eScholarship@UMMS

Syndicate content
Recent documents in eScholarship@UMMS
Updated: 11 min 19 sec ago

Medicaid lapses and low-income young adults' receipt of outpatient mental health care after an inpatient stay

Tue, 09/16/2014 - 3:18pm

OBJECTIVE: This study examined low-income young adults' use of outpatient mental health services after an inpatient mental health stay, with a focus on Medicaid enrollment lapses and public mental health safety-net coverage. METHODS: The sample included 1,174 young adults ages 18 to 26 who had been discharged from inpatient psychiatric care in a mid-Atlantic state. All were enrolled in Medicaid at the time of discharge, and all were eligible for continued outpatient public mental health services regardless of Medicaid enrollment. Administrative claims data were used to examine outpatient mental health clinic use, psychotropic medication possession, inpatient readmission, and emergency department admission during the 365-day period after the index discharge. The main independent variable was a lapse in Medicaid enrollment. An instrumental-variables regression model was used to minimize estimation bias resulting from unmeasured confounding between lapses and service use. RESULTS: Nearly a third (30%) of the young adults had an enrollment lapse. In instrumental-variables analysis, those whose coverage lapsed were less likely than those who had continuous Medicaid coverage to have at least two clinic visits (38% versus 80%); they also had a lower average psychotropic medication possession ratio (25% versus 55%). CONCLUSIONS: Age-related Medicaid enrollment lapses were common in this sample of young adults and were associated with receipt of less clinical care postdischarge despite continued eligibility for public services. States should examine opportunities to assist young adults with serious mental health problems who are aging out of Medicaid enrollment categories for children.

Identifying young adults at risk of Medicaid enrollment lapses after inpatient mental health treatment

Tue, 09/16/2014 - 3:18pm

OBJECTIVE: This study sought to describe Medicaid disenrollment rates and risk factors among young adults after discharge from inpatient psychiatric treatment. METHODS: The sample included 1,176 Medicaid-enrolled young adults ages 18 to 26 discharged from inpatient psychiatric care in a mid-Atlantic state. Medicaid disenrollment in the 365 days postdischarge and disenrollment predictors from the 180-day predischarge period (antecedent period) were identified from administrative records. Classification and regression tree and probit regression analysis were used. RESULTS: Thirty-two percent were disenrolled from Medicaid within a year of discharge. Both analytical approaches converged on four main risk factors: being in the Medicaid enrollment category for persons with a nondisabled low-income parent or for a child in a low-income household, being age 18 or 20 at discharge, having a Medicaid enrollment gap in the antecedent period, and having no primary care utilization in the antecedent period. For the 48% of the sample continuously enrolled in the antecedent period who were in the enrollment categories for disabled adults or foster care children, the disenrollment rate was 13%. CONCLUSIONS: A substantial minority of Medicaid-enrolled young adults discharged from inpatient care were disenrolled from Medicaid within a year. About half the sample had a low disenrollment risk, but the other half was at substantial risk. Risk factors largely reflected legal status changes that occur among these transition-age youths. Identifying inpatients at high risk of disenrollment and ensuring continuous coverage should improve access to needed postdischarge supports. Regular primary care visits may also help reduce unintended Medicaid disenrollment in this population.

Refocusing gun policy

Tue, 09/16/2014 - 3:18pm

Posttraumatic stress disorder and substance use disorder comorbidity among individuals with physical disabilities: findings from the National Comorbidity Survey Replication

Tue, 09/16/2014 - 3:18pm

Co-occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD) affects multiple domains of functioning and presents complex challenges to recovery. Using data from the National Comorbidity Study Replication, a national epidemiological study of mental disorders (weighted N = 4,883), the current study sought to determine the prevalence of PTSD and SUD, the symptom presentation of these disorders, and help-seeking behaviors in relation to PTSD and SUD among individuals with physical disabilities (weighted n = 491; nondisabled weighted n = 4,392). Results indicated that individuals with physical disabilities exhibited higher rates of PTSD, SUD, and comorbid PTSD/SUD than nondisabled individuals. For example, they were 2.6 times more likely to meet criteria for lifetime PTSD, 1.5 times more likely for lifetime SUD, and 3.6 times more likely for lifetime PTSD/SUD compared to their nondisabled peers. Additionally, individuals with physical disabilities endorsed more recent/severe PTSD symptoms and more lifetime trauma events than nondisabled individuals with an average of 5 different trauma events compared to 3 in the nondisabled group. No significant pattern of differences was noted for SUD symptom presentation, or for receipt of lifetime or past-year PTSD or SUD treatment. Implications of these findings and recommendations for future research are discussed.

Eye-tracking measures reveal how changes in the design of aided AAC displays influence the efficiency of locating symbols by school-age children without disabilities

Tue, 09/16/2014 - 3:18pm

PURPOSE Many individuals with communication impairments use aided augmentative and alternative communication (AAC) systems involving letters, words, or line drawings that rely on the visual modality. It seems reasonable to suggest that display design should incorporate information about how users attend to and process visual information. The organization of AAC symbols can influence the speed and accuracy with which children select a target symbol on a display. This research examined why some displays facilitate responding. METHOD Eye-tracking technology recorded point-of-gaze while children without disabilities engaged in a visual search task with 2 AAC displays. In 1 display, symbols sharing an internal color were clustered together. In the other display, like-colored symbols were distributed. Dependent measures were (a) latency to fixate on the target compared with distracters and (b) the number of fixations to target and distracters. RESULTS Participants were significantly slower to fixate on the target when like-colored symbols were distributed; there was a significant increase in the number of fixations to distracters that did not share color with the target. CONCLUSIONS Efficient search was related to minimizing fixations to nonrelevant distracters. Vulnerability to distraction can be a significant problem in individuals with disabilities who use AAC. Minimizing the intrusion of such distraction may, therefore, be of importance in AAC display design.

Recent research related to juvenile sex offending: findings and directions for further research

Tue, 09/16/2014 - 3:18pm

Serious scholarly inquiry into juvenile sex offending represents a relatively new field, dating from the mid 1940s. During the next 4 decades, a mere handful of articles exploring aspects of juvenile sex offending were added to the available literature. By the 1980s, however, the literature began to increase rapidly, a trend that continues today. The purpose of this article is a focused review of the juvenile sex offender literature cited in PubMed over the last 5 years (2009-2013). The authors have chosen studies that will bring readers up to date on research they believe impacts our current understanding of best practices in the management of juvenile sex offending. For convenience, our review is organized into topical categories including research into characteristics and typologies of juvenile sex offenders, risk assessment and recidivism, assessment and treatment, the ongoing debate about mandatory registration of sex offenders as it applies to juveniles, and other thought provoking studies that do not fit neatly into the aforementioned categories. The studies included contain findings that both reinforce and challenge currently held notions about best practices concerning treatment and public policy, suggesting that our knowledge of the field continues to evolve in important ways.

Effect of sertraline on risk of falling in older adults with psychotic depression on olanzapine: results of a randomized placebo-controlled trial

Tue, 09/16/2014 - 3:18pm

OBJECTIVE: Observational studies report that selective serotonin reuptake inhibitor (SSRI) antidepressants are associated with an increased risk of falls in the elderly, but these studies may overestimate drug-specific risk because of confounding. A randomized controlled trial (RCT) is the optimal way to assess the causal relationship between use of an SSRI and falls. We therefore analyzed data from a RCT of the treatment of psychotic depression, to examine whether combined olanzapine and sertraline interacted with older age to increase the risk of falling compared with olanzapine plus placebo. DESIGN: Double-blind placebo-controlled RCT. SETTING: Four academic medical centers. PARTICIPANTS: Two hundred fifty-nine patients with major depressive disorder with psychotic features (N = 117 aged 18-59 years and N = 142 aged 60 years or older). INTERVENTION: Twelve weeks of randomized double-blind treatment with olanzapine plus sertraline or olanzapine plus placebo. MEASUREMENTS: Proportion of participants who fell at least once. RESULTS: Older participants were significantly more likely than younger participants to fall. Among older participants, the odds ratio of falling with olanzapine plus sertraline versus olanzapine plus placebo was 1.56 (95% confidence interval: 0.63-3.83). There was not a statistically significant treatment effect or treatment x age interaction with respect to the proportion of participants falling. These negative results may have been due to low statistical power. CONCLUSION: Evaluating the association between SSRIs and falls in a RCT is limited by the large sample size that is required. An alternative approach is to examine the effect of an SSRI on measures of postural stability and gait that are valid markers of risk of falling. Elsevier Inc. All rights reserved.

Neuropsychiatry and neuroscience education of psychiatry trainees: attitudes and barriers

Tue, 09/16/2014 - 3:18pm

OBJECTIVE: The American Association of Directors of Psychiatric Residency Training (AADPRT) Task Force on Neuropsychiatry and Neuroscience Education of Psychiatry Residents was established in 2011 with the charge to seek information about what the field of psychiatry considers the core topics in neuropsychiatry and neuroscience to which psychiatry residents should be exposed; whether there are any "competencies" in this area on which the field agrees; whether psychiatry departments have the internal capacity to teach these topics if they are desirable; and what the reception would be for "portable curricula" in neuroscience. METHODS: The task force reviewed the literature and developed a survey instrument to be administered nationwide to all psychiatry residency program directors. The AADPRT Executive Committee assisted with the survey review, and their feedback was incorporated into the final instrument. RESULTS: In 2011-2012, 226 adult and child and adolescent psychiatry residency program directors responded to the survey, representing over half of all US adult and child psychiatry training directors. About three quarters indicated that faculty resources were available in their departments but 39% felt the lack of neuropsychiatry faculty and 36% felt the absence of neuroscience faculty to be significant barriers. Respectively, 64 and 60% felt that neuropsychiatry and psychiatric neuroscience knowledge were very important or critically important to the provision of excellent care. Ninety-two percent were interested in access to portable neuroscience curricula. CONCLUSIONS: There is widespread agreement among training directors on the importance of neuropsychiatry and neuroscience knowledge to general psychiatrists but barriers to training exist, including some programs that lack faculty resources and a dearth of portable curricula in these areas.

Peripartum depression and anxiety as an integrative cross domain target for psychiatric preventative measures

Tue, 09/16/2014 - 3:18pm

Exposure to high levels of early life stress has been identified as a potent risk factor for neurodevelopmental delays in infants, behavioral problems and autism in children, but also for several psychiatric illnesses in adulthood, such as depression, anxiety, autism, and posttraumatic stress disorder. Despite having robust adverse effects on both mother and infant, the pathophysiology of peripartum depression and anxiety are poorly understood. The objective of this review is to highlight the advantages of using an integrated approach addressing several behavioral domains in both animal and clinical studies of peripartum depression and anxiety. It is postulated that a greater focus on integrated cross domain studies will lead to advances in treatments and preventative measures for several disorders associated with peripartum depression and anxiety.

A scoping review of interprofessional collaborative practice and education using the lens of the Triple Aim

Tue, 09/16/2014 - 3:18pm

The Triple Aim unequivocally connects interprofessional healthcare teams to the provision of better healthcare services that would eventually lead to improved health outcomes. This review of the interprofessional education (IPE) and collaborative practice empirical literature from 2008 to 2013 focused on the impact of this area of inquiry on the outcomes identified in the Triple Aim. The preferred reporting items for systematic reviews and meta-analyses methodology were employed including: a clearly formulated question, clear inclusion criteria to identify relevant studies based on the question, an appraisal of the studies or a subset of the studies, a summary of the evidence using an explicit methodology and an interpretation of the findings of the review. The initial search yielded 1176 published manuscripts that were reduced to 496 when the inclusion criteria were applied to refine the selection of published manuscripts. Despite a four-decade history of inquiry into IPE and/or collaborative practice, scholars have not yet demonstrated the impact of IPE and/or collaborative practice on simultaneously improving population health, reducing healthcare costs or improving the quality of delivered care and patients' experiences of care received. We propose moving this area of inquiry beyond theoretical assumptions to systematic research that will strengthen the evidence base for the effectiveness of IPE and collaborative practice within the context of the evolving imperative of the Triple Aim.

Effects of perinatal depression and anxiety on labor and delivery outcomes

Tue, 09/16/2014 - 3:18pm

INTRODUCTION: The purpose of this study was to determine how perinatal depression and anxiety effect obstetric outcomes and perceptions of labor and delivery experiences. METHODS: This prospective observational study examined the labor and delivery experiences of 25 high-risk and 25 low-risk women. The high-risk group was defined by symptoms during pregnancy as determined by the Edinburgh Postnatal Depression Scale, whereas the low-risk group reported no symptoms. Women in both groups were monitored with the Hamilton Rating Scales for depression and anxiety and filled out a questionnaire about their labor and delivery. RESULTS: The high-risk cohort had significantly more depressive symptoms than the low-risk cohort throughout pregnancy and into the postpartum period (P<.001). Similarly, the high-risk cohort had significantly more anxiety symptoms than the low-risk cohort (P<.001). The high-risk cohort was significantly more likely to report their labor and delivery was a traumatic experience (P=.046) and to have their labor induced (P=.018) as compared with the low-risk cohort. There was no significant difference in the rates of preterm labor (P=.149) or method of delivery (P=1.00) between both groups. CONCLUSIONS: Factors such as preterm labor, labor induction, and cesarean deliveries can cause women to report having traumatic deliveries. It is not known whether labor induction alone caused traumatic birth experiences or whether mood was a predisposing factor to a traumatic delivery. More research must be done to identify the mechanisms by which mood can influence labor and delivery outcomes.

Early-treatment weight loss predicts 6-month weight loss in women with obesity and depression: Implications for stepped care

Tue, 09/16/2014 - 3:18pm

OBJECTIVE: Some adults with comorbid depression and obesity respond well to lifestyle interventions while others have poor outcomes. The objective of this study was to evaluate whether early-treatment weight loss progress predicts clinically significant 6-month weight loss among women with obesity and depression. METHODS: We conducted a secondary analysis of data from 75 women with obesity and depression who received a standard lifestyle intervention. Relative risks (RRs) and 95% confidence intervals (CIs) for achieving >/=5% weight loss by 6 months were calculated based on whether they achieved >/=1 lb/week weight loss in weeks 2-8. Among those on target at week 3, we examined potential subsequent time points at which weight loss progress might identify additional individuals at risk for treatment failure. RESULTS: At week 2, women who averaged >/=1 lb/week loss were twice as likely to achieve 5% weight loss by 6 months than those who did not (RR=2.40; 95% CI: 2.32-4.29); weight loss at weeks 3-8 was similarly predictive (RRs=2.02-3.20). Examining weight loss progress at week 3 and subsequently at a time point during weeks 4-8, 52-67% of participants were not on target with their weight loss, and those on target were 2-3 times as likely to achieve 5% weight loss by 6 months (RRs=1.82-2.92). CONCLUSION: Weight loss progress as early as week 2 of treatment predicts weight loss outcomes for women with comorbid obesity and depression, which supports the feasibility of developing stepped care interventions that adjust treatment intensity based on early progress in this population.

Measuring treatment response in psychotic depression: the Psychotic Depression Assessment Scale (PDAS) takes both depressive and psychotic symptoms into account

Tue, 09/16/2014 - 3:18pm

BACKGROUND: There is no established psychometric instrument dedicated to the measurement of severity in psychotic depression (PD). The aim of this study was to investigate whether a new composite rating scale, the Psychotic Depression Assessment Scale (PDAS), covering both the psychotic and the depressive domains of PD, could detect differences in effect between two psychopharmacological treatment regimens. METHODS: We reanalyzed the data from the Study of Pharmacotherapy of Psychotic Depression (STOP-PD), which compared the effect of Olanzapine+Sertraline (n=129) versus Olanzapine+Placebo (n=130). The response to the two regimens was compared using both a mixed effects model and effect size statistics on the total scores of three rating scales: the 17-item Hamilton Depression Rating Scale (HAM-D17), its 6-item melancholia subscale (HAM-D6), and the 11-item PDAS consisting of the HAM-D6 plus five items from the Brief Psychiatric Rating Scale covering psychotic symptoms. RESULTS: According to both statistical approaches, the PDAS, the HAM-D17 and the HAM-D6 were all able to detect significant differences in treatment effect between Olanzapine+Sertraline and Olanzapine+Placebo (Olanzapine+Sertraline being superior). Notably, 45% of the trial participants were at least "probable psychotic" at their last assessment in the trial. LIMITATIONS: The STOP-PD was not designed specifically to answer the research questions of the present study. CONCLUSIONS: The Psychotic Depression Assessment Scale (PDAS) is a sensitive measure of treatment response in PD. The fact that 45% of the patients still experienced psychotic symptoms at their last trial assessment emphasizes the need to include items pertaining to psychotic symptoms in rating scales for PD.

The development and expression of physical nicotine dependence corresponds to structural and functional alterations in the anterior cingulate-precuneus pathway

Tue, 09/16/2014 - 3:18pm

INTRODUCTION: Perturbations in neural function provoked by a drug are thought to induce neural adaptations, which, in the absence of the drug, give rise to withdrawal symptoms. Previously published structural data from this study indicated that the progressive development of physical dependence is associated with increasing density of white matter tracts between the anterior cingulum bundle and the precuneus. METHODS: Using functional magnetic resonance imaging, we compared 11 smokers after 11 h of abstinence from nicotine and after satiation, with 10 nonsmoking controls, using independent component analysis for brain network comparisons as well as a whole brain resting-state functional connectivity analysis using the anterior cingulate cortex as a seed. RESULTS: Independent component analysis demonstrated increased functional connectivity in brain networks such as the default mode network associated with the withdrawal state in multiple brain regions. In seed-based analysis, smokers in the withdrawal state showed stronger functional connectivity than nonsmoking controls between the anterior cingulate cortex and the precuneus, caudate, putamen, and frontal cortex (P < 0.05). Among smokers, compared to the satiated state, nicotine withdrawal was associated with increased connectivity between the anterior cingulate cortex and the precuneus, insula, orbital frontal gyrus, superior frontal gyrus, posterior cingulate cortex, superior temporal, and inferior temporal lobe (P < 0.02). The intensity of withdrawal-induced craving correlated with the strength of connectivity between the anterior cingulate cortex and the precuneus, insula, caudate, putamen, middle cingulate gyrus, and precentral gyrus (r = 0.60-0.76; P < 0.05). CONCLUSIONS: In concordance with our previous report that structural neural connectivity between the anterior cingulate area and the precuneus increased in proportion to the progression of physical dependence, resting-state functional connectivity in this pathway increases during nicotine withdrawal in correlation with the intensity of withdrawal-induced craving. These findings suggest that smoking triggers structural and functional neural adaptations in the brain that support withdrawal-induced craving.

Relationship between sunlight and the age of onset of bipolar disorder: an international multisite study

Tue, 09/16/2014 - 3:17pm

BACKGROUND: The onset of bipolar disorder is influenced by the interaction of genetic and environmental factors. We previously found that a large increase in sunlight in springtime was associated with a lower age of onset. This study extends this analysis with more collection sites at diverse locations, and includes family history and polarity of first episode. METHODS: Data from 4037 patients with bipolar I disorder were collected at 36 collection sites in 23 countries at latitudes spanning 3.2 north (N) to 63.4 N and 38.2 south (S) of the equator. The age of onset of the first episode, onset location, family history of mood disorders, and polarity of first episode were obtained retrospectively, from patient records and/or direct interview. Solar insolation data were obtained for the onset locations. RESULTS: There was a large, significant inverse relationship between maximum monthly increase in solar insolation and age of onset, controlling for the country median age and the birth cohort. The effect was reduced by half if there was no family history. The maximum monthly increase in solar insolation occurred in springtime. The effect was one-third smaller for initial episodes of mania than depression. The largest maximum monthly increase in solar insolation occurred in northern latitudes such as Oslo, Norway, and warm and dry areas such as Los Angeles, California. LIMITATIONS: Recall bias for onset and family history data. CONCLUSIONS: A large springtime increase in sunlight may have an important influence on the onset of bipolar disorder, especially in those with a family history of mood disorders.

Controlling Relations in Stimulus Equivalence Classes of Preschool Children and Individuals with Down Syndrome

Tue, 09/16/2014 - 3:17pm

We evaluated emergent stimulus-stimulus relations after two different training procedures. Participants were five typically developing preschool children and three individuals with Down Syndrome. Experiment 1 used two-comparison matching to sample (MTS) to establish AB and BC relations. Experiment 2 used two-comparison and blank-comparison MTS, each on 50% of training trials to establish AB and BC relations. In both experiments, tests for emergent relations (AC, CA) were conducted to assess equivalence class formation. In Experiment 2 subsequently, class expansion was assessed after CD training. All participants showed positive equivalence test outcomes. Seven showed class expansion. After class formation tests in both studies, probe tests were conducted for select and reject relations in baseline relations. Initial results were somewhat variable, but became more consistent after class expansion.

Frequency and pattern of childhood symptom onset reported by first episode schizophrenia and clinical high risk youth

Tue, 09/16/2014 - 3:17pm

BACKGROUND: Psychosis prevention and early intervention efforts in schizophrenia have focused increasingly on sub-threshold psychotic symptoms in adolescents and young adults. Although many youth report symptom onset prior to adolescence, the childhood incidence of prodromal-level symptoms in those with schizophrenia or related psychoses is largely unknown.

METHODS: This study reports on the retrospective recall of prodromal-level symptoms from 40 participants in a first-episode of schizophrenia (FES) and 40 participants at "clinical high risk" (CHR) for psychosis. Onset of positive and non-specific symptoms was captured using the Structured Interview for Prodromal Syndromes. Frequencies are reported according to onset during childhood (prior to age 13), adolescence (13-17), or adulthood (18+).

RESULTS: Childhood-onset of attenuated psychotic symptoms was not rare. At least 11% of FES and 23% of CHR reported specific recall of childhood-onset of unusual or delusional ideas, suspiciousness, or perceptual abnormalities. Most recalled experiencing non-specific symptoms prior to positive symptoms. CHR and FES did not differ significantly in the timing of positive and non-specific symptom onset. Other than being younger at assessment, those with childhood onset did not differ demographically from those with later onset.

CONCLUSION: Childhood-onset of initial psychotic-like symptoms may be more common than previous research has suggested. Improved characterization of these symptoms and a focus on their predictive value for subsequent schizophrenia and other major psychoses are needed to facilitate screening of children presenting with attenuated psychotic symptoms. Accurate detection of prodromal symptoms in children might facilitate even earlier intervention and the potential to alter pre-illness trajectories.