Prevalence of Opioid Use Disorder and Opioid Overdose Rates Among People With Mental Illness.

OBJECTIVE: The authors examined the prevalence and correlates of co-occurring opioid use disorder and opioid overdose among individuals receiving psychiatric services. METHODS: This was a cross-sectional study of adults with continuous enrollment in New York State Medicaid who received at least one psychiatric service in 2020 (N=523,885). Logistic regression models were used to examine the correlates of both opioid use disorder and overdose. RESULTS: In the study sample, the prevalence rate of opioid use disorder was 8.1%; within this group, 7.7% experienced an opioid overdose in the study year. Opioid use disorder rates were lower among younger (18-24 years; 2.0%) and older (≥65 years; 3.1%) adults and higher among men (11.1%) and among those residing in rural areas (9.9%). Compared with Whites (9.4%), opioid use disorder rates were lower for Asian Americans (2.0%, adjusted odds ratio [AOR]=0.22) and Blacks (6.8%, AOR=0.76) and higher for American Indians (13.2%, AOR=1.43) and Hispanics (9.6%, AOR=1.29). Individuals with any substance use (24.9%, AOR=5.20), posttraumatic stress (15.7%, AOR=2.34), bipolar (14.9%, AOR=2.29), or anxiety (11.3%, AOR=2.18) disorders were more likely to have co-occurring opioid use disorder; those with conduct (4.5%, AOR=0.51), adjustment (7.4%, AOR=0.88), or schizophrenia spectrum (7.4%, AOR=0.87) disorders were less likely to have opioid use disorder. Those with suicidality (23.9%, AOR=3.83) or economic instability (23.7%, AOR=3.35) had higher odds of having opioid use disorder. Overdose odds were higher among individuals with suicidality (34.0%, AOR=6.82) and economic instability (16.0%, AOR=2.57). CONCLUSIONS: These findings underscore the importance of providing opioid use disorder screening and treatment for patients receiving psychiatric services.

Engagement of individuals with serious mental illness in outpatient mental health services and telehealth use during the COVID-19 pandemic.

Questions remain regarding whether the transition and continued use of telehealth was associated with changes in treatment engagement among patients with serious mental illness (SMI). Using NYS Medicaid claims, we identified 116,497 individuals with SMI receiving outpatient mental health services from September 1, 2019-February 28, 2021 and a comparison cohort of 101,995 from September 1, 2017-February 28, 2019 to account for unmeasured and seasonal variation. We characterized engagement in three 6-month increments (T0-T1-T2) using clinically meaningful measures of high, partial, low, and none. Subgroup differences were compared, and telehealth users were compared to those with only in-person visits. Engagement, as characterized, was largely maintained during COVID. The 19.0 % with only in-person visits during COVID had different characteristics than telehealth users. Telehealth use was greater among younger people by T2 (33.1 %), women (57.7 %), non-Hispanic White people (38.9 %), and those with MDD (18.0 %), but lower among non-Hispanic Black people, in NYC, and those with schizophrenia or SUD. Most telehealth users were highly engaged (77.1 %); most using only in-person services had low engagement (47.5 %). The shift to telehealth preserved access to many outpatient services for this SMI population. Exploring reasons for not using telehealth may identify opportunities to increase care access.

Zero suicide implementation-effectiveness trial study protocol in outpatient behavioral health using the A-I-M suicide prevention model.

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: 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: 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: N/A.

Use of a Web-Based Shared Decision-Making Program: Impact on Ongoing Treatment Engagement and Antipsychotic Adherence.

OBJECTIVE: 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: 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: 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; ß=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; ß=.06, p<.01). CONCLUSIONS: 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.

Impact of a mental health based primary care program on emergency department visits and inpatient stays.

OBJECTIVE: Integrating primary care services into specialty mental health clinics has been proposed as a method for improving health care utilization for medical conditions by adults with serious mental illness. This paper examines the impact of a mental health based primary care program on emergency department (ED) visits and hospitalizations. METHOD: The program was implemented in seven New York City outpatient mental health clinics in two waves. Medicaid claims were used to identify patients treated in intervention clinics and a control group of patients treated in otherwise similar clinics in New York City. Impacts of the program were estimated using propensity score adjusted difference-in-differences models on a longitudinally followed cohort. RESULTS: Hospital stays for medical conditions increased significantly in intervention clinics relative to control clinics in both waves (ORs = 1.21 (Wave 1) and 1.33 (Wave 2)). ED visits for behavioral health conditions decreased significantly relative to controls in Wave 1 (OR = 0.89), but not in Wave 2. No other significant differences in utilization trends between the intervention and control clinics were found. CONCLUSION: Introducing primary care services into mental health clinics may increase utilization of inpatient services, perhaps due to newly identified unmet medical need in this population.

Integrating physical health: What were the costs to behavioral health care clinics?

OBJECTIVE: To inform providers and policy-makers about the potential costs of providing physical health care in mental health clinics. METHODS: Cost data were collected through interviews with 22 behavioral health clinics participating in New York State Office of Mental Health's health monitoring and health physicals programs. The interview data was combined with financial reporting data provided to the state to identify per interaction costs for two levels of physical health services: health monitoring and health monitoring plus health physicals. RESULTS: This study gives detailed information on the costs of clinics' health integration programs, including per interaction costs related to direct service, charting and administration, and total care coordination. Average direct costs per client interaction were 3 times higher for health physicals than for health monitoring. CONCLUSIONS: Costs of integrating physical care services are not trivial to mental health clinics, and may pose a barrier to widespread adoption. Provision of limited health monitoring services is less expensive for clinics, but generates proportionally large non-clinical costs than health physicals. The relative health impact of this more limited approach is an important area for future study. Also, shifting reimbursement to include health care coordination time may improve program sustainability.

Impact of a Mental Health Based Primary Care Program on Quality of Physical Health Care.

We examine the impact of mental health based primary care on physical health treatment among community mental health center patients in New York State using propensity score adjusted difference in difference models. Outcomes are quality indicators related to outpatient medical visits, diabetes HbA1c monitoring, and metabolic monitoring of antipsychotic treatment. Results suggest the program improved metabolic monitoring for patients on antipsychotics in one of two waves, but did not impact other quality indicators. Ceiling effects may have limited program impacts. More structured clinical programs to may be required to achieve improvements in quality of physical health care for this population.

Enrollment of Specialty Mental Health Clinics in a State Medicaid Program to Promote General Medical Services.

OBJECTIVE: To promote integrated general medical care for individuals with serious mental illness, the New York State Office of Mental Health (OMH) established regulations allowing specialty mental health clinics to provide Medicaid-reimbursable health monitoring (HM) and health physicals (HP). This study examined clinics' enrollment in this program to understand its potential to reach individuals with serious mental illness. METHODS: Information on enrollment and characteristics of clinics (N=500) was obtained from OMH administrative databases. Clinic enrollment in the HM/HP program was examined for the program's first five years (2010-2015). Logistic regression models accounting for the clustering of multiple clinics within agencies were used to examine characteristics associated with enrollment. RESULTS: A total of 291 of 500 (58%) licensed clinics in New York State in 2015 enrolled in the HM/HP program, potentially reaching 62% of all Medicaid enrollees with serious mental illness seen in specialty mental health clinics in the state. State-operated clinics were required to participate, and had 91% enrollment. Over half of hospital-affiliated and freestanding mental health clinics elected to enroll (53% and 54%, respectively). In adjusted models, enrollment was higher among freestanding clinics compared with hospital-affiliated clinics, higher in larger than smaller clinics, and higher in county-operated than in private nonprofit clinics. CONCLUSIONS: The high level of enrollment in the HM/HP program indicates strong interest among mental health clinics in providing general medical care services. However, supplemental policies may be needed to extend the program to areas of the mental health system where barriers to general medical care services are highest.

Multifamily Group Psychoeducation in New York State: Implementation and Fidelity Outcomes.

OBJECTIVE: The study examined implementation outcomes from a large state initiative to support dissemination of multifamily group (MFG) psychoeducation in outpatient mental health settings. METHODS: Thirty-one sites participated in the project. Baseline training in the MFG model was followed by monthly expert consultation delivered in either a group (16 sites) or individual format (15 sites). Research staff assessed fidelity to the MFG model by telephone at baseline and 12, 18, and 24 months and documented time to completion of three key milestones: holding a family joining session, a family educational workshop, and an MFG meeting. RESULTS: Intent-to-train analyses found that 12 sites (39%) achieved high fidelity to the MFG model, and 20 (65%) achieved moderate or high fidelity. Mean scores on the Family Psychoeducation Fidelity Assessment Scale increased over time. Twenty-five sites (81%) conducted at least one joining session, and 20 (65%) conducted at least one MFG. Mean±SD time from baseline to the first group was 11.75±4.78 months. Programs that held the first joining session within four to 12 months after training were significantly more likely than programs that did not to conduct a group (p<.05). No significant differences were found by consultation format. CONCLUSIONS: Implementation of moderate- to high-fidelity MFG programs in routine outpatient mental health settings is feasible. Sites that moved very quickly or very slowly in early implementation stages were less likely to be successful in conducting an MFG. More research on the efficiency and effectiveness of consultation formats is needed to guide future implementation efforts.

Clinicians' perceptions of challenges and strategies of transition from assertive community treatment to less intensive services.

The study aimed to identify clinical strategies and challenges around transition from Assertive Community Treatment (ACT) to less intensive services. Six focus groups were conducted with ACT team leaders (n = 49). Themes were grouped under four intervention-focused domains: (1) client/clinical, (2) family and natural supports, (3) ACT staff and team, and (4) public mental health system. Barriers to transition included beliefs that clients and families would not want to terminate services (due to loss of relationships, fear of failure, preference for ACT model), clinical concerns that transition would not be successful (due to limited client skills, relapse without ACT support), systems challenges (clinic waiting lists, transportation barriers, eligibility restrictions, stigma against ACT clients), and staff ambivalence (loss of relationship with client, impact on caseload). Strategies to support transition included building skills for transition, engaging supports, celebrating success, enhanced coordination with new providers, and integrating and structuring transition in ACT routines.

Impact of four training conditions on physician use of a web-based clinical decision support system.

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.

Use of intervention strategies by assertive community treatment teams to promote patients' engagement.

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.

Forensic and nonforensic clients in assertive community treatment: a longitudinal study.

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.

Long-term impact of web-based tools, leadership feedback, and policies on inpatient antipsychotic polypharmacy.

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.

Identifying clinically questionable psychotropic prescribing practices for medicaid recipients in new york state.

OBJECTIVE: This study sought to identify and characterize rates of clinically questionable prescribing in New York State. METHODS: As part of a quality improvement initiative, 34 national psychopharmacology experts identified a set of questionable prescribing practices recognizable from pharmacy claims data. Indicators of such practices were applied to Medicaid claims data for 217,216 beneficiaries in New York State who had an active psychotropic prescription on April 1, 2008. RESULTS: A total of 156,103 (72%) of these beneficiaries had one or more continuing (>90 days) prescriptions for a psychotropic. About 10% of adults were prescribed four or more psychotropics concurrently, and 13% of children and 2% of older adults were prescribed three or more concurrently. Prescribing an antipsychotic with a moderate-to-high risk of causing metabolic abnormalities approached 50% (46%) among individuals who had existing cardiometabolic conditions. Among beneficiaries prescribed second-generation antipsychotics with a moderate-to-high risk of causing metabolic abnormalities, over half (60%) had not received a metabolic screening test in the past year. Among women of reproductive age prescribed mood stabilizers, over one-quarter (30%) were prescribed a valproic acid-based formulation despite its potential for teratogenicity. Only 2% of youths under age 18 were prescribed benzodiazepines; however, about half (48%) had trials over 90 days' duration. CONCLUSIONS: Examination of pharmacy claims from Medicaid beneficiaries in New York State indicated that prescribing practices deemed clinically questionable by pharmacology experts are common. Aggregated pharmacy claims data can identify such practices, and reviews of these data can be a core component of efforts to improve prescribing practices.

The State Health Authority Yardstick (SHAY).

State mental health authorities have a leadership role in implementing evidence-based practices (EBPs), but few instruments are available to assess the impact of this role. We describe the development of the State Mental Health Authority Yardstick (SHAY), a behaviorally anchored instrument designed to assess state-level facilitating conditions associated with successful implementation of EBPs in community mental health centers. The SHAY assesses the SMHA role in seven domains: Planning, Financing, Training, Leadership, Policies and Regulations, Quality Improvement, and Stakeholders. Preliminary evidence from the National Evidence-Based Practices Project partially supports the construct and criterion-oriented validity of this instrument for rating state-level activities supporting or blocking the implementation of evidence-based practices.

Assertive community treatment: facilitators and barriers to implementation in routine mental health settings.

OBJECTIVE: This study identified barriers and facilitators to the high-fidelity implementation of assertive community treatment. METHODS: As part of a multistate implementation project for evidence-based practices, training and consultation were provided to 13 newly implemented assertive community treatment teams in two states. Model fidelity was assessed at baseline and at six, 12, 18, and 24 months. Key informant interviews, surveys, and monthly on-site visits were used to monitor implementation processes related to barriers and facilitators. RESULTS: Licensing processes of the state mental health authority provided critical structural supports for implementation. These supports included a dedicated Medicaid billing structure, start-up funds, ongoing fidelity monitoring, training in the model, and technical assistance. Higher-fidelity sites had effective administrative and program leadership, low staff turnover, sound personnel practices, and skilled staff, and they allocated sufficient resources in terms of staffing, office space, and cars. Lower-fidelity sites were associated with insufficient resources, prioritization of fiscal concerns in implementation, lack of change culture, poor morale, conflict among staff, and high staff turnover. In cross-state comparisons, the specific nature of fiscal policies, licensing processes, and technical assistance appeared to influence implementation. CONCLUSIONS: State mental health authorities can play a critical role in assertive community treatment implementation but should carefully design billing mechanisms, promote technical assistance centers, link program requirements to fidelity models, and limit bureaucratic requirements. Successful implementation at the organizational level requires committed leadership, allocation of sufficient resources, and careful hiring procedures.

Implications of CATIE for mental health services researchers.

The authors discuss the implications of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) for mental health services researchers, in particular the need to monitor and change prescriber behavior to encourage informed medication selection. Given the complexity and variability of response to antipsychotic medications in CATIE, use of restricted formularies is not the answer. Rather, services researchers should collaborate with service systems to develop interventions to identify questionable prescriber practices and develop interventions to change them. The CATIE results also suggest that some quality measures for antipsychotic treatment, such as the proportion of a population taking second-generation antipsychotics, need to be revisited by researchers. Also, because the CATIE findings highlighted the prevalence of cardiac and metabolic disorders among treatment populations and the potential impact of antipsychotics on these conditions, services researchers should use secondary data to monitor whether prescribers are providing appropriate screening and treatment. Given the health risks of some antipsychotics, services researchers should develop ways to identify individuals at risk, encourage behavior change among prescribers, and support informed and shared decision making about medications. Mental health services researchers can build relationships with multiple stakeholders, including service system administrators, service providers, and consumers, to help translate results from trials such as CATIE into policy and practice.

Fidelity outcomes in the National Implementing Evidence-Based Practices Project.

OBJECTIVE: This article presents fidelity outcomes for five evidence-based practices that were implemented in routine public mental health settings in the National Implementing Evidence-Based Practices Project. METHODS: Over a two-year period 53 community mental health centers across eight states implemented one of five evidence-based practices: supported employment, assertive community treatment, integrated dual disorders treatment, family psychoeducation, and illness management and recovery. An intervention model of practice dissemination guided the implementation. Each site used both human resources (consultant-trainers) and material resource (toolkits) to aid practice implementation and to facilitate organizational changes. External assessors rated fidelity to the evidence-based practice model every six months from baseline to two years. RESULTS: More than half of the sites (29 of 53, or 55%) showed high-fidelity implementation at the end of two years. Significant differences in fidelity emerged by evidence-based practice. Supported employment and assertive community treatment had higher fidelity scores at baseline and across time. Illness management and recovery and integrated dual disorders treatment had lower scores on average throughout. In general, evidence-based practices showed an increase in fidelity from baseline to 12 months, with scores leveling off between 12 and 24 months. CONCLUSIONS: Most mental health centers implemented these evidence-based practices with moderate to high fidelity. The critical time period for implementation was approximately 12 months, after which few gains were made, although sites sustained their attained levels of evidence-based practice fidelity for another year.