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This study examined factors associated with 9-month outcomes of 78 preschoolers with autism spectrum disorder ([ASD]; 66 males, mean age = 44.8 [7.0] months) receiving preschool special education services. Use of recommended intervention practices was observed in each student's primary educational setting: autism-only (n = 28), mixed-disability (n = 25), and general early education (n = 25). Recommended practice use across setting types and developmental changes were compared using generalized estimating equations. Autism-only settings had the highest implementation of classroom structure, classroom environment, and curriculum and instruction. General early education had greater implementation of practices to support social and peer relationships. Supporting social and peer relationships was the largest predictor of gains, controlling for setting type; the association was greater for children with lower initial receptive language or developmental skills. These findings highlight the importance of supporting and promoting peer engagement in students with ASD across preschool placement types. [ABSTRACT FROM AUTHOR]

Clinician fidelity to cognitive behavioral therapy (CBT) is an important mechanism by which desired clinical outcomes are achieved and is an indicator of care quality. Despite its importance, there are few fidelity measurement methods that are efficient and have demonstrated reliability and validity. Using a randomized trial design, we compared three methods of assessing CBT adherence-a core component of fidelity-to direct observation, the gold standard. Clinicians recruited from 27 community mental health agencies (n = 126; M age = 37.69 years, SD = 12.84; 75.7% female) were randomized 1:1:1 to one of three fidelity conditions: self-report (n = 41), chart-stimulated recall (semistructured interviews with the chart available; n = 42), or behavioral rehearsal (simulated role-plays; n = 43). All participating clinicians completed fidelity assessments for up to three sessions with three different clients that were recruited from clinicians' caseloads (n = 288; M age = 13.39 years SD = 3.89; 41.7% female); sessions were also audio-recorded and coded for comparison to determine the most accurate method. All fidelity measures had parallel scales that yielded an adherence maximum score (i.e., the highest-rated intervention in a session), a mean of techniques observed, and a count total of observed techniques. Results of three-level mixed effects regression models indicated that behavioral rehearsal produced comparable scores to observation for all adherence scores (all ps > .01), indicating no difference between behavioral rehearsal and observation. Self-report and chart-stimulated recall overestimated adherence compared to observation (ps < .01). Overall, findings suggested that behavioral rehearsal indexed CBT adherence comparably to direct observation, the gold-standard, in pediatric populations. Behavioral rehearsal may at times be able to replace the need for resource-intensive direct observation in implementation research and practice. [ABSTRACT FROM AUTHOR]

Background: Triptans are the most commonly prescribed acute treatments for migraine; however, not all triptan users experience adequate response. Information on real-world resource use and costs associated with triptan insufficient response are limited.Methods: A retrospective claims analysis using US commercial health plan data between 2012 and 2015 assessed healthcare resource use and costs in adults with a migraine diagnosis newly initiating triptans. Patients who either did not refill triptans but used other non-triptan medications or refilled triptans but also filled non-triptan medications over a 24-month follow-up period were designated as potential triptan insufficient responders. Patients who continued filling only triptans (i.e. triptan-only continuers) were designated as potential adequate responders. All-cause and migraine-related resource use and total (medical and pharmacy) costs over months 1-12 and months 13-24 were compared between triptan-only continuers and potential triptan insufficient responders.Results: Among 10,509 new triptan users, 4371 (41%) were triptan-only continuers, 3102 (30%) were potential triptan insufficient responders, and 3036 (29%) did not refill their index triptan or fill non-triptan medications over 24 months' follow-up. Opioids were the most commonly used non-triptan treatment (68%) among potential triptan insufficient responders over 24 months of follow-up. Adjusted mean all-cause and migraine-related total costs were $5449 and $2905 higher, respectively, among potential triptan insufficient responders versus triptan-only continuers over the first 12 months.Conclusions: In a US commercial health plan, almost one-third of new triptan users were potential triptan insufficient responders and the majority filled opioid prescriptions. Potential triptan insufficient responder patients had significantly higher all-cause and migraine-related healthcare utilization and costs than triptan-only continuers. [ABSTRACT FROM AUTHOR]

This pilot randomized clinical trial examines whether giving a financial incentive in an escalating or deescalating pattern (vs no incentive) to patients receiving antidepressants can enhance medication adherence. [ABSTRACT FROM AUTHOR]

Background: Simple nudges such as reminders and feedback reports to either a patient or a partner may facilitate improved medication adherence.Objective: To test the impact of a pill bottle used to monitor adherence, deliver a daily alarm, and generate weekly medication adherence feedback reports on statin adherence.Design: Three-month, three-arm randomized clinical trial (ClinicalTrials.gov identifier: NCT02480530).Participants: One hundred and twenty-six veterans with known coronary artery disease and poor adherence (medication possession ratio <80 %).Intervention: Patients were randomized to one of three groups: (1) a control group (n = 36) that received a pill-monitoring device with no alarms or feedback; (2) an individual feedback group (n = 36) that received a daily alarm and a weekly medication adherence feedback report; and (3) a partner feedback group (n = 54) that received an alarm and a weekly feedback report that was shared with a friend, family member, or a peer. The intervention continued for 3 months, and participants were followed for an additional 3 months after the intervention period.Main Measures: Adherence as measured by pill bottle. Secondary outcomes included change in LDL (mg/dl), patient activation, and social support.Key Results: During the 3-month intervention period, medication adherence was higher in both feedback arms than in the control arm (individual feedback group 89 %, partner feedback group 86 %, control group 67 %; p < 0.001 and = 0.001). At 6 months, there was no difference in medication adherence between either of the feedback groups and the control (individual feedback 60 %, partner feedback 52 %, control group 54 %; p = 0.75 and 0.97).Conclusions: Daily alarms combined with individual or partner feedback reports improved statin medication adherence. While neither an individual feedback nor partner feedback strategy created a sustainable medication adherence habit, the intervention itself is relatively easy to implement and low cost. [ABSTRACT FROM AUTHOR]

Background: Under the Affordable Care Act, States have obtained Medicaid waivers to overhaul their behavioral health service systems to improve quality and reduce costs. Critical to implementation of broad service delivery reforms has been the preparation of organizations responsible for service delivery. This study focused on one large-scale initiative to overhaul its service system with the goal of improving service quality and reducing costs. The study examined the participation of behavioral health organizations in technical assistance efforts and the extent to which organizational factors related to their participation.Methods: This study matched two datasets to examine the organizational characteristics and training participation for 196 behavioral health organizations. Organizational characteristics were drawn from the Substance Abuse and Mental Health Services Administration National Mental Health Services Survey (N-MHSS). Training variables were drawn from the Clinical Technical Assistance Center's master training database. Chi-square analyses and multivariate logistic regression models were used to examine the proportion of organizations that participated in training, the organizational characteristics (size, population served, service quality, infrastructure) that predicted participation in training, and for those who participated, the type (clinical or business) and intensity of training (webinar, learning collaborative, in-person) they received.Results: Overall 142 (72. 4%) of the sample participated in training. Organizations who pursued training were more likely to be large in size (p = .02), serve children in addition to adults (p < .01), provide child evidence-based practices (p = .01), and use computerized scheduling (p = .01). Of those trained, 95% participated in webinars, 64% participated in learning collaboratives and 35% participated in in-person trainings. More organizations participated in business trainings than clinical (63.8 vs. 59.2%). Organizations serving children had higher odds of participating in both clinical training (OR = 5.91, p < .01) and business training (OR = 4.24, p < .01) than those that did not serve children.Conclusions: The majority of organizations participated in trainings indicating desire for technical assistance to prepare for health care reform. Larger organizations and organizations serving children were more likely to participate potentially indicating increased interest in preparation. Over half participated in business trainings highlighting interest in learning to improve efficiency. Further understanding is needed to support organizational readiness for health care reform initiatives among behavioral health organizations. [ABSTRACT FROM AUTHOR]

Background: Anxiety disorders are prevalent in youth and associated with later depressive disorders. A recent model posits three distinct anxiety-depression pathways. Pathway 1 represents youth with a diathesis to anxiety that increases risk for depressive disorders; Pathway 2 describes youth with a shared anxiety-depression diathesis; and Pathway 3 consists of youth with a diathesis for depression who develop anxiety as a consequence of depression impairment. This is the first partial test of this model following cognitive-behavioral treatment (CBT) for child anxiety.Method: The present study included individuals (N = 66; M age = 27.23 years, SD = 3.54) treated with CBT for childhood anxiety disorders 7-19 years (M = 16.24; SD = 3.56) earlier. Information regarding anxiety (i.e., social phobia (SoP), separation anxiety disorder (SAD), generalized anxiety disorder (GAD)) and mood disorders (i.e., major depressive disorder (MDD) and dysthymic disorders) was obtained at pretreatment, posttreatment, and one or more follow-up intervals via interviews and self-reports.Results: Evidence of pathways from SoP, SAD, and GAD to later depressive disorders was not observed. Treatment responders evidenced reduced GAD and SoP over time, although SoP was observed to have a more chronic and enduring pattern.Conclusions: Evidence for typically observed pathways from childhood anxiety disorders was not observed. Future research should prospectively examine if CBT treatment response disrupts commonly observed pathways. [ABSTRACT FROM AUTHOR]

Objective: This study compared use of and associated expenditures for Medicaid-reimbursed school-based and out-of-school services for children with autism spectrum disorder (ASD) and those with other psychiatric disorders.Methods: Philadelphia County Medicaid claims were used to identify children ages five to 17 who received behavioral health services through Medicaid any time between October 2008 and September 2009 (N=24,271). Children were categorized into four diagnostic groups: autism spectrum disorder (ASD), conduct disorder or oppositional defiant disorder (conduct-ODD), attention-deficit hyperactivity disorder (ADHD), and other psychiatric disorders. Logistic regression analysis compared use of in-school and out-of-school behavioral health services between children with ASD and children with other psychiatric disorders. Generalized linear models with gamma distribution were used to estimate differences in Medicaid expenditures for in-school and out-of-school services and total Medicaid expenditures for both service types by disorder, with adjustments for age, sex, and race-ethnicity.Results: The most common diagnosis was ADHD (40%); 35% had other psychiatric disorders, 21% had conduct-ODD, and 4% had ASD. A significantly greater proportion of children with ASD (52%) received in-school behavioral health services (conduct-ODD, 5%; ADHD, 8%; and other psychiatric disorders, 1.7%) Per-child expenditures for both school-based and out-of-school behavioral health services were significantly higher for children with ASD than for children in the other groups.Conclusions: Medicaid represents an important source of in-school and out-of-school care for children with ASD and their families. States that expand Medicaid under the Affordable Care Act should give careful consideration to covering school-based mental health services for children with ASD. [ABSTRACT FROM AUTHOR]

Objective: This study estimated the impact of a statewide, centralized telepsychiatry service provided in nonpsychiatric emergency departments (EDs) on use of mental health services.Methods: Individuals treated via telepsychiatry were compared with a matched control group of individuals with mental health diagnoses who were treated in nonparticipating hospitals. Bivariate and two-part and generalized linear regression models were used to assess differences between the two groups in outpatient follow-up, hospital admission following the ED visit, length of hospital stay if admitted, and inpatient and total costs.Results: Between March 2009 and June 2013, there were 9,066 patients with at least one telepsychiatry visit. Of these, 7,261 had index telepsychiatry visits that the authors were able to successfully match. Compared with the matched control group, telepsychiatry recipients were more likely to receive 30-day outpatient follow-up (46% versus 16%, p<.001) and 90-day outpatient follow-up (54% versus 20%, p<.001). Telepsychiatry recipients were less likely than the control group to be admitted to the hospital during the index ED visit (11% versus 22%, p<.001). The combined effect of having a telepsychiatry consult during the index ED visit was a reduction of .86 days in inpatient length of stay. Thirty-day inpatient costs were $2,336 (p=.04) lower for the telepsychiatry versus the control group, but 30-day total health care costs were not statistically different.Conclusions: Telepsychiatry delivered in the ED through a centralized coordinated program has great promise for improving linkage with outpatient mental health services while reducing inpatient utilization and hospital costs. [ABSTRACT FROM AUTHOR]

The Affordable Care Act offers strong support for comparative effectiveness research, which entails comparisons among active treatments, to provide the foundation for evidence-based practice. Traditionally, a key form of research into the effectiveness of therapeutic treatments has been placebo-controlled trials, in which a specified treatment is compared to placebo. These trials feature high-contrast comparisons between treatments. Historical trends in placebo-controlled trials have been evaluated to help guide the comparative effectiveness research agenda. We investigated placebo-controlled trials reported in four leading medical journals between 1966 and 2010. We found that there was a significant decline in average effect size or average difference in efficacy (the ability to produce a desired effect) between the active treatment and placebo. On average, recently studied treatments offered only small benefits in efficacy over placebo. A decline in effect sizes in conventional placebo-controlled trials supports an increased emphasis on other avenues of research, including comparative studies on the safety, tolerability, and cost of treatments with established efficacy. [ABSTRACT FROM AUTHOR]

Objectives. We investigated whether health insurance type (private vs Medicaid) influences the delivery of acute mental health care to patients with deliberate self-harm. Methods. Using National Medicaid Analytic Extract Files (2006) and Market- Scan Research Databases (2005-2007), we analyzed claims focusing on emergency episodes of deliberate self-harm of Medicaid- (n = 8228) and privately (n = 2352) insured adults. We analyzed emergency department mental health assessments and outpatient mental health visits in the 30 days following the emergency visit for discharged patients. Results. Medicaid-insured patients were more likely to be discharged (62.7%), and among discharged patients they were less likely to receive a mental health assessment in the emergency department (47.8%) and more likely to receive follow-up outpatient mental health care (52.9%) than were privately insured patients (46.9%, 57.3%, and 41.2%, respectively). Conclusions. Acute emergency management of deliberate self-harm is less intensive for Medicaid- than for privately insured patients, although discharged Medicaid-insured patients are more likely to receive follow-up care. Programmatic reforms are needed to improve access to emergency mental health services, especially in hospitals that serve substantial numbers of Medicaid insured patients. [ABSTRACT FROM AUTHOR]

This study examines clinical and non-clinical factors associated with treatment compliance problems in 342 patients with substance use disorders (SUD) seen in routine psychiatric practice. Weighted Wald-X(2) and multivariate logistic regression assessed sociodemographic, clinical, treatment, and health plan characteristics associated with treatment compliance problems. Among patients with SUD, 40.5% were reported to currently have treatment compliance problems. Patients with treatment compliance problems were significantly more likely to have personality disorders, lower global assessment of functioning scores, and medication side effects than those without treatment compliance problems. Patients seen by psychiatrists who were reimbursed by discounted rather than undiscounted fee-for-service were five times more likely to be reported to have treatment compliance problems. Both clinical and non-clinical factors appear to be associated with treatment compliance problems. Understanding these factors and targeting treatment interventions may improve treatment compliance and patient outcomes. [ABSTRACT FROM AUTHOR]

This study examined the sociodemographic and practice characteristics of psychiatrists whose caseloads consist primarily of patients with Substance Use Disorders (SUD). A survey instrument was completed by a random sample of 865 psychiatrists. Study groups were defined as high-SUD providers if psychiatrists reported having 51% or more patients with SUD (n=92) and non-SUD providers as those who reported not having any patients with SUD (n=128). High-SUD providers tended to be younger, more likely to graduate from international medical schools, have larger caseloads, work more hours per week, and have a higher proportion of inpatients and publicly funded patients than non-SUD providers. Results suggest that psychiatrists who primarily treat patients with SUD are in their early careers and treat patients with more clinical, psychosocial, and economic disadvantages. The implications of these findings for psychiatry training programs and policy makers will be discussed. [ABSTRACT FROM AUTHOR]