Acceptability of potential interventions to increase firearm safety among patients in VA mental health treatment.

OBJECTIVE: Veterans in mental health care have high rates of firearm-related suicide; reducing firearm access during high-risk periods could save lives. We assessed veteran patients' attitudes towards voluntary interventions to reduce access. METHODS: Descriptive data came from surveys mailed to random samples of veterans receiving mental health care in five geographically diverse VA facilities. Survey items inquired about the acceptability of seven voluntary health system interventions to address firearm access, ranging from lower-intensity interventions that addressed safety but might not reduce access (i.e., clinician screening; distribution of gunlocks) to interventions substantially limiting access (i.e., storage of firearms offsite; gun disposal). Mailings occurred between 5/11/15 and 10/19/15; 677 of 1354 veterans (50%) returned the surveys. RESULTS: 93.2% of respondents endorsed one or more health system interventions addressing firearm access; 75.0% endorsed interventions substantially limiting access. Although veterans with household firearms were less likely to endorse interventions, fully 50.4% would personally participate in at least one intervention that substantially limited access. DISCUSSION: A majority of veterans in VA mental health care endorse voluntary health system interventions addressing firearm access during high-risk periods for suicide. Approximately half of veterans with firearms would personally participate in an intervention that substantially limited firearm access.

STRONG MILITARY FAMILIES INTERVENTION ENHANCES PARENTING REFLECTIVITY AND REPRESENTATIONS IN FAMILIES WITH YOUNG CHILDREN.

Military families face many challenges due to deployment and parental separation, and this can be especially difficult for families with young children. The Strong Military Families (SMF) intervention is for military families with young children, and consists of two versions: the Multifamily Group, and a Home-based psychoeducational written materials program. The Multifamily Group was designed to enhance positive parenting through both educational components and in vivo feedback and support during separations and reunions between parents and children (n = 78 parents). In the present study, we examine parenting reflectivity and mental representations in mothers versus fathers in military families, service members versus civilian spouses/parenting partners, and before versus after participation in the SMF Multifamily Group and Home-based interventions. Parenting reflectivity and mental representations were coded from the Working Model of the Child Interview (WMCI; C.H. Zeanah & D. Benoit, 1995). Results suggest that neither parenting reflectivity nor WMCI typology differs between mothers and fathers in military families, or between service members and civilian parenting partners. Furthermore, there was substantial stability in parenting reflectivity and WMCI typology from baseline to posttest, but participation in the Multifamily Group, relative to Home-based, was associated with improvements in both parenting reflectivity and WMCI ratings from baseline to postintervention.

Delays in adopting evidence-based dosages of conventional antipsychotics.

By the 1980s, strong research evidence had emerged supporting the use of moderate doses of conventional antipsychotics-between 300 and 1,000 mg of chlorpromazine equivalent daily. We conducted a cross-sectional study of dosages of antipsychotics prescribed for 936 veterans with schizophrenia in 14 facilities between 1991 and 1995. Only 52 percent of these patients received prescriptions for recommended dosages; dosages were below the recommended range for 20 percent and above the range for 28 percent. African Americans were more likely than others to have received high dosages. These data suggest that there was considerable delay in the adoption of evidence-based dosing of conventional antipsychotics. Efforts must be made to transfer research findings more rapidly into practice.

Adherence assessments and the use of depot antipsychotics in patients with schizophrenia.

BACKGROUND: Antipsychotic medications significantly ameliorate the symptoms of schizophrenia, but patients are often noncompliant with these medications. Research evidence supports the use of depot antipsychotics in noncompliant patients. METHOD: Between January 9, 1991, and December 19, 1995, 1307 veterans with schizophrenia or schizoaffective disorder (ICD-9) were enrolled in a study of enhanced psychosocial programming at 14 Veterans Administration Medical Centers. All had a history of high inpatient use. At enrollment, clinicians listed patient medications, rated patient compliance, and completed a Brief Psychiatric Rating Scale (BPRS) and Global Assessment of Functioning (GAF). Patients reported medication side effects. We describe depot antipsychotic use among these patients and examine the relationship between depot use, assessed compliance, and patient characteristics. RESULTS: At enrollment, 18% of patients in this cohort were receiving depot antipsychotics; however, clinicians reported that 49% had been noncompliant with medication in the past year. Depot use varied significantly with treatment site; African Americans were more likely to receive depot antipsychotics and less likely to receive atypical antipsychotics than white patients. Patients on depot and oral agents had similar levels of psychiatric symptoms, but patients on depot antipsychotics were more likely to receive high doses and complain of side effects. CONCLUSION: Clinicians prescribed depot antipsychotics relatively infrequently, despite high rates of noncompliance and high levels of inpatient use. Variation in use with treatment site and ethnic group suggests barriers to implementing research-based recommendations for depot use in noncompliant patients. Quality improvement programs should consider facilitating the appropriate use of depots.

The cost-utility of screening for depression in primary care.

BACKGROUND: Depressive disorders are common in primary care and cause substantial disability, but they often remain undiagnosed. Screening is a frequently proposed strategy for increasing detection of depression. OBJECTIVE: To examine the cost-utility of screening for depression compared with no screening. DESIGN: Nonstationary Markov model. DATA SOURCES: The published literature. TARGET POPULATION: Hypothetical cohort of 40-year-old primary care patients. TIME HORIZON: Lifetime. PERSPECTIVE: Health care payer and societal. INTERVENTIONS: Self-administered questionnaire followed by provider assessment. OUTCOME MEASURES: Costs and quality-adjusted life-years (QALYs). RESULTS OF BASE-CASE ANALYSIS: Compared with no screening, the cost to society of annual screening for depression in primary care patients is $192 444/QALY. Screening every 5 years and one-time screening cost $50 988/QALY and $32 053/QALY, respectively, compared with no screening. From the payer perspective, the cost of annual screening is $225 467. RESULTS OF SENSITIVITY ANALYSES: Cost-utility ratios are most sensitive to the prevalence of major depression, the costs of screening, rates of treatment initiation, and remission rates with treatment. In Monte Carlo sensitivity analyses, the cost-utility of annual screening is less than $50 000/QALY only 2.2% of the time. In multiway analyses, four model variables must be changed to extreme values for the cost-utility of annual screening to fall below $50 000/QALY, but a change in only one variable increases the cost-utility of one-time screening to more than $50 000/QALY. One-time screening is more robustly cost-effective if screening costs are low and effective treatments are being given. CONCLUSIONS: Annual and periodic screening for depression cost more than $50 000/QALY, but one-time screening is cost-effective. The cost-effectiveness of screening is likely to improve if treatment becomes more effective.

Targeting quality improvement activities for depression. Implications of using administrative data.

BACKGROUND: Large health care organizations may use administrative data to target primary care patients with depression for quality improvement (QI) activities. However, little is known about the patients who would be identified by these data or the types of QI activities they might need. We describe the clinical characteristics and outcomes of patients identified through administrative data in 2 family practice clinics. METHODS: Patients with depression aged 18 to 65 years were identified through review of encounter/administrative data during a 16-month period. Patients agreeing to participate (N=103) were interviewed with the Primary Care Evaluation of Mental Disorders questionnaire and completed the Depression Outcomes Modules (with an embedded Medical Outcomes Short Form-36 [SF-36]), Symptom Check List-25 (SCL-25), and Alcohol use Disorders Identification Test. Follow-up assessments were completed by 83 patients at a median of 7 months. RESULTS: A large majority of identified patients (85%) met full criteria for a Diagnostic and Statistical Manual of Mental Disorders depressive disorder; those not meeting criteria usually had high levels of symptoms on the SCL-25. Seventy-seven percent of the patients reported recurrent episodes of depressed mood, and 60% reported chronic depression. Although most improved at follow-up, they continued to have substantial functional deficits on the SF-36, and 60% still had high levels of depressive symptoms. CONCLUSIONS: QI programs that use administrative data to identify primary care patients with depression will select a cohort with relatively severe, recurrent depressive disorders. Most of these patients will receive standard treatments without QI interventions and will continue to be symptomatic. QI programs targeting this population may need to offer intensive alternatives rather than monitor standard care.

Concurrent treatment of patients with depression in the community: provider practices, attitudes, and barriers to collaboration.

BACKGROUND: In randomized controlled trials, patients with major depression who receive broad-based collaborative treatment by both primary care physicians (PCPs) and mental health providers (MHPs) have better outcomes than patients who receive usual care. However, little is known about the concurrent treatment of patients with depression in the community. This study describes the perceptions of PCPs of the frequency of concurrent treatment in community settings, the degree of collaboration between co-treating providers, and factors associated with greater interaction and collaboration. METHODS: A survey was distributed to a stratified, random sample of 276 eligible family physicians in Michigan. Primary analyses were descriptive statistics (point estimation) of PCP practice patterns. Secondary analyses explored predictors of collaboration with multivariable regression. RESULTS: A total of 162 eligible PCPs (59%) returned the survey. PCPs reported that they co-treated approximately 30% of their depressed patients with MHPs. They made contact with co-treating MHPs in approximately 50% of shared cases; however, provider contact seldom included joint treatment planning. PCPs perceived collaborative treatments to be more problematic when patients were enrolled in managed care programs. In multivariable regression, co-location of MHP and PCP practices (in the same building) was strongly associated with increased interaction and collaboration (P <.001). CONCLUSIONS: Concurrent treatment of depressed patients is common in the community, but these treatments are less interactive and collaborative than the treatment models proven effective in randomized controlled trails. If concurrent treatments are to become more collaborative-with regular contact and effective communication-co-location of practices appears important.

Psychiatric diagnosis and intervention in older and younger patients in a primary care clinic: effect of a screening and diagnostic instrument.

OBJECTIVES: To determine whether patient age is associated with psychiatric diagnosis or provider intervention in a busy primary care clinic, and, if so, whether a screening and diagnostic tool, the PRIME-MD, modifies age-related differences. DESIGN, SETTING, AND PARTICIPANTS: PRIME-MD use, psychiatric diagnosis, and provider interventions for psychiatric conditions were recorded for eligible patients attending a Veterans Affairs Medical Center primary care clinic. Data from 952 younger (<65 years) and 1135 older patients (> or =65 years) were analyzed to determine whether there were age-related differences in diagnosis/intervention and if use of the PRIME-MD modified these differences. INTERVENTION: Implementation of the PRIME-MD, a two-step instrument consisting of a self-administered patient questionnaire and a provider-administered structured diagnostic interview. MEASUREMENTS: Outcome measures were rates of (1) PRIME-MD use, (2) overall psychiatric diagnosis, (3) new psychiatric diagnosis, and (4) provider intervention for psychiatric conditions. RESULTS: There was no association between patient age and PRIME-MD use. Older patients were less likely to receive a psychiatric diagnosis in analyses that adjusted for "highly positive" screening questionnaires (OR = .45; P<.001). Older patients were also less likely to receive an intervention for a psychiatric condition in analyses that adjusted for whether a psychiatric diagnosis (OR = .62, P = .015) or a new psychiatric diagnosis (OR = .36, P<.001) was made during the study visit. The PRIME-MD increased rates of diagnosis and intervention but did not alter age-related disparities. CONCLUSIONS: Decreased rates of psychiatric diagnosis and intervention in older primary care patients are of concern. Implementing the PRIME-MD will likely increase rates of diagnosis and intervention but will need to be accompanied by additional measures to eliminate age-related disparities.

Agreement between seriously mentally ill veterans and their clinicians about medication compliance.

OBJECTIVES: Levels of agreement about medication compliance in a large cohort of seriously mentally ill veterans and their clinicians were examined to determine whether agreement increased with exposure to enhanced treatment programs emphasizing compliance and whether compliance reports were associated with hospitalization. METHODS: A total of 1,369 seriously mentally ill patients and their treating clinicians at 14 Veterans Affairs medical centers rated medication compliance at enrollment in enhanced programs or comparison programs offering standard care. Patients and clinicians reassessed compliance one and two years after enrollment. Overall agreement, agreement about compliance and noncompliance, and kappa statistics were determined for concurrent assessments. RESULTS: Overall, patients rated themselves as significantly more compliant with medication than did clinicians at enrollment. Cohen's kappa at enrollment was .095, indicating little patient-clinician agreement beyond that expected by chance. Kappa values increased significantly at one and two years for patients in the enhanced programs but continued to indicate poor-to-modest levels of agreement. Patient-clinician pairs in enhanced programs did not differ from those in comparison programs in overall agreement. Reports of good compliance by both patients and clinicians were associated with significantly decreased odds of hospital admission in the 30 days after the report was made. CONCLUSIONS: Seriously mentally ill patients and their clinicians showed little agreement about medication use beyond that expected by chance. Intensive programming appeared to have little effect on agreement. Both patients' and clinicians' compliance assessments predicted hospitalization and thus can be used in research models that attempt to predict relapse and readmission.

Screening for psychiatric illness with a combined screening and diagnostic instrument.

OBJECTIVE: To determine 1) if the PRIME-MD, a two-step screening and diagnostic instrument for psychiatric disorders, increases diagnosis and intervention when actively implemented in a busy general medicine clinic, and 2) the type of staff support required to achieve sufficient implementation to realize gains in diagnosis and treatment. DESIGN: We introduced the PRIME-MD into a large general medicine clinic with repeated rotation of four support conditions for implementation: (1) no support, (2) nonclinical staff support (NCSS), (3) nursing staff (RN) support, and (4) a written "Prompt" condition. SETTING AND PATIENTS: Patients (N = 2,263) attending a general medicine clinic at a Veterans Affairs Medical Center. MEASUREMENTS AND MAIN RESULTS: Outcome measures were (1) PRIME-MD questionnaire and interview use, (2) overall psychiatric diagnosis, (3) new psychiatric diagnosis, and (4) provider intervention for psychiatric conditions. The NCSS, RN support, and prompt conditions resulted in similar rates of questionnaire use but significantly different rates of structured interview use. The NCSS condition was associated with significant increases in new diagnosis, and the RN support and Prompt condition were associated with significant increases in new diagnosis and intervention compared with no support. CONCLUSIONS: Nursing staff support resulted in sufficient PRIME-MD implementation to achieve gains in both new diagnosis and provider intervention compared with no support. These gains occurred in a busy primary care clinic with nonselected providers and customary visit lengths. This level of support should be achievable in most clinical settings.

Catatonia in the emergency department.

The catatonic syndrome has a wide differential diagnosis that includes both psychiatric and organic disorders. We present the cases of two patients with catatonia seen acutely in the emergency department. In these cases, the striking clinical picture proved to be secondary to psychiatric disturbances, and were accompanied by dementia in the second patient. The examining physicians were confused by the presentations, and the correct diagnosis and disposition were delayed. The clinical presentation of the catatonic complex, its differential diagnosis, and the pertinent physical signs are discussed.