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Objective: During the transition to adulthood, youths face challenges that may limit their likelihood of obtaining services for psychiatric problems. The goal of this analysis was to estimate changes in rates of service use and untreated psychiatric disorders during the transition from adolescence to adulthood. Methods: In a prospective, population-based study, participants were assessed up tofour times in adolescence (ages 13-16; 3,983 observations of 1,297 participants, 1993-2000) and three times in young adulthood (ages 19, 21, and 24-26; 3,215 observations of 1,273 participants, 1999-2010). Structured diagnostic interviews were used to assess service need (participants meeting DSM-IV diagnostic criteria for a psychiatric disorder) and use of behavioral services in 21 service settings in the past three months. Results: During young adulthood, 28.9% of cases of psychiatric disorders were associated with some treatment, compared with a rate of 50.9% for the same participants during adolescence. This decrease included a near-complete drop in use of educational and vocational services as well as declines in use of specialty behavioral services. Young adults most frequently accessed services in specialty behavioral or general medical settings. Males, African Americans, participants with substance dependence, and participants living independently were least likely to get treatment. For cases of psychiatric disorders among young adults, insurance and poverty status were unrelated to likelihood of service use. Conclusions: Young adults were much less likely to receive treatment for psychiatric problems than they were as adolescents. Public policy must address gaps in service use during the transition to adulthood. [ABSTRACT FROM AUTHOR]

Objectives: This article reports the initial findings from a randomized trial to enhance treatment foster care (TFC) in "usual care" agencies. The intervention, Together Facing the Challenge, was built on a combination of practice-based elements from a prior descriptive study of TFC and selected elements from Chamberlain's evidence-based model (multidimensional treatment foster care) to fill conspicuous gaps in usual practice. The study was designed to examine whether additional training and consultation to staff and treatment foster parents improved outcomes for youths.Methods: The study was conducted with 247 youths in TFC and their treatment parents from 14 TFC agencies in a southeastern state in 2003-2008. Half of the agencies were randomly assigned to the intervention condition and received study-provided training and consultation. Agencies in the control group continued to provide training and treatment as usual. Data for the analyses presented here were from interviews with treatment parents at baseline, six months, and 12 months.Results: Compared with youths in the control group, youths in the intervention group showed improvement on the three focal domains--symptoms, behaviors, and strengths. Effects were significant for all outcomes at six months. Effects for behaviors remained significant by 12 months.Conclusions: This study employed a hybrid model to improve practice. It built on current practices in existing agencies and infused additional training and consultation to overcome observed deficits. Such an approach has tremendous potential for moving beyond a singular focus on disseminating evidence-based interventions to a broader view of improving practice in a wide range of agencies. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: While the evidence base for treatments for adolescent depression is building, little is known about the relative efficiency of such treatments. Treatment costs are a relevant concern given the competing demands on family and health care budgets. The authors evaluated the cost-effectiveness of three active treatments among adolescents with major depressive disorder. Method: Volunteers (N=439) ages 12 to 18 with a primary diagnosis of major depressive disorder participated in a randomized, controlled trial conducted at 13 U.S. academic and community clinics from 2000 to 2004. Subjects included those participants who did not drop out and had evaluable outcome and cost data at 12 weeks (N=369). Subjects were randomly assigned to 12 weeks of either fluoxetine alone (10-40 mg/day), CBT alone, CBT combined with fluoxetine (10- 40 mg/day), or placebo (equivalent to 10- 40 mg/day). Both placebo and fluoxetine were administered double-blind; CBT alone and CBT in combination with fluoxetine were administered unblinded. Societal cost per unit of improvement on the Children's Depression Rating Scale-Revised and cost per quality-adjusted life year (QALY) were compared. Results: Results ranged from an incre- mental cost over placebo of $24,000 per QALY for treatment with fluoxetine to $123,000 per QALY for combination therapy treatment. The cost-effectiveness ratio for CBT treatment was not evaluable due to negative clinical effects. The models were robust on a variety of assumptions. Conclusions: Both fluoxetirie and combination therapy are at least as cost-effective in the short-term as other treatments commonly used in primary care (using a threshold of $1 25,000/QALY). Fluoxetine is more cost-effective than combination therapy after 12 weeks of treatment. [ABSTRACT FROM AUTHOR]

Objective: Study findings indicating that involuntary outpatient commitment can improve treatment outcomes among persons with severe mental illness remain controversial. Opponents of outpatient commitment argue that its coerciveness is unacceptable even given its arguable benefits. However, it is unclear to what extent the public debate surrounding outpatient commitment represents the preferences of persons with a stake in the benefit or harm resulting from outpatient commitment. This study examines and compares views of outpatient commitment among four stakeholder groups: 1) persons in treatment for schizophrenia and related disorders, 2) family members of persons with these disorders, 3) clinicians treating persons with these disorders, and 4) members of the general public. Method: Subjects from the Piedmont region of North Carolina who were members of the four stakeholder groups were presented with short vignettes that depicted potential outcomes that were associated alternatively with outpatient commitment and with voluntary treatment. Subjects rated each vignette according to how positively or negatively they viewed the overall situation for the individual described. Multivariate regression techniques were used to estimate preference weights for each stakeholder group. Results: With some exceptions, each group gave the highest preference to avoiding involuntary hospitalization, followed by avoiding interpersonal violence and maintaining good interpersonal relationships. No group gave appreciable importance to outpatient commitment, which suggests that avoiding its coerciveness is a lesser concern compared to other outcomes. Conclusions: The findings suggest that these stakeholders are willing to accept the coerciveness of outpatient commitment to gain improved outcomes for certain persons with schizophrenia and related disorders. [ABSTRACT FROM AUTHOR]

Objective: This study examined points of entry into the mental health service system for children and adolescents as well as patterns of movement through five service sectors: specialty mental health services, education, general medicine, juvenile justice, and child welfare. Methods: The data were from the Great Smoky Mountains Study, a longitudinal epidemiologic study of mental health problems and service use among youths. The sample consisted of 1,420 youths who were nine, 11, or 13 years old at study entry. Each youth and a parent were interviewed at baseline and every year thereafter about the use of services for mental health problems over the three-year study period. Results: Population estimates indicated that 54 percent of youths have used mental health services at some time during their lives. The education sector was the most common point of entry and provider of services across all age groups. The specialty mental health sector was the second most common point of entry for youths up to age 13 years, and juvenile justice was the second most common point of entry for youths between the ages of 14 and 16. Youths who entered the mental health system through the specialty mental health sector were the most likely to subsequently receive services from other sectors, and those who entered through the education sector were the least likely to do so. Conclusions: The education sector plays a central role as a point of entry into the mental health system. Interagency collaboration among three primary sectors--education, specialty mental health services, and general medicine--is critical to ensuring that youths who are in need of mental health care receive appropriate services. [ABSTRACT FROM AUTHOR]

Objective: This study examined the lifetime use of alcohol, drug, and mental health treatment services by recently incarcerated women prison inmates. Methods: A total of 805 women entering a North Carolina prison for new felony charges in 1991 and 1992 were interviewed in person shortly after incarceration. The women were assessed for psychiatric disorders and lifetime use of substance abuse and mental health treatment services. Rates of service use were analyzed by inmate characteristics and were compared with rates for a sample of women in the community in North Carolina. Results: The majority of women inmates reported a history of using substance abuse services or mental health services or both. Those with psychiatric disorders and prison recidivists were the most likely to have used such services. Rates of service use were substantially higher for the inmates than for the women in the community, even when the effects of having a psychiatric or substance use disorder were controlled for. Conclusions: Many of the incarcerated women in the study met lifetime criteria for alcohol, drug, and mental health disorders that were significantly related to their use of substance abuse and mental health treatment services. The majority of the inmates met criteria for a current disorder despite past treatment. Further research is needed to help in developing programs to reduce women inmates' alcohol, drug, and mental health problems [ABSTRACT FROM AUTHOR]

The authors review the status, strength, and quality of evidence-based practice in child and adolescent mental health services. The definitional criteria that have been applied to the evidence base differ considerably across treatments, and these definitions circumscribe the range, depth, and extensionality of the evidence. The authors describe major dimensions that differentiate evidence-based practices for children from those for adults and summarize the status of the scientific literature on a range of service practices. The readiness of the child and adolescent evidence base for large-scale dissemination should be viewed with healthy skepticism until studies of the fit between empirically based treatments and the context of service delivery have been undertaken. Acceleration of the pace at which evidence-based practices can be more readily disseminated will require new models of development of clinical services that consider the practice setting in which the service is ultimately to be delivered. [ABSTRACT FROM AUTHOR]

This article describes the assertive community treatment model of comprehensive community-based psychiatric care for persons with severe mental illness and discusses issues pertaining to implementation of the model. The assertive community treatment model has been the subject of more than 25 randomized controlled trials. Research has shown that this type of program is effective in reducing hospitalization, is no more expensive than traditional care, and is more satisfactory to consumers and their families than standard care. Despite evidence of the efficacy of assertive community treatment, it is not uniformly available to the individuals who might benefit from it. [ABSTRACT FROM AUTHOR]

Objective: A randomized controlled trial of outpatient commitment was conducted in North Carolina to provide empirical data on involuntary outpatient commitment and to evaluate its effectiveness in improving outcomes among persons with severe mental illnesses. Methods: A total of 331 involuntarily hospitalized patients awaiting discharge under outpatient commitment were randomly assigned to be released or to undergo outpatient commitment. Each received case management services and outpatient treatment. Participants in both groups were monitored for one year. After the initial 90-day outpatient commitment order, a patient could receive a renewable 180-day extension. Patients in the control group were immune from outpatient commitment for one year. Information was obtained from self-reports and reports of several informants as well as from outpatient treatment, hospital, and arrest records. Results: In most bivariate analyses, outcomes for the outpatient commitment group and the control group did not differ significantly when the duration of outpatient commitment was not taken into account. However, patients who underwent sustained outpatient commitment and who received relatively intensive outpatient treatment had fewer hospital admissions and fewer days in the hospital, were more likely to adhere to community treatment, and were less likely to be violent or to be victimized. Extended outpatient commitment was also associated with fewer arrests of participants with a combined history of multiple rehospitalizations and previous arrests. The intervention was particularly effective among individuals with psychotic disorders. Conclusions: Outpatient commitment can improve treatment outcomes when the court order is sustained and combined with relatively intensive community treatment. A court order alone cannot substitute for effective treatment in improving outcomes. [ABSTRACT FROM AUTHOR]

Extensive empirical research, summarized in several reviews and codified in practice guidelines, recommendations, and algorithms, demonstrates that several pharmacological and psychosocial interventions are effective in improving the lives of persons with severe mental illnesses. Yet the practices validated by research are not widely offered in routine mental health practice settings. As part of an effort to promote the implementation of evidence-based practice, the authors summarize perspectives on how best to change and sustain effective practice from the research literature and from the experiences of administrators, clinicians, family advocates, and services researchers. They describe an implementation plan for evidence-based practices based on the use of toolkits to promote the consistent delivery of such practices. The toolkits will include integrated written material, Web-based resources, training experiences, and consultation opportunities. Special materials will address the concerns of mental health authorities (funders), administrators of provider organizations, clinicians, and consumers and their families. [ABSTRACT FROM AUTHOR]

Examines how insurance coverage for mental health services affects outpatient mental health service utilization among those with and among those without a DSM-III psychiatric diagnosis. Regressive effects of insurance coverage on utilization of mental health services; Ordinary least squares and logistic regression effects; Implications.

Features a study which examined the combined effect of substance abuse and medication noncompliance on greater risk of serious violence among persons with severe mental illness. Increased focus on violent behavior among individuals with severe mental illness; Findings of the study.

Mental health coverage generally limits benefits for high use, which is assumed to be discretionary. The authors present data from the National Medical Care Utilization and Expenditure Survey. Of the individuals who made mental health outpatient visits in 1980, 9.4% made 25 or more visits and accounted for 50% of mental health visits and expenditures. These high users were compared with low users and with high users of other health care. One-third of the mental health high users were highly disabled and had multiple medical disorders. The authors point out the heterogeneity of this population and suggest that psychiatric benefits be differentiated according to patients' needs and services offered. [ABSTRACT FROM AUTHOR]

Examines the use of psychotropic medications among youths in residential community-based placements. Data from a study funded by the National Institute of Mental Health of therapeutic foster care and group homes; Number of youths receiving psychotropic medications and multiple psychotropic medication in both settings.