Planning Patient-Centered Health Homes for Medicaid Psychiatric Patients at Greatest Risk for Intensive Service Use.

This study identified characteristics of Medicaid psychiatric patients at risk of hospitalizations and emergency department (ED) visits to identify their service delivery needs. A total of 4,866 psychiatrists were randomly selected from the AMA Physician Masterfile; 62 % responded, 32 % met eligibility criteria and reported on 1,625 Medicaid patients. Patients with schizophrenia, substance use disorders, suicidal and violent ideation/behavior, and psychotic, substance use, or manic symptoms were at high risk for intensive service use, along with homeless and incarcerated patients. Patients with schizophrenia or psychotic symptoms represented 37 % of patients, but used 73 % of all hospital days and 61 % of all ED visits. Patients with substance use problems comprised 21 % of patients, but used nearly half of all ED visits. Our findings highlight opportunities to enhance treatments and interventions, and inform the development of patient-centered health homes to address the needs of patients at high risk for intensive service use.

Mental health treatment access and quality in the army: survey of mental health clinicians.

OBJECTIVE: The goal of this study was to identify factors affecting timely, quality mental health and substance abuse treatment for service members and characterize patients at the greatest risk of having problems accessing treatment. METHODS: An electronic survey was emailed to 2,310 Army mental healthcare providers. After providers with undeliverable emails and who self-reported not being behavioral health providers were excluded, 543 (26%) of the remaining 2,104 providers responded. This represented approximately a quarter of all Army behavioral health providers at the time of the survey. Of these 543 providers, 399 (73%) reported treating at least one service member during their last typical work week and provided clinically detailed data on one systematically selected service member. RESULTS: The majority of the clinicians reported being able to spend sufficient time with patients (91.8%) and schedule encounters to meet patients' needs (82.4%). The clinicians also identified services where treatment access was more limited and patient subgroups with an unmet need for additional clinical care or services. Specifically, a significant proportion of clinicians reported that they were "never, rarely, or sometimes" able to provide or arrange for mental health treatment for the sampled service member's children (52.0%), provide or arrange for marriage and family therapy (40.1%), coordinate care effectively with primary care (36.7%), provide or arrange for care/case management (28.3%), or provide or arrange for substance abuse treatment (24.9%). Patients with more severe symptoms and diagnostic and clinical complexity had higher rates of problems with treatment access. CONCLUSIONS: Our findings highlight opportunities to improve access to timely, quality treatment for service members and their families.

Use of evidence-based treatment for posttraumatic stress disorder in Army behavioral healthcare.

OBJECTIVE: To identify the extent to which evidence-based psychotherapy (EBP) and psychopharmacologic treatments for posttraumatic stress disorder (PTSD) are provided to U.S. service members in routine practice, and the degree to which they are consistent with evidence-based treatment guidelines. METHOD: We surveyed the majority of Army behavioral health providers (n = 2,310); surveys were obtained from 543 (26%). These clinicians reported clinical data on a total sample of 399 service member patients. Of these patients, 110 (28%) had a reported PTSD diagnosis. Data were weighted to account for sampling design and nonresponses. RESULTS: Army providers reported 86% of patients with PTSD received evidence-based psychotherapy (EBP) for PTSD. As formal training hours in EBPs increased, reported use of EBPs significantly increased. Although EBPs for PTSD were reported to be widely used, clinicians who deliver EBP frequently reported not adhering to all core procedures recommended in treatment manuals; less than half reported using all the manualized core EBP techniques. CONCLUSIONS: Further research is necessary to understand why clinicians modify EBP treatments, and what impact this has on treatment outcomes. More data regarding the implications for treatment effectiveness and the role of clinical context, patient preferences, and clinical decision-making in adapting EBPs could help inform training efforts and the ways that these treatments may be better adapted for the military.

Treatment of anxiety disorders by psychiatrists from the American Psychiatric Practice Research Network.

OBJECTIVE: Anxiety disorders are highly prevalent in the United States, and if untreated, result in a number of negative outcomes. This study aimed to investigate psychiatrists' current treatment practices for patients with anxiety disorders in the United States. METHODS: Psychiatrist-reported data from the 1997 and 1999 American Psychiatric Institute for Research and Education Practice Research Network (PRN) Study of Psychiatric Patients and Treatments (SPPT) were examined, focusing on patients diagnosed with anxiety disorders. Information related to diagnostic and clinical features and treatments provided were obtained. RESULTS: Anxiety disorders remain underdiagnosed and undertreated, since only 11.4% of the sample received a principal diagnosis of an anxiety disorder in a real world setting. Posttraumatic stress disorder was associated with particularly high comorbidity and disability, and social anxiety disorder was relatively rarely diagnosed and treated. Although combined pharmacotherapy and psychotherapy was commonly used to treat anxiety disorders, anxiolytics were more commonly prescribed than selective serotonin reuptake inhibitors (SSRIs). CONCLUSIONS: These data provide a picture of diagnosis and practice patterns across a range of psychiatric settings and suggest that anxiety disorders, despite being among the most prevalent of psychiatric disorders remain underdiagnosed and undertreated particularly in respect of the use of psychotherapeutic interventions.

Sustaining practice change one year after completion of the national depression management leadership initiative.

OBJECTIVE: This report describes the sustainability of quality improvement interventions for depression care in psychiatric practice one year after the completion of the National Depression Management Leadership Initiative (NDMLI) in 2006. The main intervention involved continued use of the nine-item depression scale of the Patient Health Questionnaire (PHQ-9) for routine care of patients with depressive disorders. METHODS: One year after project completion, lead psychiatrists from the 17 participating practices were surveyed about the sustainability of key practice interventions and dissemination of the interventions. RESULTS: All 14 practices that provided baseline and follow-up data reported sustained use of the PHQ-9 for screening, diagnosis, or monitoring purposes. Moreover, practices reported dissemination of this approach to clinicians within and outside their practices. CONCLUSIONS: Psychiatrists reported sustainability and dissemination of PHQ-9 use one year after the conclusion of the NDMLI. The model has potential as a depression care improvement strategy and is worthy of additional study.

Treatment of anxiety disorders by psychiatrists from the American Psychiatric Practice Research Network

Objective: Anxiety disorders are highly prevalent in the United States, and if untreated, result in a number of negative outcomes. This study aimed to investigate psychiatrists' current treatment practices for patients with anxiety disorders in the United States. Methods: Psychiatrist-reported data from the 1997 and 1999 American Psychiatric Institute for Research and Education Practice Research Network (PRN) Study of Psychiatric Patients and Treatments (SPPT) were examined, focusing on patients diagnosed with anxiety disorders. Information related to diagnostic and clinical features and treatments provided were obtained. Results: Anxiety disorders remain underdiagnosed and undertreated, since only 11.4% of the sample received a principal diagnosis of an anxiety disorder in a real world setting. Posttraumatic stress disorder was associated with particularly high comorbidity and disability, and social anxiety disorder was relatively rarely diagnosed and treated. Although combined pharmacotherapy and psychotherapy was commonly used to treat anxiety disorders, anxiolytics were more commonly prescribed than selective serotonin reuptake inhibitors (SSRIs). Conclusions: These data provide a picture of diagnosis and practice patterns across a range of psychiatric settings and suggest that anxiety disorders, despite being among the most prevalent of psychiatric disorders remain underdiagnosed and undertreated particularly in respect of the use of psychotherapeutic interventions. .

Clinically unintended medication switches and inability to prescribe preferred medications under Medicare Part D.

Medicare Part D has expanded medication access; however, there is some evidence that dually eligible psychiatric patients have experienced medication access problems. The aim of this study was to characterize medication switches and access problems for dually eligible psychiatric patients and associations with adverse events, including emergency department visits, hospitalizations, homelessness, and incarceration. Reports on 986 systematically sampled, dually eligible patients were obtained from a random sample of practicing psychiatrists. A total of 27.6% of previously stable patients had to switch medications because clinically indicated and preferred refills were not covered or approved. An additional 14.0% were unable to have clinically indicated/preferred medications prescribed because of drug coverage/approval. Adjusting for case-mix, switched patients (p = 0.0009) and patients with problems obtaining clinically indicated medications (p = 0.0004) had significantly higher adverse event rates. Patients at greatest risk were prescribed a medication in a different class or could not be prescribed clinically-indicated atypical antipsychotics, other antidepressants, mood stabilizers, or stimulants. Patients with problems obtaining clinically preferred/indicated antipsychotics had a 17.6 times increased odds (p = 0.0039) of adverse events. These findings call for caution in medication switches for stable patients and support prescription drug policies promoting access to clinically indicated medications and continuity for clinically stable patients.

Sleep problems, psychiatric hospitalization, and emergency department use among psychiatric patients with Medicaid.

OBJECTIVE: This study examined the prevalence of sleep problems and their association with the use of inpatient and emergency department services by Medicaid recipients with serious mental illness. METHODS: The sample consisted of 1,560 psychiatric patients with Medicaid coverage who were identified in a ten-state random survey of psychiatrists. Sleep problems were assessed by clinician ratings. RESULTS: Over 75% of the patients experienced a sleep problem, and approximately 50% of these patients had problems that were moderate to severe. Greater sleep problem severity was associated with an increased risk of psychiatric hospitalization and emergency department visits for mental health reasons. CONCLUSIONS: Sleep problems were highly prevalent among Medicaid patients with serious mental illness and were associated with greater inpatient and emergency mental health service use. More careful monitoring and management of sleep problems in this patient population could address a common clinical need and might help to reduce costly service use.

Depression outcomes in psychiatric clinical practice: using a self-rated measure of depression severity.

OBJECTIVES: This study determined rates of response and remission at 12 and 24 weeks among patients being treated by psychiatrists for depression on the basis of Patient Health Questionnaire-9 (PHQ-9) scores and identified factors associated with response and remission. METHODS: Adult patients at 17 psychiatric practices participating in the National Depression Management Leadership Initiative completed the PHQ-9 at every office visit for one year irrespective of severity or chronicity of symptoms or adherence to treatment. Treating psychiatrists recorded the date when formal self-management goals were documented. Patients with a diagnosis of depression and a PHQ-9 score ≥10 were included in the response and remission analysis. Results are based on "last observation carried forward" analysis. RESULTS: Of the 1,763 patients with a depressive disorder, 960 had PHQ-9 scores ≥10 (mean±SD of 16.4±4.6) on their first study visit, indicating moderate to severe depression. At 12 weeks, 41% of the 792 who returned for follow-up had responded to treatment, and by 24 weeks 45% had responded. Response was defined as a PHQ-9 score <10. Symptoms were in remission for 13% and 18% of patients at 12 and 24 weeks, respectively. Severity of initial PHQ-9 score, weeks to first follow-up, and documented self-management were the three factors that predicted remission. CONCLUSIONS: Administering the PHQ-9 at each visit allowed psychiatrists to determine rates of response and remission among patients, but as anticipated, the rates were lower than those reported in trials of efficacy and effectiveness of psychiatric treatment of depression.

Suicidality is associated with medication access problems in publicly insured psychiatric patients.

BACKGROUND: Beginning January 1, 2006, the Medicare Part D prescription drug benefit shifted drug coverage from Medicaid to the new Medicare Part D program for patients who were eligible for both Medicare and Medicaid benefits ("dual-eligibles"). These patients were randomly assigned to a private Part D plan and came under specific formulary and utilization management procedures of the plan in which they were enrolled. OBJECTIVE: To examine the relationship between physician-reported medication switches, discontinuations, and other access problems and suicidal ideation or behavior among "dual-eligible" psychiatric patients. METHOD: Data were collected in 3 cross-sectional cycles in 2006 (January-April, May-August, and September-December) as part of the National Study of Medicaid and Medicare Psychopharmacologic Treatment Access and Continuity using through-the-mail, practice-based survey research methods. Data from the third cycle, representing all events since January 1, 2006, were used for these analyses. A national sample of psychiatrists randomly selected from the AMA Masterfile provided clinically detailed data on 1 systematically selected, dual-eligible psychiatric patient (N = 908). Propensity score analyses adjusted for patient sociodemographics, treatment setting, diagnoses, and psychiatric symptom severity. RESULTS: Patients who experienced medication switches, discontinuations, and other access problems had 3 times the rate of suicidal ideation or behavior compared with patients with no access problems (22.0% vs 7.4%, P < .0001). Mean odds ratios and excess probabilities were highest for patients who were clinically stable but were required to switch medications (31.8%; mean OR = 4.87, mean P = 8.92(-5), excess probability = 0.21). Patients who experienced discontinuations (26.4%; mean OR = 2.13, mean P = 2.12(-2), excess probability = 0.12), other access problems (18.7%; mean OR = 3.01, mean P = 1.03(-5), excess probability = 0.15), and multiple access problems (22.3%; mean OR = 2.88, mean P = 4.10(-5), excess probability = 0.14) also had significantly increased suicidal ideation or behavior. CONCLUSION: Increased occurrences of suicidal ideation or behavior appear to be associated with disruptions in patient medication access and continuity. Clinicians need to be aware of the possibility of increased suicidality when, for administrative reasons, a clinically stable patient's medication regimen is altered. Dual-eligible psychiatric patients represent a highly vulnerable group with a substantial burden of illness; these findings underscore the need to provide special protections for this population.

Medicaid medication access problems and increased psychiatric hospital and emergency care.

OBJECTIVES: To quantify the extent to which Medicaid programs may incur increased psychiatric emergency department and hospital use associated with clinically unintended medication discontinuations, gaps, switches and other access problems attributed to prescription drug coverage and management. METHOD: This study uses clinically detailed, physician-reported data. A total of 4866 psychiatrists in 10 states were randomly selected from the AMA Masterfile; 62% responded and 32% treated Medicaid patients and reported on 1625 systematically selected Medicaid patients. Propensity score multivariate models assessed predicted probabilities and mean number of emergency department visits and hospital days. RESULTS: Many patients (46.0%, S.E.=1.3%) had medication access problems reported during the past year, including discontinuing or switching medications or inability to obtain clinically indicated prescriptions because of drug coverage or management. The expected number of emergency department visits was estimated to be 73.8% higher among patients with medication access problems reported compared to matched patients without access problems reported. Among acute stay inpatients, the expected number of hospital days was 71.7% higher for patients with medication access problems reported. CONCLUSIONS: Medication access problems may have significant implications for Medicaid programs. The potential indirect costs of these policies in psychiatric and social services utilization should be considered in addition to direct pharmacy costs.

First-year Medicare Part D prescription drug benefits: medication access and continuity among dual eligible psychiatric patients.

OBJECTIVE: This study provides national data on medication access and continuity problems experienced during the first year of the Medicare Part D prescription drug program, which was implemented on January 1, 2006, among a national sample of Medicare and Medicaid "dual eligible" psychiatric patients. METHOD: Practice-based research methods were used to collect clinician-reported data across the full range of public and private psychiatric treatment settings. A random sample of psychiatrists was selected from the American Medical Association Physician Masterfile. Among these physicians, 1,490 provided clinically detailed data on a systematically selected sample of 2,941 dual eligible psychiatric patients. RESULTS: Overall, 43.3% of patients were reported to be unable to obtain clinically indicated medication refills or new prescriptions in 2006 because they were not covered or approved; 28.9% discontinued or temporarily stopped their medication(s) as a result of prescription drug coverage or management issues; and 27.7% were reported to be previously stable on their medications but were required to switch medications. Adjusting for case mix to control for sociodemographic and clinical confounders, the predicted probability of an adverse event among patients with medication access problems was 0.64 compared to 0.36 for those without access problems (P < .0001). All prescription drug utilization management features studied were associated with increased medication access problems (P < .0001). Adjusting for patient case mix, patients with "step therapy" (P < .0001), limits on medication number/dosing (P < .0001), or prior authorization (P < .0001) had 2.4 to 3.4 times the increased likelihood of an adverse event. CONCLUSIONS: More effective Part D policies and management practices are needed to promote clinically safer and appropriate pharmacotherapy for psychiatric patients to enhance treatment outcomes.

Part D and dually eligible patients with mental illness: medication access problems and use of intensive services.

OBJECTIVE: This study examined the occurrence of medication access problems and use of intensive mental health services after the transition in January 2006 from Medicaid drug coverage to Medicare Part D for persons dually eligible for Medicaid and Medicare benefits. METHODS: Psychiatrists randomly selected from the American Medical Association's Physicians Masterfile reported on experiences of one systematically selected dually eligible patient (N=908) in the nine to 12 months after Part D implementation. Propensity score matching was used to compare use of psychiatric emergency department care and inpatient care between individuals who experienced a problem accessing a psychiatric medication after Part D and those who did not. RESULTS: Approximately 44% of dually eligible patients were reported to have experienced a problem accessing medications. The likelihood of visiting an emergency department was significantly higher for those who experienced an access problem than for those who did not (mean odds ratio=1.75, mean p=.003). There was no difference in number of emergency department visits or hospitalizations for those who had at least one. CONCLUSIONS: Many dually eligible patients had difficulty accessing psychiatric medications after implementation of Part D. These patients were significantly more likely to visit psychiatric emergency departments than patients who did not experience difficulties. These findings raise concerns about possible negative effects on quality of care. Additional study is needed to understand the full effects of Part D on outcomes and functioning as well as treatment costs for this population.

Medicaid prescription drug policies and medication access and continuity: findings from ten states.

OBJECTIVES: The aims of this study were to compare medication access problems among psychiatric patients in ten state Medicaid programs, assess adverse events associated with medication access problems, and determine whether prescription drug utilization management is associated with access problems and adverse events. METHODS: Psychiatrists from the American Medical Association's Masterfile were randomly selected (N=4,866). Sixty-two percent responded; 32% treated Medicaid patients and were randomly assigned a start day and time to report on two Medicaid patients (N=1,625 patients). RESULTS: A medication access problem in the past year was reported for a mean+/-SE of 48.3%+/-2.0% of the patients, with a 37.6% absolute difference between states with the lowest and highest rates (p<.001). The most common access problems were not being able to access clinically indicated medication refills or new prescriptions because Medicaid would not cover or approve them (34.0%+/-1.9%), prescribing a medication not clinically preferred because clinically indicated or preferred medications were not covered or approved (29.4%+/-1.8%), and discontinuing medications as a result of prescription drug coverage or management issues (25.8%+/-1.6%). With patient case mix adjusted to control for sociodemographic and clinical confounders, patients with medication access problems had 3.6 times greater likelihood of adverse events (p<.001), including emergency visits, hospitalizations, homelessness, suicidal ideation or behavior, or incarceration. Also, all prescription drug management features were significantly associated with increased medication access problems and adverse events (p<.001). States with more access problems had significantly higher adverse event rates (p<.001). CONCLUSIONS: These associations indicate that more effective Medicaid prescription drug management and financing practices are needed to promote medication continuity and improve treatment outcomes.

Systematic use of patient-rated depression severity monitoring: is it helpful and feasible in clinical psychiatry?

OBJECTIVE: The gap between evidence-based treatments and routine care has been well established. Findings from the Sequenced Treatments Alternatives to Relieve Depression (STAR*D) emphasized the importance of measurement-based care for the treatment of depression as a key ingredient for achieving response and remission; yet measurement-based care approaches are not commonly used in clinical practice. METHODS: The Nine-Item Patient Health Questionnaire (PHQ-9) for monitoring depression severity was introduced in 19 diverse psychiatric practices. During the one-year course of the project the helpfulness and feasibility of implementation of PHQ-9 in these psychiatric practices were studied. The project was modeled after the Institute for Healthcare Improvement Breakthrough Series. Two of the 19 practices dropped out during the course of the project. RESULTS: By the conclusion of the study, all remaining 17 practices had adopted PHQ-9 as a routine part of depression care in their practice. On the basis of responses from 17 psychiatrists from those practices, PHQ-9 scores influenced clinical decision making for 93% of 6,096 patient contacts. With the additional information gained from the PHQ-9 score, one or more treatment changes occurred during 40% of these clinical contacts. Changing the dosage of antidepressant medication and adding another medication were the most common treatment changes recorded by psychiatrists, followed by starting or increasing psychotherapy and by switching or initiating antidepressants. In 3% of the patient contacts, using the PHQ-9 led to additional suicide risk assessment. CONCLUSIONS: The study findings suggest that adopting measurement-based care, such as using the PHQ-9, is achievable, even in practices with limited resources.

Medicare Part D prescription drug benefits and administrative burden in the care of dually eligible psychiatric patients.

OBJECTIVE: With implementation of Medicare Part D, concerns were raised that patients with severe mental illness who were dually eligible for both Medicaid and Medicare benefits would be at clinical risk. In addition to concerns about medication access and continuity, there were concerns about administrative burden for physicians and their staffs. This study aimed to quantify the amount of administrative burden for psychiatrists and their staff related to Medicare Part D prescription drug plan administration in a national sample of dually eligible psychiatric patients and to identify factors associated with increased burden. METHODS: A total of 5,833 psychiatrists were randomly selected from the American Medical Association's Physicians Masterfile. Responses were obtained from 64% (N=3,247) with a mailed survey using practice-based survey research methods during the first four months of Medicare Part D implementation (January to April 2006); 1,183 psychiatrists met eligibility requirements. RESULTS: Psychiatrists and their staff spent 45 minutes in administrative tasks for every one hour of direct patient care for dually eligible patients. Drug plan features, including prior authorization and preferred drug formularies, and medication access problems were associated with increased administrative time. CONCLUSIONS: Results of this study indicate several drug plan features and medication access problems related to Part D implementation were associated with significant increases in administrative burden for psychiatrists and their staff, which may result in less time for direct patient care. Given the vulnerability of this high-risk population, this increased administrative burden may pose a significant risk to the overall quality of care for psychiatric patients.

Parity and the use of out-of-network mental health benefits in the FEHB program.

Two current congressional bills mandate parity for benefits for mental disorders with benefits for medical/surgical conditions in private insurance when mental health benefits are provided; the bills differ in regard to benefit levels and access to out-of-network coverage. This study assessed clinicians' and beneficiaries' participation in managed care networks in the national capital area under the Federal Employees Health Benefits (FEHB) parity program. Approximately one-third of the clinicians studied participated in FEHB networks, and only 44 percent of FEHB patients received care from network clinicians. Out-of-network mental health benefits are an important policy consideration to ensure access to mental health treatment under parity proposals.

Medication access and continuity: the experiences of dual-eligible psychiatric patients during the first 4 months of the Medicare prescription drug benefit.

OBJECTIVE: This study attempted to systematically assess the experiences of Medicare and Medicaid "dual-eligible" psychiatric patients, including evaluating patients' access to medications and the administrative functioning of the program, during the first 4 months of the Medicare Part D prescription drug benefit. METHOD: Psychiatrists (N=5,833) were randomly selected from the American Medical Association's Physicians Masterfile. After exclusion of those not practicing and with undeliverable addresses, 64% responded; 35% met study eligibility criteria of treating at least one dual-eligible patient during their last typical workweek and reported clinically detailed information on one systematically selected patient. RESULTS: A total of 53.4% had at least one medication access problem to report between Jan. 1 and April 30, 2006. Although 9.7% experienced improved medication access, 22.3% discontinued or temporarily stopped taking medication because of prescription drug coverage or management issues, and 18.3% were previously stable but were required to switch medications. Among those with medication access problems, 27.3% experienced a significant adverse clinical event; 19.8% had an emergency room visit. Most drug plan features studied, including preferred drug/formulary lists, prior authorization, medication dosing/number limits, "fail-first" protocols, and requirements to switch to generics, were associated with significantly higher rates of medication access problems. CONCLUSIONS: The findings indicate consequential medication access problems for psychiatric patients during the implementation of Medicare Part D. Although Centers for Medicare and Medicaid Services policies were enacted to ensure access to protected classes of psychopharmacologic medications, the high rates of medication access problems observed indicate further refinement of these policies is needed.

Comorbidity patterns in routine psychiatric practice: is there evidence of underdetection and underdiagnosis?

OBJECTIVE: The purpose of this study is to present data on the rates of diagnosis and patterns of Axis I comorbidity treated by psychiatrists in routine psychiatric practice, ascertained by practicing psychiatrists, and compare them with those ascertained through structured interview in a national sample of individuals treated in the specialty mental health sector for evidence of underdetection or underdiagnosis of comorbid disorders in routine psychiatric practice. METHODS: Data on 2117 psychiatric patients gathered by 754 psychiatrists participating in the 1997 and 1999 American Psychiatric Institute for Research and Education's Practice Research Network's Study of Psychiatric Patients and Treatments (SPPT) were analyzed, assessing psychiatrist-reported rates of Axis I disorders and comorbidities. SPPT data on patients treated by psychiatrists were compared with a clinical subset of patients in the National Comorbidity Survey who had been treated in the specialty mental health sector (SMA). RESULTS: Rates of comorbidity were higher in the SMA (53.9%) than in the SPPT (31.5%). The prevalence of schizophrenia diagnoses was more than twice as prevalent in the SPPT as in the SMA sample; anxiety disorders were 2 to 22 times more prevalent in the SMA sample. In the SPPT, 4 of the 10 most prevalent comorbid pairs included schizophrenia or bipolar disorder; only one pair in the SMA sample included either diagnoses. Of the 10 most prevalent comorbidity pairings in the SMA sample, 6 included a phobia diagnosis. CONCLUSIONS: Results of these analyses suggest greater differences in the patterns and rates of comorbidities than one might expect between these 2 samples. Possible reasons for these disparities, including methodological differences in diagnostic ascertainment and underdiagnosis of anxiety disorders, are discussed.

Patterns of adult psychotherapy in psychiatric practice.

OBJECTIVE: Psychotherapy has long been recognized as a key component of psychiatric care. However, concerns have been raised about access to psychotherapy as a result of changes in the financing and management of care. This study examined patterns and predictors of receipt of psychotherapy among patients of psychiatrists. METHODS: Data were collected for 587 psychiatrists who participated in the American Psychiatric Institute for Research and Education's Practice Research Network 1999 Study of Psychiatric Patients and Treatments, which generated nationally representative data for 1,589 adult patients. RESULTS: Findings indicate that more than 66 percent of patients of psychiatrists received some form of psychotherapy from the psychiatrist or another provider in the past 30 days--56 percent from their psychiatrist and 10 percent from another clinician. Although 72 percent of patients with depression received psychotherapy, more than half of those with schizophrenia did not. CONCLUSIONS: A majority of patients of psychiatrists received psychotherapy from their psychiatrist. However, these rates varied by demographic, diagnostic, and health plan characteristics and by practice setting. Further research determining if these observed patterns of psychotherapy are related to differential outcomes is needed.