Faculty Bibliography

States face new federal requirements to monitor psychotropic prescribing practices for children and adults enrolled in Medicaid. Effective use of quality measurement and quality improvement strategies hold the promise of improved outcomes for public mental health systems. The Medicaid/Mental Health Network for Evidence-Based Treatment (MEDNET), funded by the Agency for Healthcare Research and Quality, is a multistate Medicaid quality collaborative with the Rutgers University Center for Health Services Research on Pharmacotherapy, Chronic Disease Management, and Outcomes. This column describes the development, infrastructure, challenges, and early evidence of success of this public-academic partnership, the first multistate Medicaid quality improvement collaborative to focus on psychotropic medications.

BACKGROUND: Antipsychotic prescribing for youth has increased rapidly, is linked with serious health concerns, and lacks clear measures of quality for pediatric care. We reviewed treatment guidelines relevant to 7 quality concepts for appropriate use and management of youth on antipsychotics: 1) use in very young children, 2) multiple concurrent antipsychotics, 3) higher-than-recommended doses, 4) use without a primary indication, 5) access to psychosocial interventions, 6) metabolic screening, and 7) follow-up visits with a prescriber. METHODS: We searched for clinical practice guidelines meeting the following criteria: developed or endorsed by a national body, published after 2000, and specific treatment recommendations made related to 1 or more of the 7 quality concepts. Sources included electronic databases, the American Academy of Child and Adolescent Psychiatry Web site, and stakeholder and expert advisory committee recommendations. Two raters reviewed the 11 guidelines identified, extracting treatment recommendations, including details that could support measure definitions, and ratings of strength of recommendation and evidence. RESULTS: All 7 quality concepts were strongly endorsed by 1 or more guidelines, and 2 or more guidelines assigned their highest strength of recommendation ratings to 6 of the 7 concepts. Two guidelines rated evidence, providing high strength of evidence for 2 quality concepts: psychosocial interventions and metabolic monitoring. CONCLUSIONS: Guidelines provide support for 7 quality concepts addressing antipsychotic prescribing for youth. However, guideline support is often based on strong clinical consensus rather than a robust evidence base.

Purpose Given the metabolic and neurologic side effects of antipsychotics and concerns about the increased risks associated with concomitant use, antipsychotic polypharmacy is a quality concern. This study assessed the operating characteristics of a Medicaid claims-based measure of antipsychotic polypharmacy. Methods A random sample from 10 public mental health clinics and 312 patients met criteria for this study. Medical record extractors were blind to measure status. We examined the prevalence, sensitivity, specificity, and positive predictive value (PPV) in Medicaid claims, testing nine different definitions of antipsychotic polypharmacy, including >14, >60, or >90 days concurrent use of >/=2 antipsychotic agents, each with allowable gaps of up to 0, 14, or 32 days in days' supply of antipsychotic medications. Results All Medicaid claims measure definitions tested had excellent specificity and PPV (>91%). Good to excellent sensitivity was dependent upon use of a 32-day gap allowance, particularly as duration of concurrent antipsychotic use increased. The proposed claims-based measure (90-day concurrent use of >/=2 or more antipsychotics, allowing for a 32-day gap) had excellent specificity (99.1%, 95%CI: 98.2-99.6) and PPV (90.9%, 95%CI: 83.1-95.7) with good sensitivity (79.4%, 95%CI: 70.4-86.6). The overall level of concordance between claims and medical record-based categorization of antipsychotic polypharmacy was high (96.4%, n = 301/312 clients, Cohen's K = 84.7, 95%CI: 75.9-93.5). Discrepant cases were reviewed, and implications are discussed. Conclusions Administrative claims data can be used to construct valid measures of antipsychotic polypharmacy

Dissemination of innovations is widely considered the sine qua non for system improvement. At least two dozen states are rolling out evidence-based mental health practices targeted at children and families using trainings, consultations, webinars, and learning collaboratives to improve quality and outcomes. In New York State (NYS) a group of researchers, policymakers, providers, and family support specialists have worked in partnership since 2002 to redesign and evaluate the children's mental health system. Five system strategies driven by empirically based practices and organized within a state-supported infrastructure have been used in the child and family service system with more than 2,000 providers: (a) business practices, (b) use of health information technologies in quality improvement, (c) specific clinical interventions targeted at common childhood disorders, (d) parent activation, and (e) quality indicator development. The NYS system has provided a laboratory for naturalistic experiments. We describe these initiatives, key findings and challenges, lessons learned for scaling, and implications for creating evidence-based implementation policies in state systems.

This study was undertaken among Latinos receiving treatment from a community mental health center in New York City. The primary mental health concern was schizophrenia. We conducted three focus groups and present the viewpoints of consumers, family members, and providers. Using qualitative content analysis we identified four predominant categories: (1) the importance of family ties; (2) stigma about mental illness; (3) respect and trust in interpersonal relationships; and (4) facilitators and barriers to implementing Family Psychoeducation. Analysis of transcripts revealed specific subthemes for each category. Implications for imparting culturally sensitive material into mental health services for Latinos are discussed.

BACKGROUND: Training has been identified as an important barrier to implementation of clinical decision support systems (CDSSs), but little is known about the effectiveness of different training approaches. METHODS: Using an observational retrospective cohort design, we examined the impact of four training conditions on physician use of a CDSS: (1) computer lab training with individualized follow-up (CL-FU) (n=40), (2) computer lab training without follow-up (CL) (n=177), (3) lecture demonstration (LD) (n=16), or (4) no training (NT) (n=134). Odds ratios of any use and ongoing use under training conditions were compared to no training over a 2-year follow-up period. RESULTS: CL-FU was associated with the highest percent of active users and odds for any use (90.0%, odds ratio (OR)=10.2, 95% confidence interval (CI): 3.2-32.9) and ongoing use (60.0%, OR=6.1 95% CI: 2.6-13.7), followed by CL (any use=81.4%, OR=5.3, CI: 2.9-9.6; ongoing use=28.8%, OR=1.7, 95% CI: 1.0-3.0). LD was not superior to no training (any use=47%, ongoing use=22.4%). CONCLUSION: Training format may have differential effects on initial and long-term follow-up of CDSSs use by physicians.

OBJECTIVE: This study explored the range of interventions and the use of more intrusive techniques by staff of assertive community treatment (ACT) teams to promote engagement, manage problem behaviors, and reinforce positive behaviors among patients. Individual and organizational characteristics that may be associated with these practices were identified. METHODS: Between January and March 2006, clinicians (N=239) from 34 ACT teams participated in a one-time survey about their intervention strategies with patients, perceptions about the ACT team environment, and beliefs about persons with severe mental illness. RESULTS: Significant variation existed in the types of interventions employed across teams. The less intrusive strategies, including positive inducements and verbal guidance, were the most common. Other strategies that placed limits on patients but that were still considered less intrusive-such as medication monitoring and money management-were also common. Clinicians who reported working in more demoralized climates and having negative perceptions of mental illness were more likely to endorse leveraged or intrusive interventions. CONCLUSIONS: The findings of this study suggest significant variation across teams in the use of intervention strategies. Both perceptions of a demoralized organizational climate and stigmatizing beliefs about mental illness were correlated with the use of more intrusive intervention strategies. Future research on the role and appropriateness of more intrusive interventions in mental health treatment and the impact of such interventions on patient outcomes is warranted.

OBJECTIVE: This study compared rates of arrest and incarceration, psychiatric hospitalization, homelessness, and discharge from assertive community treatment (ACT) programs for forensic and nonforensic clients in New York State and explored associated risk factors. METHODS: Data were extracted from the New York State Office of Mental Health's Web-based outcome reporting system. ACT clients admitted between July 1, 2003, and June 30, 2007 (N=4,756), were divided into three groups by their forensic status at enrollment: recent (involvement in the past six months), remote (forensic involvement was more than six months prior), and no history. Client characteristics as of ACT enrollment and outcomes at one, two, and three years were compared over time. RESULTS: Clients with forensic histories had a significantly higher ongoing risk of arrest or incarceration, and those with recent criminal justice involvement had a higher risk of homelessness and early discharge from ACT. Psychiatric hospitalization rates did not differ significantly across groups. Rates of all adverse outcomes were highest in the first year for all ACT clients, especially for those with a recent forensic history, and rates of psychiatric hospitalization, homelessness, and discharge declined over time for all clients. For all ACT clients, homelessness and problematic substance abuse at enrollment were significant risk factors for arrest or incarceration and for homelessness on three-year follow-up. CONCLUSIONS: Clients with recent forensic histories were vulnerable to an array of adverse outcomes, particularly during their first year of ACT. This finding highlights the need for additional strategies to improve forensic and other outcomes for this high-risk population.

This column describes a series of interventions to decrease antipsychotic polypharmacy in the New York State Office of Mental Health (NYSOMH) network of psychiatric hospitals. Phase 1 consisted of implementation of the Psychiatric Services Clinical Knowledge Enhancement System (PSYCKES), a Web-based application supporting clinical decision making and quality improvement, and a policy requiring approval by NYSOMH's medical director to prescribe more than two antipsychotics per patient. In phase 2 hospital leaders received feedback from the office of the medical director identifying specific patients on polypharmacy. In phase 3, access to PSYCKES continued, but the prior-approval policy and feedback were discontinued. Polypharmacy decreased significantly during phase 1, from 16.9 to 9.7 inpatients per 1,000, and decreased further in phase 2, to 3.9 inpatients per 1,000. In phase 3 the prevalence of antipsychotic polypharmacy remained low at six-month follow-up (3.1 inpatients per 1,000), despite the ending of state-level oversight. On long-term follow-up, polypharmacy increased, eventually rising to 9.2 inpatients per 1,000 after 36 months, but remained well below baseline levels.

OBJECTIVE: Valproate is associated with polycystic ovary syndrome as well as congenital malformations and developmental delays of infants who were prenatally exposed. The frequency of valproate use for mental health conditions among women of childbearing age was determined. METHODS: Using New York State Medicaid claims for persons with psychiatric disorders, 40,526 individuals with active prescriptions for mood stabilizers (non-antipsychotic) on May 1, 2009, were identified. Chi square tests were used to compare valproate use among women of childbearing age with similarly aged men and older women. RESULTS: Valproate was the most commonly prescribed agent for young women (23.4%). Men were more likely than women, and older women more likely than younger women, to take valproate. CONCLUSIONS: Over 20% of childbearing-aged women receiving mood stabilizers were treated with valproate, although increasing data on the reproductive toxicity of this agent compel consideration of other non-antipsychotic mood stabilizers as first-line choices.