Is more better than less? An analysis of children's mental health services.
(65/1841)
OBJECTIVE: To assess the dose-response relationship for outpatient therapy received by children and adolescents-that is, to determine the impact of added outpatient visits on key mental health outcomes (functioning and symptomatology). DATA SOURCES/STUDY SETTING: The results presented involve analyses of data from the Fort Bragg Demonstration and are based on a sample of 301 individuals using outpatient services. STUDY DESIGN: This article provides estimates of the impact of outpatient therapy based on comparisons of individuals receiving differing treatment doses. Those comparisons involve standard multiple regression analyses as well as instrumental variables estimation. The latter provides a means of adjusting comparisons for unobserved or unmeasured differences among individuals receiving differing doses, differences that would otherwise be confounded with the impact of treatment dose. DATA COLLECTION/EXTRACTION METHODS: Using structured diagnostic interviews and behavior checklists completed by the child and his or her caretaker, detailed data on psychopathology, symptomatology, and psychosocial functioning were collected on individuals included in these analyses. Information on the use of mental health services was taken from insurance claims and a management information system. Services data were used to describe the use of outpatient therapy within the year following entry into the study. PRINCIPAL FINDINGS/CONCLUSIONS: Instrumental variables estimation indicates that added outpatient therapy improves functioning among children and adolescents. The effect is statistically significant and of moderate practical magnitude. These results imply that conventional analyses of the dose-response relationship may understate the impact of additional treatment on functioning. This finding is robust to choice of functional form, length of time over which outcomes are measured, and model specification. Dose does not appear to influence symptomatology. (+info)
Survey of patients from an inner-London health authority in medium secure psychiatric care.
(66/1841)
BACKGROUND: Underprovision by the National Health Service (NHS) has led to an increase in medium secure psychiatric beds managed by the independent sector. Black people are overrepresented in medium secure care. AIMS: To describe those people from an inner-London health authority occupying all forms of medium secure provision. To compare those in NHS provision with those in the independent sector, and Black patients with White patients. METHOD: A census of those in medium secure care in August 1997. RESULTS: The 90 patients in independent-sector units were similar to the 93 patients in NHS units except that they were more likely to have been referred from general psychiatric services (48% v. 19%) and less likely to have been referred from the criminal justice system or a high-security hospital (37% v. 63%). There were few differences between Black and White patients. CONCLUSIONS: The NHS meets only part of the need for medium secure care of the population of this London health authority. This comparison of the characteristics of Black and White patients does not help to explain why Black people are overrepresented in medium secure settings. (+info)
Legal pitfalls of psychiatric research.
(67/1841)
BACKGROUND: The increasing complexity of psychiatric research, including recent attempts to evaluate mental health legislation, suggests legal advice may be valuable in a wide range of research contexts. AIMS: We aim to illustrate both the legal pitfalls of research in psychiatry and the potential for solutions if the methods are carefully chosen. METHOD: Two examples of research are subject to legal analysis, one involving advance directives, the other the random discharge of compulsory out-patients. RESULTS: This analysis illustrates that participation in research may expose clinicians to additional forms of liability, but the legal risks can be minimised through changes in the methods or additional safeguards. CONCLUSIONS: Collaboration between academic law and psychiatry can enrich research agendas and avoid serious legal pitfalls. We argue that sound legal advice should be sought at the planning stage of research in psychiatry, but the fear of liability should not lead to overly defensive research practices. The aim should be to strike the right balance between avoiding unacceptable exposure to liability and stifling innovative research. (+info)
Prevalence, comorbidity, disability and service utilisation. Overview of the Australian National Mental Health Survey.
(68/1841)
BACKGROUND: Health planning should be based on data about prevalence, disability and services used. AIMS: To determine the prevalence of ICD-10 disorders and associated comorbidity, disability and service utilisation. METHOD: We surveyed a national probability sample of Australian households using the Composite International Diagnostic Interview and other measures. RESULTS: The sample size was 10 641 adults, response rate 78%. Close to 23% reported at least one disorder in the past 12 months and 14% a current disorder. Comorbidity was associated with disability and service use. Only 35% of people with a mental disorder in the 12 months prior to the survey had consulted for a mental problem during that year, and most had seen a general practitioner. Only half of those who were disabled or had multiple comorbidity had consulted and of those who had not, more than half said they did not need treatment. CONCLUSIONS: The high rate of not consulting among those with disability and comorbidity is an important public health problem. As Australia has a universal health insurance scheme, the barriers to effective care must be patient knowledge and physician competence. (+info)
Intellectual functioning and outcome of patients with severe psychotic illness randomised to intensive case management. Report from the UK700 trial.
(69/1841)
BACKGROUND: Little research has been carried out on the benefits of intensive case management (ICM) for people with borderline IQ and severe mental illness. AIMS: To compare outcome and costs of care of patients with severe psychotic illness with borderline IQ to patients of normal IQ and to assess whether ICM is more beneficial for the former than for the latter. METHOD: The study utilises data from the UK700 multi-centre randomised controlled trial of case management. The main outcome measure was the number of days spent in hospital for psychiatric reasons. Secondary outcomes were costs of care and clinical outcome. RESULTS: ICM was significantly more beneficial for borderline-IQ patients than those of normal IQ in terms of reductions in days spent in hospital, hospital admissions, total costs and needs and increased satisfaction. CONCLUSIONS: ICM appears to be a cost-effective strategy for a subgroup of patients with severe psychosis with cognitive deficits. (+info)
The construct of resilience: implications for interventions and social policies.
(70/1841)
The focus of this article is on the interface between research on resilience-a construct representing positive adaptation despite adversity--and the applications of this work to the development of interventions and social policies. Salient defining features of research on resilience are delineated, as are various advantages, limitations, and precautions linked with the application of the resilience framework to developing interventions. For future applied efforts within this tradition, a series of guiding principles are presented along with exemplars of existing programs based on the resilience paradigm. The article concludes with discussions of directions for future work in this area, with emphases on an enhanced interface between science and practice, and a broadened scope of resilience-based interventions in terms of the types of populations, and the types of adjustment domains, that are encompassed. (+info)
Embedded evaluation of preferences sampled from person-centered plans for people with profound multiple disabilities.
(71/1841)
We investigated a brief, embedded assessment for evaluating preferences sampled from person-centered plans. After developing person-centered plans for individuals with multiple disabilities, systematic assessments were conducted with preferences sampled from the plans. An assessment of sampled preferences was then embedded within the participants' daily routines. The two assessments identified similar preferences based on participant approach responses. Both assessments also indicated inconsistencies with reported preferences in the person-centered plans. Overall, results suggested the embedded assessment may be an alternative means of evaluating some preferences reported through person-centered planning. (+info)
How would mental health parity affect the marginal price of care?
(72/1841)
OBJECTIVE: To determine the impact of parity in mental health benefits on the marginal prices that consumers face for mental health treatment. DATA SOURCES/DATA COLLECTION: We used detailed information on health plan benefits for a nationally representative sample of the privately insured population under age 65 taken from the 1987 National Medical Expenditure Survey (Edwards and Berlin 1989). The survey was carefully aged and reweighted to represent 1995 population and coverage characteristics. STUDY DESIGN: We computed marginal out-of-pocket costs from the cost-sharing benefits described by policy booklets under current coverage and under parity for various mental health treatment expenditure levels using the MEDSIM health care microsimulation model developed by researchers at the Agency for Healthcare Research and Quality. Descriptive analyses and two-limit Tobit regression models are used to examine how insurance generosity varies across individuals by demographic and socioeconomic characteristics. Our analyses are limited to a description of how parity would change the marginal incentives faced by consumers under their existing plan's cost-sharing arrangements for mental and physical health care. We do not attempt to simulate how parity might affect the level of benefits, including whether benefits are offered at all, or the level of managed care that affects the actual benefits that plan members receive. Rather, we focus only on the nominal benefits described in their policy booklets. PRINCIPAL FINDINGS: Our results show that as of 1995 parity coverage would substantially reduce the share of mental health expenditures that consumers would pay at the margin under their existing plan's cost-sharing provisions, with larger changes for outpatient care than for inpatient care. Because current mental health coverage generally becomes less generous as expenditures rise, while coverage for other medical care becomes more generous (due to stop-loss provisions), the difference in incentives between current mental health coverage and the assumed parity coverage widens as total expenditure grows. We also find that the impact of parity on marginal incentives would vary greatly across the privately insured population. CONCLUSIONS: Based on the large variation in the impact of parity on marginal incentives across the population under current plan cost-sharing arrangements, changes in the demand for mental health treatment will likely also vary across the population. (+info)