Do the psychopathic personality traits of fearless dominance and self-centered impulsivity predict attitudes about and influences on research participation?

Little is known about potential participants' views about research, their willingness to participate in research, and the extent to which they might be susceptible to coercive attempts to compel their participation, particularly among populations at risk for exploitation (e.g., offenders). The extent to which individual differences variables, such as personality constructs (e.g., psychopathic traits), might affect participants' attitudes toward research is also essentially unknown. The present study sought to examine the psychopathy constructs of Fearless Dominance (FD) and Self-Centered Impulsivity (SCI) via the Multidimensional Personality Questionnaire-Brief Form (MPQ-BF) to assess the extent to which these traits predict attitudes towards research and susceptibility to coercion within a diverse criminal justice sample (N = 631). SCI was modestly associated with perceptions that illicit pressures regarding research participation were likely to occur, and participants high in these traits appeared somewhat vulnerable to succumbing to coercive influences. In contrast, FD failed to predict the likelihood that illicit pressures regarding research participation would occur as well as the potential that these pressures would have to impact participants' voluntariness and likelihood of participating. Implications for recruiting potential participants for research in correctional settings are discussed.

Examining attitudes about and influences on research participation among forensic psychiatric inpatients.

Although a growing body of research has examined various types of coercive practices that may occur among psychiatric patients over the years, almost no attention has been given to coercive influences that may occur specifically in the context of recruitment into research projects. Particularly for those who are institutionalized (e.g., in-patient insanity acquittees), there are significant concerns that their autonomous decision-making to consent or not may be significantly impaired due to the highly restrictive and controlled environment in which they live. This exploratory study sought to examine patients' perceptions of coercive influences by presenting them with hypothetical research vignettes regarding possible recruitment into either a biomedical or social-behavioral research project. Among 148 multi-ethnic male and female participants across two facilities, participants reported relatively minimal perceptions that their autonomous decision-making would be impacted or that various potentially coercive factors (e.g., pressures from staff) would impair their free choice to participate (or not) in such research. To the extent that such perceptions of coercion did occur, they were moderately associated with patients' more general personality traits and attitudinal variables, such as alienation and external locus of control. Limitations of this study and their implications for future research are discussed.

Voluntary consent in correctional settings: do offenders feel coerced to participate in research?

A major ethical concern in research with criminal offenders is the potential for abuse due to coercive influences that may adversely affect offenders' capacity to give voluntary consent to participate in research conducted in correctional settings. Despite this concern, to date there have been almost no systematic scientific investigations of the extent to which offenders themselves perceive that coercion occurs in these settings or that it is likely to influence their decisions about research participation. In a sample of over 600 ethnically diverse men and women recruited from various prisons and community corrections facilities in Texas and Florida, we used a vignette-based survey concerning a hypothetical research project to measure and compare offenders' global perceptions of coercive processes, as well as the differential salience and perceived coercive influence of specific factors (e.g., coercion by other inmates, inducements from staff). Somewhat surprisingly, across multiple outcome measures our participants on average reported relatively little in the way of significant coercive influences on their capacity to make voluntary decisions concerning research participation. Implications and directions for future research on coercive influences in offender research are discussed.

Formal assessment of voluntariness with a three-part consent process.

Informed consent that is voluntary and made by an individual who is knowledgeable and competent is a foundational requirement for protecting human subjects from harm and exploitation that could result from research participation. In 1974 Miller and Willner proposed a two-part consent process that involved disclosure of information and assessment of comprehension. The authors propose a brief third component to the consent process: assessment of voluntariness. Three steps are involved: generate a list of potential coercive influences on the basis of the research population and the study context, develop a set of questions to assess the presence and intensity of the impact of these influences, and identify alternative courses of action should coercion be identified.

Adherence to practice guidelines, clinical outcomes, and costs among Medicaid enrollees with severe mental illnesses.

The treatment of Medicaid enrollees diagnosed with depression or schizophrenia was examined to determine whether adherence to treatment guideline was associated with health care financing strategy, clinical outcomes, and cost-effectiveness. Individuals in a fee-for-service condition were significantly more likely to receive treatment consistent with guidelines than those in managed care. Mental health costs were higher for individuals diagnosed with schizophrenia, individuals in an acute phase of illness at intake into the study, and those receiving treatment consistent with practice guidelines. Being in an acute phase of illness and having treatment that comported with recommended practice guidelines were associated with higher total social costs. Policy implications of the findings and recommendations for future research are discussed.

Behavioral health services utilization among older adults identified within a state abuse hotline database.

PURPOSE: This study examined the extent to which older adults identified in a statewide abuse hotline registry utilized behavioral health services. This is important as mental health issues have been identified as a high priority for filling gaps in services for victims of mistreatment. DESIGN AND METHODS: We compared Medicaid and Medicare claims data for two groups of older adults: those using health services and identified within a statewide abuse hotline information system and those claimants not identified within the hotline database. RESULTS: Behavioral health service use was greater among those identified in the abuse hotline database. The penetration rate (percentage of service users out of all enrollees) for Medicaid behavioral health service claims was more than twice that of other service users, with costs of services about 30% greater. Analyses of Medicare data revealed that the penetration rate for those in the hotline data was almost 6 times greater at approximately twice the cost compared to other service users. IMPLICATIONS: The results provide evidence for previous assumptions that mistreated individuals experience a higher rate of behavioral health disorders. As mental health screening by adult protective services is rarely conducted, the results suggest the need to train investigators and other service providers to screen older adults for behavioral health and substance-abuse issues as well as physical signs of abuse. Further research on the relationship of abuse to behavioral health might focus on collection of additional data involving more specific victim-related characteristics and comparisons of cases of mistreatment versus self-neglect.

Poor and depressed, the tip of the iceberg: the unmet needs of enrollees in an indigent health care plan.

Depression is a leading cause of disability [World Health Organization (WHO), 2001] with economic costs exceeding 63 billion dollars per year in the US [U.S. Department of Health and Human Services (DHHS), 1999]. The challenges of treating depression among the poor are compounded by broader social needs. This study examined the prevalence of depression and psychosocial needs among enrollees in an indigent health care plan. Results indicated clinical levels of depression were present in 28.6% of respondents (n=1,405). Depressed respondents were significantly more likely (p<0.001) to have co-occurring alcohol (OR=1.78; CI(95) =1.32-2.40), drug (OR=2.67; CI(95) =1.80-3.98), and health (OR=5.44; CI(95) = 4.12-7.19) problems compared to non-depressed respondents. Significantly more social needs were also associated with depression. Depressed respondents averaged 7.8 needs compared to 3.6 among non-depressed respondents. Needs included a significantly increased likelihood (p<0.001) of lacking sufficient food (OR=2.56; CI(95) =1.97-3.34), shelter (OR=3.67; CI(95) =2.23-6.05), or money (OR=3.18; CI(95) = 2.39-4.23) and having more legal (OR=2.95; CI(95) =2.22-3.92) and family (OR=3.00; CI(95) =2.32-3.86) problems. The high rates of co-occurring social needs among individuals with clinical depression underscores the need for comprehensive, coordinated care in order to improve their quality of life and also reduce high utilization of crisis management services.

Effects of antipsychotic medication on psychiatric service utilization and cost.

BACKGROUND: Based on randomized clinical trials, consensus has been emerging that the first line of treatment for individuals with psychotic disorders should be the newer atypical or second generation antipsychotic medications rather than the older neuroleptics. Given that acquisition costs of atypical antipsychotics are generally higher than typical antipsychotics, uncertainty exists whether the newer atypicals are cost effective alternatives when used in ordinary practice settings. AIMS OF THE STUDY: The introduction of newer atypical antipsychotic agents has prompted evaluation of their overall effectiveness in reducing health care costs given their higher acquisition costs. This paper focuses on the effects of differing classes of atypical versus typical antipsychotic medications on psychiatric service utilization and cost for persons with serious mental illness treated in usual practice settings. METHODS: Descriptive statistics are used to compare patient characteristics, service rates and costs across psychotropic medication groups. Prediction equations employing ordinary least squares regression models are used to explain variation in cost due to pharmacy group membership controlling for demographics, clinical diagnoses and symptoms. Subjects were 338 Medicaid clients with serious mental illness from Florida, Pennsylvania and Oregon treated in ordinary clinical settings. Resource utilization and costs were operationalized using administrative databases to measure consumption of treatment services and pharmaceuticals for a six month period. RESULTS: Inpatient service use was significantly higher for individuals on atypical only and combination atypical/typical medications compared to those on typical medications only, whereas outpatient use was highest for those on typicals. Furthermore, six-month costs for both pharmacy and psychiatric services were significantly greater for persons in the atypical only (USD 6528) and combination typical/atypical groups (USD 6589) compared to those on typicals only (USD 3463). There were still significantly higher costs associated with atypical only and the combination typical/atypical users after multivariate controls were used. DISCUSSION: This study showed that Medicaid clients in community settings using atypical only and typical/atypical combination medications had the highest costs both in pharmacy and service use when compared to those on typical only medications. However, this study design does not allow us to ascribe a causal relationship between medication group and service costs. Given that olanzapine was the most recent medication in the compendium of available drugs at the time of this study, it is possible that those in the olanzapine only group were failing on other drugs. Caution must be used in drawing policy implications regarding cost effectiveness of newer medications since individuals who are getting the newer atypical or combination medications in community mental health center settings may be unstable on the older medications. IMPLICATIONS FOR FUTURE RESEARCH: A longer follow-up period is needed to determine if the cohort remaining on current atypical medications stabilize over time while those taking the newest drug on the market become the most costly population.

Children's use of mental health services in different Medicaid insurance plans.

This study examined the effect of different Medicaid insurance plans on children's mental health service use through survey, claims, and encounter data collected between February 1998 and February 1999. Participants were assigned to 1 of 3 insurance plans: fee-for-service, a Health Maintenance Organization and a prepaid carve-out. Logistic and stratified logistic regression were used to examine the effect of plan on service utilization, adjusting for caregiver report of need for services and psychosocial functioning. There was no difference in service use by plan controlling for demographic characteristics; however, when psychopathology and caregiver report of need for services were included in the model, the odds of using services in the Health Maintenance Organization was half of and the odds in the carve-out 29% less than the odds of using services in fee-for-service. Characteristics of the interaction between need, psychopathology, and insurance plan that may be associated with the reduction in service use are discussed.

Emergency involuntary psychiatric examinations in Florida.

The authors used statewide data from 2000 on 80,869 examination initiations to determine characteristics of emergency involuntary psychiatric examinations in Florida and the individuals subject to them. Information about the evidence indicated on the initiation forms and the types of professionals who initiated the examinations is presented. These data allow not only description of involuntary examinations and the characteristics of those subject to them for an entire state, but also investigation of the involvement of these individuals with certain services, such as mental health services, and systems, such as the criminal justice system.

Service penetration by persons with severe mental illness: how should it be measured?

As performance indicators and outcomes measures become essential parts of doing business, providers of mental health services are developing and using a number of access measures. One that is being used with increasing frequency is service penetration. However, the lack of standard methods for calculating and reporting service penetration has made the comparison of penetration rates cross studies difficult. This article discusses the conceptualization and operationalization of service penetration. In addition, it presents an exploratory study of service penetration using data from the same persons using very different data sources; these data were collected during an evaluation of a Medicaid managed care system in Florida. The article offers recommendations for the use and reporting of service penetration rates.