Receipt of Evidence-Based Pharmacotherapy and Psychotherapy Among Children and Adolescents With New Diagnoses of Depression.

OBJECTIVE: Little is known about utilization rates of the various depression treatment options available in the private sector for children and adolescents. For privately insured youths, this study examined the utilization frequency of six treatment options for depression with varying degrees of empirical support. METHODS: A nationally representative administrative claims database of privately insured individuals (Truven Analytics database, 2008-2010) was used to construct a cohort of 61,599 youths (ages six to 17 years) with depression. Multivariable logistic regression controlling for insurance type, region, and illness severity and complexity assessed, by physician specialty, the likelihood of receiving six different depression treatments (medication combined with psychotherapy, first-line medication, second-line medication, non-evidence-based medication, second-generation antipsychotics, and psychotherapy alone). RESULTS: Only 58.4% of depressed youths received at least one type of depression treatment; 33.6% received psychotherapy alone, 24.8% received medication alone, and 2.7% received combination treatment. Of depressed youths receiving only medication, 24.8% received medications unsupported by empirical evidence (non-evidence-based or second-generation antipsychotics) and 50.6% received medications with equivocal support. Mental health specialists were approximately nine times (odds ratio=8.61) more likely than primary care providers to prescribe combination treatment. Other predictors of receiving combination treatment included having diagnosed major depressive disorder, being a young adolescent (ages 12-14), and residing in the Northeast. CONCLUSIONS: Large proportions of depressed youths are not receiving any treatment or are receiving treatments unsupported or equivocally supported by empirical evidence. Additional research is warranted to assess factors associated with nonrecommended use of pharmacotherapies for youths with depression.

Understanding Care Integration from the Ground Up: Five Organizing Constructs that Shape Integrated Practices.

PURPOSE: To provide empirical evidence on key organizing constructs shaping practical, real-world integration of behavior health and primary care to comprehensively address patients' medical, emotional, and behavioral health needs. METHODS: In a comparative case study using an immersion-crystallization approach, a multidisciplinary team analyzed data from observations of practice operations, interviews, and surveys of practice members, and implementation diaries. Practices were drawn from 2 studies of practices attempting to integrate behavioral health and primary care: Advancing Care Together, a demonstration project of 11 practices located in Colorado, and the Integration Workforce Study, a study of 8 practices across the United States. RESULTS: We identified 5 key organizing constructs influencing integration of primary care and behavioral health: 1) Integration REACH (the extent to which the integration program was delivered to the identified target population), 2) establishment of continuum of care pathways addressing the location of care across the range of patient's severity of illness, 3) approach to patient transitions: referrals or warm handoffs, 4) location of the integration workforce, and 5) participants' mental model for integration. These constructs intertwine within an organization's historic and social context to produce locally adapted approaches to integrating care. Contextual factors, particularly practice type, influenced whether specialty mental health and substance use services were colocated within an organization. CONCLUSION: Interaction among 5 organizing constructs and practice context produces diverse expressions of integrated care. These constructs provide a framework for understanding how primary care and behavioral health services can be integrated in routine practice.

Erasing epilepsy stigma: eight key messages.

Historically, epilepsy has been ignored by the public health community, despite the fact that there are more than 2 million people with epilepsy in the United States. Although epilepsy affects 1 in 26 people during their lifetime, the general public lacks basic knowledge and holds misperceptions about epilepsy that contribute to its associated stigma. Consequently, people with epilepsy continue to fare poorly, with lower physical, mental, and social well-being. Recently, the 2012 Institute of Medicine (IOM) report Epilepsy Across the Spectrum: Promoting Health and Understanding inspired a new sense of enthusiasm in the epilepsy community that can serve as a catalyst to change public perceptions about epilepsy. To erase stigma, the IOM committee made recommendations in two areas: (a) informing the media and (b) coordinating public awareness. The committee also identified eight key messages about epilepsy that the public should know. Health promotion and education professionals can play a critical role in disseminating these messages to the general public in their local communities and supporting interventions and policies to change the face of epilepsy.

Epilepsy across the spectrum: promoting health and understanding. A summary of the Institute of Medicine report.

Approximately 1 in 26 people will develop epilepsy at some point in their lives. Although epilepsy is one of the nation's most common neurological disorders, public understanding is limited. A complex spectrum of disorders, epilepsy affects an estimated 2.2 million people in the United States. Living with epilepsy is about more than just seizures; it is often defined in practical terms, such as challenges, uncertainties, and limitations in school, social situations, employment, driving, and independent living. People with epilepsy are also faced with health and community services that are fragmented, uncoordinated, and difficult to obtain. The Institute of Medicine's report (2012) [1], Epilepsy across the spectrum: promoting health and understanding, examines the public health dimensions of epilepsy with a focus on (a) public health surveillance and data collection and integration; (b) population and public health research; (c) health policy, health care, and human services; and (d) education for providers, people with epilepsy and their families, and the public. The report's recommendations range from the expansion of collaborative epilepsy surveillance efforts to the independent accreditation of epilepsy centers, to the coordination of public awareness efforts, and to the engagement of people with epilepsy and their families in education, dissemination, and advocacy activities. Given the current gaps in epilepsy knowledge, care, and education, there is an urgent need to take action-across multiple dimensions-to improve the lives of people with epilepsy and their families. The realistic, feasible, and action-oriented recommendations in this report can help enable short- and long-term improvements for people with epilepsy.

Can psychiatry cross the quality chasm? Improving the quality of health care for mental and substance use conditions.

In 2001, a seminal Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century, put forth a comprehensive strategy for improving the quality of U.S. health care. This strategy attained considerable traction within the overall U.S. health care system and subsequent attention in the mental health community as well. A new Institute of Medicine report, Improving the Quality of Health Care for Mental and Substance Use Conditions, examines the quality chasm strategy in light of the distinctive features of mental and substance use health care, including concerns about patient decision-making abilities and coercion into care, a less developed quality measurement and improvement infrastructure, lagging use of information technology and participation in the development of the National Health Information Infrastructure, greater separations in care delivery accompanied by more restrictions on sharing clinical information, a larger number of provider types licensed to diagnose and treat, more solo practice, and a differently structured marketplace. This article summarizes the Institute of Medicine's analysis of these issues and recommendations for improving mental and substance use health care and discusses the implications for psychiatric practice and related advocacy efforts of psychiatrists, psychiatric organizations, and other leaders in mental and substance use health care.

Introductory remarks.

The American Medical Women's Association has chosen as one of its strategic goals for the next year, and probably for a lot longer, preventing young women from smoking. Smoking is of great concern to all as the death rate from lung cancer among women skyrockets to bypass even breast cancer.In alcohol and drug abuse, women who abuse alcohol and other drugs face a greater social stigma than the male abuser of these substances. The higher incidence of depression among women adds to the likelihood of self-medication with alcohol and other drugs.Reproductive and sexual dysfunctions are frequent in women who have alcohol, drug abuse, and mental health problems, and they are more vulnerable to rape and other forms of sexual exploitation. Sexual abuse and assault may also have played an integral part in their problems.