mental health systems in response to to individuals living in poor neighborhoods who are at risk for a range of behavioral two developments: (1) In the 1970s, the difficulty of treating some individuals with sehealth disorders, rather than outreach to an identified sub-group of persons with serious and persistent mental illness (SPMI). Michael Rowe, Ph.D.; Paul Falzer, Ph.D.; Miriam The former individuals may find services Delphin, Ph.D.; Vangie Vargas, B.A.; Thomas more helpful when they are delivered withStyron, Ph.D.; and Larry Davidson, Ph.D., are in the physical and socioeconomic context affiliated with the Yale School of Medicine, Department of Psychiatry. Lynelle Thomas, M.D., of their daily lives, including poverty, stigma, is affiliated with the Yale School of Medicine, and lack of access to economic and social Child Study Center. Joseph Berryhill, Ph.D., is resources (Davidson et al., 2001; Timko & associated with the University of North CaroMoos, 1998). In this report, we use our work lina at Asheville. This paper was written, in part, with the supwith a federally funded service demonstraport of a grant from the federal Substance Abuse tion project that aims to increase access to and Mental Health Services Administration for behavioral healthcare among residents of improving access to mental health services for public housing as a case example of this less persons residing in public and assisted housing, discussed form of behavioral health outCMHS GFA No. SM00–12. Address for correspondence: Michael Rowe, reach. After the case history of this workPh.D., Yale University School of Medicine, Dein-progress, we discuss the challenges that partment of Psychiatry, Program on Poverty, have emerged in our work, and we offer Disability, and Urban Health, 205 Whitney Aveexamples of how we have tried to address nue, New Haven, CT 06511. E-mail: michael.rowe @yale.edu. them.

Implementation Past, Present, … and Future?

Lomas (1993) defined implementation research and called for strategies to close the gap between science and service by changing the behavior of practitioners. This idea remains current and resonates with views expressed by Grimshaw, Proctor, Chambers, and other leaders (Chambers 2008; Hutton et al. 2008; Proctor et al. 2009). However, three years after his landmark paper, Lomas argued that implementation as he described it was unlikely to achieve its aim (Lomas and Lavis 1996). It was designed for practitioners who persisted in using interventions that were likely to be ineffective or harmful in lieu of evidence-based alternatives. After compiling studies from nine areas of medicine, he concluded that these instances are rather infrequent. The studies indicated that about one-third of potential interventions fell into what he called the ‘‘white zone’’, which are comprised of situations in which there is good evidence that an intervention is likely to do more good than harm. Another third fell into what he called the ‘‘black zone’’ of ineffective or harmful practices. Looking at actual treatment decisions, about 55% in the specialties he reviewed fell into the white zone and 20% were in the black zone. This 20% ranged from 0% in general practice and inpatient general medicine to 35% in angioplasty. Lomas believed that the numbers demonstrated considerable progress since the late 1980s, and that dissemination and implementation initiatives could further reduce the incidence of black zone practices. Lomas’s concern focused on an emerging problem that implementation was not designed to address. The problem lies with interventions that are neither black nor white but fall in the middle. They are the roughly 25% of treatment decisions that are made when evidence is incomplete or equivocal, or when evidence-based practices are supervened by factors such as administrative policy or patient preference. Concurring with Naylor (1995), Lomas projected a substantial growth in this ‘‘gray zone’’ over the coming years. He attributed its growth to dramatic changes the healthcare system that were already underway. Paternalistic healthcare was coming to an end. In Blumenthal’s words, those who once laid claim to be the arbiters of how evidence informs practice were now ‘‘tongue-tied and uncomprehending’’ as their discretion was rapidly diminishing and quality of care was being ‘‘contested daily in industrial boardrooms, legislative-hearing rooms, and even medical-consultation rooms’’ (Blumenthal 1996, p. 891). This development opened the door for implementation, but it also activated the cost containment, resource allocation, and risk sharing initiatives of managed care (Smith et al. 1996), and the preference-based initiatives of patient-centered care (Institute of Medicine 2001; Laine and Davidoff 1996). The continued viability of implementation depends on an ever-increasing white zone, as new evidence-based interventions come on line and new evidence determines which interventions actually work. Concomitantly, the agents of the emerging system were advancing their own priorities and establishing mandates that trump the evidence. Even with a rapid growth in outcome research, the relationship between evidence, practice, and outcome was likely to become more uncertain than ever. The classic example of healthcare policy suffused by realpolitik concerns a treatment guideline published by the newly created policy arm of the National Institutes of Health (Bigos et al. 1994). This guideline challenged the use of spinal fusion for treating acute back pain; it was adamantly opposed by a vocal group of back surgeons who P. R. Falzer (&) VA Connecticut Healthcare System, Clinical Epidemiology Research Center/151B, 950 Campbell Avenue, Building 35A, West Haven, CT 06516, USA e-mail: paul.falzer@yale.edu