Faculty Bibliography

Importance/UNASSIGNED:Individuals with serious mental illness are at increased risk of severe COVID-19 infection. Several psychotropic medications have been identified as potential therapeutic agents to prevent or treat COVID-19 but have not been systematically examined in this population. Objective/UNASSIGNED:To evaluate the associations between the use of psychotropic medications and the risk of COVID-19 infection among adults with serious mental illness receiving long-term inpatient psychiatric treatment. Design, Setting, and Participants/UNASSIGNED:This retrospective cohort study assessed adults with serious mental illness hospitalized in a statewide psychiatric hospital system in New York between March 8 and July 1, 2020. The final date of follow-up was December 1, 2020. The study included 1958 consecutive adult inpatients with serious mental illness (affective or nonaffective psychoses) who received testing for SARS-CoV-2 by reverse transcriptase-polymerase chain reaction or antinucleocapsid antibodies and were continuously hospitalized from March 8 until medical discharge or July 1, 2020. Exposures/UNASSIGNED:Psychotropic medications prescribed prior to COVID-19 testing. Main Outcomes and Measures/UNASSIGNED:COVID-19 infection was the primary outcome, defined by a positive SARS-CoV-2 reverse transcriptase-polymerase chain reaction or antibody test result. The secondary outcome was COVID-19-related death among patients with laboratory-confirmed infection. Results/UNASSIGNED:Of the 2087 adult inpatients with serious mental illness continuously hospitalized during the study period, 1958 (93.8%) underwent testing and were included in the study; 1442 (73.6%) were men, and the mean (SD) age was 51.4 (14.3) years. A total of 969 patients (49.5%) had laboratory-confirmed COVID-19 infection that occurred while they were hospitalized; of those, 38 (3.9%) died. The use of second-generation antipsychotic medications, as a class, was associated with decreased odds of infection (odds ratio [OR], 0.62; 95% CI, 0.45-0.86), whereas the use of mood stabilizers was associated with increased odds of infection (OR, 1.23; 95% CI, 1.03-1.47). In a multivariable model of individual medications, the use of paliperidone was associated with decreased odds of infection (OR, 0.59; 95% CI, 0.41-0.84), and the use of valproic acid was associated with increased odds of infection (OR, 1.39; 95% CI, 1.10-1.76). Clozapine use was associated with reduced odds of mortality in unadjusted analyses (unadjusted OR, 0.25; 95% CI, 0.10-0.62; fully adjusted OR, 0.43; 95% CI, 0.17-1.12). Conclusions and Relevance/UNASSIGNED:In this cohort study of adults hospitalized with serious mental illness, the use of second-generation antipsychotic medications was associated with decreased risk of COVID-19 infection, whereas the use of valproic acid was associated with increased risk. Further research is needed to assess the mechanisms that underlie these findings.

OBJECTIVE:This study examined the impact of Pathway Home™ (PH) transition services for high utilizers of psychiatric hospitalization on inpatient days and outpatient engagement post-hospital discharge. METHODS:This case series study of forty PH graduates (5/22/2015-8/31/2018) used Medicaid claims to assess psychiatric inpatient days-per-month, average proportion of months with psychiatric emergency room, outpatient, and health home care management services. T-tests compared three time periods: the year prior, during, and after enrollment. RESULTS:Graduates had significantly fewer psychiatric inpatient days/month during (M = 1.84, p < 0.001) and after PH enrollment (M = 1.88, p < 0.001) compared to prior to enrollment (M = 7.1), while emergency services were stable. Outpatient visits increased from 45% prior to 76% during enrollment (p < 0.001) and was sustained on follow-up (67%, p = 0.008). A similar pattern emerged for health home services (32%, 60%, and 50%). CONCLUSION/CONCLUSIONS:PH is a promising approach for improving outcomes for high utilizers of psychiatric inpatient services, with sustained impact on follow-up.

BACKGROUND:Behavioral health outpatients are at risk for self-harm. Identifying individuals or combination of risk factors could discriminate those at elevated risk for self-harm. METHODS:The study population (N=248,491) included New York State Medicaid-enrolled individuals aged 10 to 64 with mental health specialty clinic visits 11/1/15-11/1/16. Self-harm episodes were defined using ICD-10 codes from emergency department and inpatient visits. Multi-predictor logistic regression models were fit on a subsample of the data and compared to a testing sample based on discrimination performance (Area Under the Curve or AUC). RESULTS:Of N=248,491 patients, 4,224 (1.70%) had an episode of intentional self-harm. Factors associated with increased self-harm risk were age17-25, being female and having recent diagnoses of depression (AOR=4.3, 95%CI: 3.6-5.0), personality disorder (AOR=4.2, 95%CI: 2.9-6.1), or substance use disorder (AOR=3.4, 95%CI: 2.7-4.3) within the last month. A multi-predictor logistic regression model including demographics and new psychiatric diagnoses within 90 days prior to index date had good discrimination and outperformed competitor models on a testing sample (AUC=0.86, 95%CI:0.85-0.87). LIMITATIONS/CONCLUSIONS:New York State Medicaid data may not be generalizable to the entire U.S population. ICD-10 codes do not allow distinction between self-harm with and without intent to die. CONCLUSIONS:Our results highlight the usefulness of recency of new psychiatric diagnoses, in predicting the magnitude and timing of intentional self-harm risk. An algorithm based on this finding could enhance clinical assessments support screening, intervention and outreach programs that are at the heart of a Zero Suicide prevention model.

OBJECTIVE:Many public health approaches to suicide prevention emphasize connecting at-risk individuals to professional treatment. However, it is unclear to what degree the outpatient mental health workforce has the requisite knowledge and skills to provide the evidence-based care needed to help those at risk. In this project, prior to the implementation of a statewide suicide prevention initiative, we assessed the baseline suicide prevention training and clinical practices of the New York State outpatient mental health workforce, a group likely representative of the broader U.S. clinical workforce. METHOD:A workforce survey of suicide prevention training and clinical practices was administered to 2,257 outpatient clinicians, representing 169 clinics serving approximately 90,000 clients. Clinicians were asked to complete the survey online, and all responses were confidential. RESULTS:Clinicians reported substantial gaps in their suicide prevention knowledge and training. The vast majority reported moderate self-efficacy working with suicidal clients and endorsed using evidence-based assessment procedures, but varied in utilization of recommended intervention practices. CONCLUSIONS:This study highlights gaps in clinicians' training and clinical practices that need to be overcome to provide evidence-based suicide care. Promisingly, positive associations were found between training and clinician knowledge, self-efficacy, and use of evidence-based practices.

Providing physical health care in specialty mental health clinics is a promising approach to improving the health status of adults with serious mental illness, but most programs examined in prior studies are not financially sustainable. This study assessed the impact on quality of care of a low-cost program implemented in New York State that allowed mental health clinics to be reimbursed by Medicaid for provision of health monitoring and health physicals (HM/HP). Medicaid claims data were analyzed with generalized linear multilevel models to examine change over time in quality of physical health care associated with HM/HP services. Recipients of HM/HP services were compared to control clinic patients [Per protocol (PP)] and with non-recipients of HM/HP services from both intervention and control clinics [As-Treated (AT)]. HM/HP clinic patients, regardless of receipt of HM/HP services, were compared with control clinic patients [Intent-to-Treat (ITT)]. Analyses were conducted with adjustment for patient demographic and clinical characteristics and prior year service use. The PP and AT analyses found significant improvement in measure of blood glucose screening for patients on antipsychotic medication and HbA1C testing for patients with diabetes (AOR range 1.26-1.33) and the AT analysis found significant improvement in cholesterol screening for patients on antipsychotic medication (AOR 1.24). However, ITT analysis found no significant changes in quality of care in HM/HP clinic caseloads relative to control clinics. The low-cost HM/HP program has the potential to benefit patients who receive supported services, but its impact is limited by remaining barriers to service implementation.

BACKGROUND:The treatment of suicidal patients often suffers owing to a lack of integrated care and standardized approaches for identifying and reducing risk. The National Strategy for Suicide Prevention endorsed the Zero Suicide (ZS) model, a multi-component, system-wide approach to identify, engage, and treat suicidal patients. The ZS model is a framework for suicide prevention in healthcare systems with the aspirational goal of eliminating suicide in healthcare. While the approach is widely endorsed, it has yet to be evaluated in a systematic manner. This trial evaluates two ZS implementation strategies statewide in specialty mental health clinics. METHODS/STUDY DESIGN/UNASSIGNED:This trial is the first large-scale implementation of the ZS model in mental health clinics using the Assess, Intervene, and Monitor for Suicide Prevention (A-I-M) clinical model. Using a hybrid effectiveness-implementation type 1 design, we are testing the effectiveness of ZS implementation in 186 mental health clinics in 95 agencies in New York State. Agencies are randomly assigned to either: "Basic Implementation" (BI; a large group didactic learning collaboratives) or "Enhanced Implementation" (EI; participatory small group learning collaboratives; enhanced consultation for site champions). Primary outcomes include suicidal behaviors, hospitalizations and Emergency Department visits; implementation outcomes include protocol adoption, protocol fidelity and barriers/facilitators to implementation. DISCUSSION/CONCLUSIONS:This project has the potential to have a significant public health impact by determining the effectiveness of the ZS model in mental health clinics, a setting where suicide attempts and suicides occur at a higher rate than any other healthcare setting. It will also provide guidance on the implementation level required to achieve uptake and sustainability of ZS. TRIAL REGISTRATION/BACKGROUND:N/A.

OBJECTIVE/UNASSIGNED:This cross-sectional study examined the relationship between antipsychotic medication adherence and preventable diabetes-related hospitalizations for individuals with diabetes and schizophrenia. METHODS/UNASSIGNED:Hospitalizations related to diabetes, an ambulatory care sensitive condition, were assessed among Medicaid recipients in New York State with comorbid diabetes and schizophrenia (N=14,365) for three levels of antipsychotic medication adherence: very low to no engagement (two or fewer prescriptions or none in first 6 months), moderate to low adherence, and adherent (proportion of days covered ≥80%). RESULTS/UNASSIGNED:Rates of preventable diabetes hospitalization were highest among individuals with very low to no engagement in antipsychotic treatment (4.7%), followed by those with moderate to low adherence (3.3%). Diabetes hospitalizations among adherent individuals were comparable with those of the total diabetes population (both 2.0%). The odds of a preventable diabetes hospitalization were significantly higher among individuals with very low to no engagement in antipsychotic treatment (adjusted odds ratio [AOR]=2.42) and among those with moderate to low adherence (AOR=1.57) than among adherent individuals. Black individuals were also at increased risk of a preventable diabetes hospitalization after the analyses adjusted for antipsychotic adherence and other variables (AOR=1.38). CONCLUSIONS/UNASSIGNED:This study indicates a relationship between antipsychotic adherence and improved diabetes outcomes among individuals with schizophrenia. Engagement in mental health treatment may be a critical path toward improving health disparities for individuals with schizophrenia. Individuals with very low to no engagement were a particularly vulnerable group, and the exclusion of persons with less than two prescriptions from research and quality measures should be revisited.

To inform efforts to improve physical health care for adults with serious mental illness, this study examines predictors of provision and receipt of physical health services in freestanding mental health clinics in New York state. The number of services provided over the initial 12-months of implementation varied across clinics from 0 to 1407. Receipt of services was associated with a diagnosis of schizophrenia, frequent mental and physical health visits in the prior year, and prescription of antipsychotic medications. Additional support may also be needed to enable clinics to target patients without established patterns of frequent mental health or medical visits.

Electronic shared-decision making programs may provide an assistive technology to support physician-patient communication. This mixed methods study examined use of a web-based shared decision-making program (MyCHOIS-CommonGround) by individuals receiving specialty mental health services, and identified qualitative factors influencing adoption during the first 18 months of implementation in two Medicaid mental health clinics. T-tests and χ² analyses were conducted to assess differences in patient use between sites. Approximately 80% of patients in both clinics created a MyCHOIS-CommonGround user profile, but marked differences emerged between clinics in patients completing shared decision-making reports (79% vs. 28%, χ²₍₁₎ = 109.92, p < .01) and average number of reports (7.20 vs. 3.60, t = - 3.64, p < .01). Results suggest high penetration of computer-based programs in specialty mental health services is possible, but clinic implementation factors can influence patient use including leadership commitment, peer staff funding to support the program, and implementation strategy, most notably integration of the program within routine clinical workflow.

OBJECTIVE:/UNASSIGNED:The authors examined the impact of a Web-based shared decision-making application, MyCHOIS-CommonGround, on ongoing outpatient mental health treatment engagement (all users) and antipsychotic medication adherence (users with schizophrenia). METHODS:/UNASSIGNED:An intervention study was conducted by comparing Medicaid-enrolled MyCHOIS-CommonGround users in 12 participating mental health clinics (N=472) with propensity score-matched adults receiving services in nonparticipating clinics (N=944). Medicaid claims were used to assess ongoing treatment engagement and antipsychotic adherence (among individuals with schizophrenia) one year prior to and after entry into the cohort. Multilevel linear models were conducted to estimate the effects of the MyCHOIS-CommonGround program over time. RESULTS:/UNASSIGNED:No differences during the baseline year were found between the MyCHOIS-CommonGround group and the matched control group on demographic, diagnostic, or service use characteristics. At one-year follow-up, engagement in outpatient mental health services was significantly higher for MyCHOIS-CommonGround users than for the control group (months with a service, 8.54±.22 versus 6.95±.15; β=1.40, p<.001). Among individuals with schizophrenia, antipsychotic medication adherence was also higher during the follow-up year among MyCHOIS-CommonGround users compared with the control group (proportion of days covered by medication, .78±.04 versus .69±.03; β=.06, p<.01). CONCLUSIONS:/UNASSIGNED:These findings provide new evidence that shared decision-making tools may promote ongoing mental health treatment engagement for individuals with serious mental illness and improved antipsychotic medication adherence for those with schizophrenia.