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A few clients in every mental health center present challenging behaviors, have difficulty engaging in services, and create stress within the treatment team. The authors provided consultations on clients with these characteristics over 4 years in the Social Security Administration's Supported Employment Demonstration (SED).Four experienced community mental health leaders provided consultations on 105 of nearly 2,000 clients receiving team-based behavioral health and employment services in the SED. Using document analysis, consultants coded their notes and identified themes that described barriers to client engagement and strategies teams used to overcome them.Clients who were difficult to engage experienced complex and interacting behavioral health, medical, and social conditions, which made it hard for therapists to develop therapeutic relationships and help clients find employment. Faced with engagement barriers, staff were often discouraged and felt hopeless about achieving success. To address these barriers, consultants and teams developed several strategies: using supervisors and teammates for support, providing persistent outreach, pursuing referrals and consultations to help with complex conditions, and developing realistic goals.Supervisors, team leaders, and consultants in community mental health settings should help staff develop realistic strategies to manage the small number of clients whose behaviors present the greatest challenges. Effective strategies involve providing team-based outreach and support, fostering staff morale, obtaining specialist consultations regarding complex conditions, and calibrating realistic goals.

This survey examined the experiences of individuals receiving treatment in a large public mental health system during the early months of the COVID-19 pandemic.The survey, conducted between May and June 2020, assessed four domains: impacts on mental health, experiences with telehealth, access to care and resources, and sources and adequacy of support. Descriptive analyses were conducted.Of 4,046 respondents, 70% reported increases in their anxiety and stress because of the pandemic. A majority (55%) reported experiencing challenges related to the social determinants of health and functional needs. Most respondents reported that their care went undisrupted, with 92% using telehealth and 90% reporting feeling adequately supported.The pandemic substantially affected individuals with mental illness, particularly with regard to mental health related to the social determinants of health and functional needs. However, respondents felt that their mental health care was maintained and that they were adequately supported.

ObjectiveThis study examined the extent to which prehospital treatment engagement is related to posthospital follow-up treatment among psychiatric inpatients and whether the effects of inpatient discharge planning on posthospital follow-up treatment vary by level of pretreatment engagement in care.MethodsNew York State Medicaid and other administrative databases were used to examine service use by 18,793 adult patients discharged to the community after inpatient psychiatric care in 2012-2013. Outcomes included attending an outpatient mental health service within 7 days and within 30 days after discharge. The sample was stratified by whether patients had high, partial, low, or no engagement in outpatient psychiatric services in the 6 months before admission.ResultsScheduling an outpatient appointment as part of the patient's discharge plan was significantly associated with attending outpatient psychiatric appointments, regardless of the patient's level of engagement in care before admission. The differences were most pronounced for patients who had not received any outpatient care in the 6 months before admission. When an appointment was scheduled, these patients were three times more likely to follow up with care within 7 days and more than twice as likely to follow up within 30 days than were patients without a scheduled appointment.ConclusionsThe likelihood of psychiatric inpatients following up with outpatient psychiatric care was directly related to their level of outpatient care engagement before hospital admission. Even among those who had not been engaged in outpatient care, inpatient discharge planning was associated with a greater likelihood of receiving follow-up outpatient care.

Individuals with serious mental illness are particularly vulnerable to COVID-19. The New York State (NYS) Office of Mental Health implemented patient and staff rapid testing, quarantining, and vaccination to limit COVID-19 spread in 23 state-operated psychiatric hospitals between November 2020 and February 2021. COVID-19 infection rates in inpatients and staff decreased by 96% and 71%, respectively, and the NYS population case rate decreased by 6%. Repeated COVID-19 testing and vaccination should be priority interventions for state-operated psychiatric hospitals. (Am J Public Health. 2021;111(10):1780–1783. https://doi.org/10.2105/AJPH.2021.306444 )

BackgroundMany healthcare workers do not seek help, despite their enormous stress and greater risk for anxiety, depression and post-traumatic stress disorder (PTSD).AimsThis study screened for psychopathology and evaluated the efficacy of a brief, social contact-based video intervention in increasing treatment-seeking intentions among healthcare workers (trial registration: NCT04497415). We anticipated finding high rates of psychopathology and greater treatment-seeking intentions post-intervention.MethodHealthcare workers (n = 350) were randomised to (a) a brief video-based intervention at day 1, coupled with a booster video at day 14; (b) the video at day 1 only; or (c) a non-intervention control. In the 3 min video, a female nurse described difficulty coping with stress, her anxieties and depression, barriers to care and how therapy helped her. Assessments were conducted pre- and post-intervention and at 14- and 30-day follow-ups.ResultsOf the 350 healthcare workers, 281 (80%) reported probable anxiety, depression and/or PTSD. Participants were principally nurses (n = 237; 68%), physicians (n = 52; 15%) and emergency medical technicians (n = 30; 9%). The brief video-based intervention yielded greater increases in treatment-seeking intentions than the control condition, particularly among participants in the repeat-video group. Exploratory analysis revealed that in both video groups, we found greater effect among nurses than non-nurses.ConclusionsA brief video-based intervention increased treatment-seeking intention, possibly through identification and emotional engagement with the video protagonist. A booster video magnified that effect. This easily disseminated intervention could increase the likelihood of seeking care and offer employers a proactive approach to encourage employees to search for help if needed.

Background Schizophrenia (SZ) is associated with devastating emotional, cognitive and language impairments. Understanding the deficits in each domain and their interactions is important for developing novel, targeted psychotherapies. This study tested whether negative-threat word processing is altered in individuals with SZ compared to healthy controls (HC), in relation to SZ symptom severity across domains. Methods Thirty-one SZ and seventeen HC subjects were scanned with functional magnetic resonance imaging while silently reading negative-threat and neutral words. Post-scan, subjects rated the valence of each word. The effects of group (SZ, HC), word type (negative, neutral), task period (early, late), and severity of clinical symptoms (positive, negative, excitement/hostility, cognitive, depression/anxiety), on word valence ratings and brain activation, were analyzed. Results SZ and HC subjects rated negative versus neutral words as more negative. The SZ subgroup with severe versus mild excitement/hostility symptoms rated the negative words as more negative. SZ versus HC subjects hyperactivated left language areas (angular gyrus, middle/inferior temporal gyrus (early period)) and the amygdala (early period) to negative words, and the amygdala (late period) to neutral words. In SZ, activation to negative versus neutral words in left dorsal temporal pole and dorsal anterior cingulate was positively correlated with excitement/hostility scores. Conclusions A negatively-biased behavioral response to negative-threat words was seen in SZ with severe versus mild excitement/hostility symptoms. The biased behavioral response was mediated by hyperactivation of brain networks associated with semantic processing of emotion concepts. Thus, word-level semantic processing may be a relevant psychotherapeutic target in SZ.

Strengthening evidence base and earmarked federal funding has spurred implementation of Coordinated Specialty Care (CSC) for people experiencing early psychosis. However, existing funding mechanisms are insufficient and unsustainable to support population deployment of CSC. This paper describes the design framework of an innovative payment model for CSC that includes a bundled case rate payment and an optional outcome-based payment. To assist CSC payer and provider organizations in designing payment systems tailored to local preferences and circumstances, the research team is developing a decision-support tool that allows users to define design choices and provide inputs. This paper documents the analytical algorithms underlying the tool and discusses ways by which the tool could be further developed or expanded for CSC and other behavioral health interventions that feature an interdisciplinary team of clinicians and non-clinical professionals, public education and outreach, patient-centeredness, and a recovery orientation.

Reducing the overrepresentation of individuals with serious mental illnesses in the criminal legal system requires a better understanding of the charges for which they are most commonly arrested. This study aimed to compare violent offenses, penal code classifications, Uniform Crime Reporting (UCR) codes, and specific charges in arrests among individuals with and individuals without serious mental illnesses.The authors analyzed all arrests (N=2,224,847) in New York State during 2010-2013. Medicaid data and the state mental health authority's records were used to create an indicator of serious mental illness for each arrest.Among arrests involving individuals with the serious mental illness indicator (N=91,363), 7.3% were for violent offenses, compared with 7.6% of arrests involving individuals without the indicator. Among 10 penal code classifications, class B felonies and class A misdemeanors were more likely in arrests among those with the indicator than among those without it. Of the 14 UCR codes examined, seven were more common in arrests with the serious mental illness indicator. Criminal trespass was among the most common charges in arrests involving individuals with the indicator.Most arrests involving people with serious mental illnesses were for misdemeanors, specifically class A misdemeanors, and this class comprised a larger proportion of arrests for those with the indicator than of arrests for those without it. New approaches are needed to address the situations-usually related to socioeconomic disadvantage-that result in individuals with mental illnesses receiving misdemeanor charges and cycling through the criminal legal system.

This analysis examined the distribution of four social determinants of health among recipients of state-licensed mental health services and analyzed relationships between determinants and individuals' clinical and demographic characteristics.With data from the New York State Office of Mental Health 2017 Patient Characteristics Survey (N=103,416), prevalences of four social determinants (education, employment, housing, and criminal legal involvement) among mental health service recipients were described. Results were stratified to explore differences by diagnosis, gender, race and ethnicity, and region of residence.High proportions had low education (20.9%), unemployment (79.1%), homelessness (8.2%), and criminal legal involvement (12.2%), surpassing statistics for the general state population. Prevalences of alcohol-related, drug-related, and psychotic disorders were higher among these groups than were prevalences of other diagnoses. People of color and male recipients were overrepresented among those with adverse social determinants.Results highlight the magnitude of social adversity among those receiving mental health services, as well as potential inequities.

Individuals with serious mental illness are at increased risk of severe COVID-19 infection. Several psychotropic medications have been identified as potential therapeutic agents to prevent or treat COVID-19 but have not been systematically examined in this population.To evaluate the associations between the use of psychotropic medications and the risk of COVID-19 infection among adults with serious mental illness receiving long-term inpatient psychiatric treatment.This retrospective cohort study assessed adults with serious mental illness hospitalized in a statewide psychiatric hospital system in New York between March 8 and July 1, 2020. The final date of follow-up was December 1, 2020. The study included 1958 consecutive adult inpatients with serious mental illness (affective or nonaffective psychoses) who received testing for SARS-CoV-2 by reverse transcriptase-polymerase chain reaction or antinucleocapsid antibodies and were continuously hospitalized from March 8 until medical discharge or July 1, 2020.Psychotropic medications prescribed prior to COVID-19 testing.COVID-19 infection was the primary outcome, defined by a positive SARS-CoV-2 reverse transcriptase-polymerase chain reaction or antibody test result. The secondary outcome was COVID-19-related death among patients with laboratory-confirmed infection.Of the 2087 adult inpatients with serious mental illness continuously hospitalized during the study period, 1958 (93.8%) underwent testing and were included in the study; 1442 (73.6%) were men, and the mean (SD) age was 51.4 (14.3) years. A total of 969 patients (49.5%) had laboratory-confirmed COVID-19 infection that occurred while they were hospitalized; of those, 38 (3.9%) died. The use of second-generation antipsychotic medications, as a class, was associated with decreased odds of infection (odds ratio [OR], 0.62; 95% CI, 0.45-0.86), whereas the use of mood stabilizers was associated with increased odds of infection (OR, 1.23; 95% CI, 1.03-1.47). In a multivariable model of individual medications, the use of paliperidone was associated with decreased odds of infection (OR, 0.59; 95% CI, 0.41-0.84), and the use of valproic acid was associated with increased odds of infection (OR, 1.39; 95% CI, 1.10-1.76). Clozapine use was associated with reduced odds of mortality in unadjusted analyses (unadjusted OR, 0.25; 95% CI, 0.10-0.62; fully adjusted OR, 0.43; 95% CI, 0.17-1.12).In this cohort study of adults hospitalized with serious mental illness, the use of second-generation antipsychotic medications was associated with decreased risk of COVID-19 infection, whereas the use of valproic acid was associated with increased risk. Further research is needed to assess the mechanisms that underlie these findings.

OBJECTIVE: Although specialized early intervention services (EISs) for psychosis promote engagement in care, a substantial number of individuals who receive these services are discharged from care earlier than expected. The main goal of this study was to examine predictors of early discharge in a large sample of individuals enrolled in an EIS program in the United States.METHODS: This cohort study (N=1,349) used programmatic data from OnTrackNY, an EIS program that delivers evidence-based interventions to youths across New York State experiencing a first episode of nonaffective psychosis. The main outcome was "early discharge," which was operationalized as discharge prior to completing 12 months of treatment. Cox proportional hazard regression models were used to assess the association between sociodemographic, clinical, and support system predictors and early discharge.RESULTS: The estimated probability of discharge before 1 year was 32%. Participants who at baseline had poor medication adherence, had no health insurance, were living alone or with nonparental family, or were using cannabis were at higher risk of leaving services within the first 12 months after enrollment. Individuals with higher social functioning were at lower risk of being discharged early from OnTrackNY, but those with higher occupational functioning were at a higher risk.CONCLUSIONS: Predictors of early discharge from EISs largely overlapped with previously identified predictors of poor prognosis in early psychosis. However, the association between early discharge and high occupational functioning indicates that trajectories leading up to discharge are heterogeneous.

Readmission after inpatient care for a psychiatric condition is associated with a range of adverse events including suicide and all-cause mortality. This study estimated 30-day readmission rates in a large cohort of inpatient psychiatric admissions in New York State and examined how these rates varied by patient, hospital, and service system characteristics. Data were obtained from Medicaid claims records, and clinician, hospital, and region data, for individuals with a diagnosis of any mental disorder admitted to psychiatric inpatient units in New York State from 2012 to 2013. Psychiatric readmission was defined as any unplanned inpatient stay with a mental health diagnosis with an admission date within 30 days of being discharged. Unadjusted and adjusted odds ratios of being readmitted within 30 days were estimated using logistic regression analyses. Over 15% of individuals discharged from inpatient units between 2012 and 2013 were readmitted within 30 days. Patients who were readmitted were more likely to be homeless, have a schizoaffective disorder or schizophrenia, and have medical comorbidity. Readmission rates varied in this cohort mainly because of individual-level characteristics. Homeless patients were at the highest risk of being readmitted after discharge.

OBJECTIVES: People with severe mental illness (SMI) are ten times more likely to have HIV/AIDS than the general population, yet little is known about the characteristics and frequency of recognition of pre-existing HIV/AIDS diagnoses among inpatients with SMI. This study examines documentation rates of pre-existing HIV/AIDS among inpatients within psychiatric hospitals in New York State. DESIGN: Retrospective cohort study to examine recognition of pre-existing HIV/AIDS among psychiatric inpatients. METHODS: Patient-level Medicaid claims records were linked with hospital and regional data for people admitted to psychiatric inpatient units in New York State. Presence of HIV/AIDS diagnoses prior to psychiatric hospitalization was coded for each inpatient (n=14,602). Adjusted odds ratios (aORs) of undocumented HIV/AIDS diagnoses at the time of discharge were calculated using logistic regression analyses. RESULTS: 5.1% (741/14,602) of unique psychiatric inpatients had pre-existing HIV/AIDS diagnoses. Of these inpatients, 58.3% (432/741) were not coded as having HIV/AIDS upon discharge. Higher rates of missed detection were associated with younger age, non-Hispanic white race/ethnicity, shorter length of stay, more distal coding of an HIV/AIDS diagnosis, and fewer HIV/AIDS-related Medicaid claims in the past year. Hospitals with higher re-admission rates also had higher rates of undetected HIV/AIDS diagnoses. CONCLUSION: Over half of inpatients previously diagnosed with HIV/AIDS did not have their HIV-positive status noted upon discharge from psychiatric hospitalization. This finding underscores how frequently clinically significant medical comorbidities fail to be incorporated into psychiatric treatment and treatment planning. Inpatient clinicians are missing important opportunities to optimize HIV/AIDS treatment and reduce morbidity and mortality.

Individuals with serious mental illnesses and poorly managed medical conditions known as serious medical-psychiatric illnesses (SMPIs) are vulnerable to disruptions in care, resulting in poor outcomes. Intensive integrated care management approaches are indicated when these individuals are hospitalized on medical-surgical inpatient units in order to ensure continuity of medical and psychiatric services. This column describes a manualized intervention for hospitalized individuals with SMPIs that was developed in a National Institute of Mental Health ALACRITY research center. The approach uses a critical time intervention model incorporating motivational interviewing and shared decision making to maximize engagement and continuity of care for individuals with SMPIs.

BackgroundEmerging cross-sectional data indicate that healthcare workers (HCWs) in the COVID-19 era face particular mental health risks. Moral injury – a betrayal of one’s values and beliefs, is a potential concern for HCWs who witness the devastating impact of acute COVID-19 illness while too often feeling helpless to respond. This study longitudinally examined rates of depression, generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), and moral injury among United States HCWs in the COVID-19 era. We anticipated finding high levels of clinical symptoms and moral injury that would remain stable over time. We also expected to find positive correlations between clinical symptoms and moral injury.MethodsThis three-wave study assessed clinical symptoms and moral injury among 350 HCWs at baseline, 30, and 90 days between September and December 2020. Anxiety, depression, PTSD, and moral injury were measured using the Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), Primary Care PTSD Screen (PC-PTSD), and Moral Injury Events Scale (MIES).ResultsOf the 350 HCWs, 72% reported probable anxiety, depression, and/or PTSD disorders at baseline, 62% at day 30, and 64% at day 90. High level of moral injury was associated with a range of psychopathology including suicidal ideation, especially among healthcare workers self-reporting COVID-19 exposure.ConclusionsFindings demonstrate broad, persisting, and diverse mental health consequences of the COVID-19 pandemic among United States HCWs. This study is the first to longitudinally examine the relationships between moral injury and psychopathology among HCWs, emphasizing the need to increase HCWs’ access to mental healthcare.

Synopsis Numerous reports describe how individual hospitals responded to the COVID-19 pandemic, but few describe how these changes occurred across a large public health system of care. As the early epicenter of the pandemic, New York State’s response, particularly the New York City metropolitan area, included a range of coordinated planning and regulatory efforts to preserve and create medical and intensive care unit capacity where needed; maintain access to acute psychiatric services; and redefine inpatient psychiatric care through strict infection control, easing of regulatory requirements, and use of telehealth. These strategies reflected similar efforts across the United States. Integration of public and not-for-profit hospital systems with each other and the residential and outpatient community remain key challenges.

OBJECTIVE: This study examined whether communications between inpatient and outpatient mental health providers during patients’ inpatient stays were associated with attendance at post-hospital discharge appointments. METHODS: One-hundred-eighty-nine psychiatric inpatient medical records of Medicaid recipients at two hospitals were reviewed to document whether inpatient staff communicated with current or prior outpatient providers. Medicaid claims provided demographic, clinical, and outpatient attendance data. Analyses evaluated the association between provider communications and follow-up care for patients who had/had not received outpatient mental health care within 30 days prior to admission. RESULTS: Inpatient staff communicated with outpatient providers for 118 (62%) patients. For patients who did not receive outpatient care within 30 days of admission, communication was associated with increased odds of attending timely outpatient appointments post discharge (OR:2.73, 95% CI:1.09–6.84). CONCLUSIONS: Communicating with outpatient providers may be especially important for patients who were not engaged in outpatient care prior to admission.

Background Substantial data from high-income countries support early interventions in the form of evidence-based Coordinated Specialty Care (CSC) for people experiencing First Episode Psychosis (FEP) to ameliorate symptoms and minimize disability. Chile is unique among Latin American countries in providing universal access to FEP services through a national FEP policy that mandates the identification of FEP individuals in primary care and guarantees delivery of community-based FEP treatments within a public health care system. Nonetheless, previous research has documented that FEP services currently provided at mental health clinics do not provide evidence-based approaches. This proposal aims to address this shortfall by first adapting OnTrackNY (OTNY), a CSC program currently being implemented across the USA, into OnTrackChile (OTCH), and then examine its effectiveness and implementation in Chile. Methods The Dynamic Adaptation Process will be used first to inform the adaptation and implementation of OTCH to the Chilean context. Then, a Hybrid Type 1 trial design will test its effectiveness and cost and evaluate its implementation using a cluster-randomized controlled trial (RCT) (N = 300 from 21 outpatient clinics). The OTCH program will be offered in half of these outpatient clinics to individuals ages 15-35. Usual care services will continue to be offered at the other clinics. Given the current COVID-19 pandemic, most research and intervention procedures will be conducted remotely. The study will engage participants over the course of 2 years, with assessments administered at enrollment, 12 months, and 24 months. Primary outcomes include implementation (fidelity, acceptability, and uptake) and service outcomes (person-centeredness, adherence, and retention). Secondary outcomes comprise participant-level outcomes such as symptoms, functioning, and recovery orientation. Over the course of the study, interviews and focus groups with stakeholders will be conducted to better understand the implementation of OTCH. Discussion Findings from this study will help determine the feasibility, effectiveness, and cost for delivering CSC services in Chile. Lessons learned about facilitators and barriers related to the implementation of the model could help inform the approach needed for these services to be further expanded throughout Latin America. Trial registration www.ClinicalTrials.govNCT04247711. Registered 30 January 2020. Trial status The OTCH trial is currently recruiting participants. Recruitment started on March 1, 2021, and is expected to be completed by December 1, 2022. This is the first version of this protocol (5/12/2021).

Social determinants are receiving renewed attention as research demonstrates the effects of social factors on individuals’ physical and mental health and elucidates the biological and psychological mechanisms underlying those effects. Through spheres of influence from policy and regulation development to direct service provision, state mental health agencies are in a unique position to lead primary and secondary prevention efforts aimed at addressing social determinants with both client-level and structural-level interventions. A survey of social determinants-related activity was sent to the Medical Directors of the state offices of mental health in all 50 states. The survey results suggest consensus among respondents as to the importance of addressing specific social determinants. However, few state mental health agencies have taken on a comprehensive and intentional approach to addressing social determinants as a unique area of activity. Specific activities are reviewed, and implications for future work is discussed.

OBJECTIVE: Therapeutic benefits associated with early services for psychosis are influenced by the degree to which participants engage in treatment. The main objective of this review was to analyze rates of disengagement in early psychosis services and identify predictors of disengagement in these settings.METHODS: A systematic search for studies published in the 1966-2019 period was conducted in PubMed, Google Scholar, EBSCO, Ovid, and Embase. The Observational Cohort and Cross-Sectional Studies scale was used to assess the methodological quality of reports identified in this search. A revised version of the behavioral model of health service use was employed to evaluate and understand predictors of disengagement (categorized as predisposing, enabling, and need factors) identified in the studies with the highest quality.RESULTS: Twenty studies met the inclusion criteria. Disengagement rates (12% to 53%) and definitions of disengagement varied widely across these studies. Most did not find a compelling association between predisposing factors (e.g., age) and disengagement. Enabling factors, such as lack of family support and living alone, were consistently found to be related to increased disengagement across studies. Finally, need factors, such as lower medication adherence and higher drug misuse, were associated with higher risk for disengagement.CONCLUSIONS: Enabling and need factors seemed to be the most predictive of disengagement from early psychosis services. Substantial between-study variation in identified predictors of disengagement may be addressed by developing and applying a consensus definition of disengagement in future research.

Patients diagnosed with basal-like breast cancer suffer from poor prognosis and limited treatment options. There is an urgent need to identify new targets that can benefit patients with basal-like and claudin-low (BL-CL) breast cancers. We screened fractions from our Marine Invertebrate Compound Library (MICL) to identify compounds that specifically target BL-CL breast cancers. We identified a previously unreported trisulfated sterol, i.e., topsentinol L trisulfate (TLT), which exhibited increased efficacy against BL-CL breast cancers relative to luminal/HER2+ breast cancer. Biochemical investigation of the effects of TLT on BL-CL cell lines revealed its ability to inhibit activation of AMP-activated protein kinase (AMPK) and checkpoint kinase 1 (CHK1) and to promote activation of p38. The importance of targeting AMPK and CHK1 in BL-CL cell lines was validated by treating a panel of breast cancer cell lines with known small molecule inhibitors of AMPK (dorsomorphin) and CHK1 (Ly2603618) and recording the increased effectiveness against BL-CL breast cancers as compared with luminal/HER2+ breast cancer. Finally, we generated a drug response gene-expression signature and projected it against a human tumor panel of 12 different cancer types to identify other cancer types sensitive to the compound. The TLT sensitivity gene-expression signature identified breast and bladder cancer as the most sensitive to TLT, while glioblastoma multiforme was the least sensitive.

The prevalence of smoking is higher among individuals with serious mental illnesses than the general population. Evidence-based practices exist for tobacco cessation, but little is known about mental health clinics' tobacco cessation treatment practices/protocols. Mental health clinics in New York State were surveyed about their tobacco use treatment protocols and outdoor-smoking policies. One-third of clinics were not providing individual counseling for tobacco use disorder, 39% were not prescribing nicotine replacement therapy, and nearly half reported not prescribing bupropion or varenicline. Even smaller proportions reported implementing other clinical practice guidelines, with only 25.2% providing staff training and 20.3% having a dedicated staff member for coordinating tobacco use disorder treatment. Regarding outdoor smoke-free policies, 38% of clinics reported not allowing any tobacco use anywhere on grounds. Despite some successes, many clinics do not provide evidence-based tobacco use treatments, meaning important opportunities exist for mental health clinics and oversight agencies to standardize practices.

Objective This study examined a cohort of 15,520 inpatient psychiatric discharges to determine associations between scheduling an outpatient mental health appointment as part of discharge planning and attending outpatient care following discharge after control for patient, hospital, and system characteristics. Methods 2012-2013 New York State Medicaid and other administrative databases were used to examine patients who were aged under 65 years, admitted to an inpatient psychiatric unit, and discharged to the community. Outcomes included attending an outpatient mental health service within 7 and 30 days following inpatient discharge. Scheduling a mental health outpatient appointment as part of the discharge plan was the primary predictor variable, and potentially confounding covariates were addressed by adjusting for propensity scores estimating the likelihood of having an outpatient appointment scheduled. Results Among 15,520 discharged patients, 11,945 (77%) had an outpatient appointment scheduled with a mental health provider as part of their discharge planning. After adjustment for propensity scores, patients who had an outpatient appointment scheduled were significantly more likely to attend an outpatient mental health service within 7 (OR = 1.69; 95% CI, 1.48-1.94) and 30 days (OR = 1.65; 95% CI, 1.42-1.93) compared to patients who did not have an appointment scheduled. Even among those with a low propensity to have an appointment scheduled, scheduling an outpatient appointment was associated with attending outpatient services. Conclusions Scheduling an outpatient mental health appointment is an effective and low-resource discharge planning practice that should be an important target for inpatient psychiatric clinical quality measurement and improvement.

Chemistry drives many biological interactions between the microbiota and host animals, yet it is often challenging to identify the chemicals involved. This poses a problem, as such small molecules are excellent sources of potential pharmaceuticals, pretested by nature for animal compatibility. We discovered anti-HIV compounds from small, marine tunicates from the Eastern Fields of Papua New Guinea. Tunicates are a reservoir for novel bioactive chemicals, yet their small size often impedes identification or even detection of the chemicals within. We solved this problem by combining chemistry, metagenomics, and synthetic biology to directly identify and synthesize the natural products. We show that these anti-HIV compounds, the divamides, are a novel family of lanthipeptides produced by symbiotic bacteria living in the tunicate. Neighboring animal colonies contain structurally related divamides that differ starkly in their biological properties, suggesting a role for biosynthetic plasticity in a native context where biological interactions take place.

OBJECTIVE The study aimed to clarify the potential role and impact of behavioral health peer support providers on community hospital acute inpatient psychiatric units. METHOD Qualitative interviews were conducted to examine perspectives of peer support providers (peers) and individuals who initially received peer services (recipients) during an inpatient stay on a community hospital psychiatric unit. Interviews elicited perspectives on interactions between peers and recipients, the role of peers vis-a-vis the clinical treatment team, and involvement of peers in discharge planning and transitions to community-based care. Fourteen interviews were completed (6 peers and 8 recipients of peer services); all were recorded, transcribed, and coded using a thematic analysis approach. RESULTS Emergent themes were grouped into 3 domains: (a) initial impressions and client engagement, (b) peer interventions to support discharge planning, and (c) shared or sharing experiences in an inpatient setting. Recipients described inpatient experiences as disempowering and humiliating and reported powerful positive initial reactions to peers who had had similar experiences but who also displayed competence and professionalism. Peers and recipients described strong emotional connections that differed from traditional attitudes and relationships with clinical staff. Peers described challenges and obstacles related to interactions with the clinical treatment team, and both peers and recipients strongly endorsed the role of peers in facilitating successful care transitions. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Behavioral health peers can play important roles in acute inpatient psychiatric care, supplementing clinical treatment team activities and filling important gaps related to engagement, discharge planning, and care transitions. (PsycINFO Database Record

Objective Shortened life expectancy of people with mental disorders has been attributed to medical comorbidities, yet these conditions remain under-recognized and under-treated. This study characterizes the medical demands placed on inpatient psychiatric units to help guide medical assessment and management practices in these settings. Methods Medicaid claims records and clinician data were linked with hospital and regional data for individuals with a principal diagnosis of any mental disorder admitted to psychiatric inpatient units in New York State from 2012 to 2013. A modified Elixhauser Comorbidity Index (ECI) score was calculated for each unique individual (n = 14,458). Adjusted odds ratios (AORs) of having a medical comorbidity were calculated using logistic regression analyses. Results 74.9% of psychiatric inpatients had at least one medical comorbidity, including 57.5% of people ages 18–24. Higher rates of medical comorbidity were associated with older age, female gender, non-schizophrenia diagnoses, and engagement in care prior to hospitalization. Patients with medical comorbidities had lower odds (AOR 0.54; 99% CI 0.35–0.83) of being treated in hospitals with 100 or more total beds compared to smaller hospitals. Conclusions A high prevalence of common medical diagnoses among psychiatric inpatients underscores the importance of adequate detection and medical treatment of medical comorbidities in psychiatric inpatient settings.

Involving family in the care of inpatients with serious mental illness is known to be beneficial. This study examined frequencies of involvement by family in the care and discharge planning for 179 psychiatric inpatients.Involvement by family in care and discharge planning was assessed from randomly selected medical records of inpatients with Medicaid and severe mental illness at two New York hospitals from 2012 to 2013. "Family" also included anyone close to the patient who provided support. Medicaid claims were reviewed for patient demographic and clinical characteristics and for postdischarge outpatient attendance data. Multiple regression models were used to test whether involvement by family was associated with comprehensive discharge planning (contacting outpatient providers, scheduling follow-up appointments, and forwarding a discharge summary to a provider) and initiation of outpatient treatment.Inpatient staff contacted a family member for 134 (75%) patients. Sixty-seven (37%) patients received comprehensive discharge planning, and 96 (53%) and 139 (78%) attended an outpatient appointment within 7 and 30 days of discharge, respectively. Inpatient staff contacting family, communicating about the patient's health and/or mental health, and communicating about the discharge plan were significantly associated with entry into follow-up care by 7 and 30 days postdischarge. Family phone calls and/or visits with patients, attendance at family therapy sessions, and communication with inpatient staff about services available to families were significantly associated with patients receiving comprehensive discharge planning. When analyses controlled for demographic and clinical factors, having any involvement between family members and inpatient staff was significantly associated with patients' attending an outpatient appointment by 7 days (odds ratio [OR]=2.79, 95% confidence interval [CI]=1.28-6.08) or 30 days (OR=3.07, 95% CI=1.29-7.32) after discharge.The association of family involvement with comprehensive discharge planning and prompt entry into outpatient care underscores the importance of family contact and communication with staff during inpatient hospitalizations.

As coordinated specialty care for first-episode psychosis is implemented nationally, questions arise regarding financial sustainability. To address this, New York State undertook a time study in which 13 coordinated specialty care sites reported all activities provided to 75 randomly selected Medicaid clients with first-episode psychosis over a 2-week period. The average estimated cost was $1,375 per client per month, yet under optimal billing conditions, estimated revenues were only $662 per client per month, or 48% of the costs. These results underscore the need for continued subsidies and novel payment schemes for coordinated specialty care.

This study examined discharge planning practices by hospital providers for 17,053 psychiatric discharges in New York's statewide Medicaid program.Claims data were linked to information reported to New York State by managed behavioral health care organizations (MBHOs) conducting inpatient utilization reviews. MBHOs documented hospital providers' reports of the presence of three discharge planning practices for each discharge: communicating with an outpatient provider prior to discharge, scheduling an aftercare appointment, and forwarding a discharge summary.Hospital providers reported completing at least one of the three discharge planning practices for 85% of discharges. Individuals who received all three discharge planning practices had a higher likelihood of follow-up and kept their first outpatient follow-up visit at almost twice the speed compared with individuals who received none of the practices (hazard ratio=1.96, p.001).This study provided baseline information concerning routine discharge planning practices and their relationship to timeliness of care transitions.

This study examined the adherence of psychiatrists to the Schedule of Recommended First and Second Line Antipsychotic Medications ("Antipsychotic Schedule"), which was implemented in two Recovery After an Initial Schizophrenia Episode (RAISE) Connection Program Implementation and Evaluation Study clinics.Sixty-five individuals with a first episode of psychosis were enrolled in the RAISE Connection Program clinics. Two psychiatrists received training and ongoing consultation on use of a shared decision-making approach to prescribing antipsychotic medications according to the Antipsychotic Schedule. Information about participants, prescribed antipsychotic medications, and completion of side-effect assessments were obtained from standardized research assessments and chart extractions. Descriptive statistics were used to characterize the extent to which patterns of antipsychotic prescribing and side-effect monitoring were consistent with the Antipsychotic Schedule.Ninety-two percent of participants were prescribed an antipsychotic medication and received the medication on 76%±35% of the days they were in treatment. Seventy-seven percent of participants were prescribed at least one Antipsychotic Schedule first-line antipsychotic, 20% were prescribed olanzapine, and 10% received a trial of clozapine. Regarding monitoring for metabolic side effects, 92% of participants had at least one weight recorded, 72% had at least one blood glucose measure recorded, and 62% had at least one lipid profile recorded.In the context of a study in which training and ongoing clinical supervision by experts was provided to psychiatrists and shared decision making was encouraged, antipsychotic prescribing patterns closely adhered to recommendations established by the RAISE Connection Program.

OnTrackNY is a coordinated specialty care program that delivers early intervention services to youths experiencing a first episode of nonaffective psychosis. Treatment aims to help individuals improve their mental health and achieve personal goals related to work, school, and social relationships. This column describes OnTrackNY's progression from a research project to real-world implementation. The authors describe the treatment model, approach to training and dissemination, and procedures for collecting and sharing data with OnTrackNY teams and provide data on client characteristics and selected outcomes.

The New York State Medicaid program is pursuing reforms that would shift reimbursement from fee-for-service to value-based models. Behavioral health populations and services are key to these reforms, but important gaps exist in the breadth and relevance of available quality measures for the behavioral health field. This column describes how the state addressed these gaps by using both inter- and intra-agency collaborations. As part of this effort, the state convened a panel of consultants, including academics, providers, and consumers, to develop a behavioral health quality measurement agenda. Panel recommendations and ongoing partnerships are described as a model for states considering similar value-based reform initiatives.

This study prospectively evaluated outcomes of OnTrackNY, a statewide coordinated specialty care (CSC) program for treatment of early psychosis in community settings, as well as predictors of outcomes.The sample included 325 individuals ages 16-30 with recent-onset nonaffective psychosis who were enrolled in OnTrackNY and who had at least one three-month follow-up. Clinicians provided data at baseline and quarterly up to one year. Domains assessed included demographic and clinical characteristics, social and occupational functioning, medications, suicidality and violence, hospitalization, and time to intervention. Primary outcomes included the symptoms, occupational functioning, and social functioning scales of the Global Assessment of Functioning (GAF), as adapted by the U.S. Department of Veterans Affairs Mental Illness Research, Education and Clinical Center; education and employment status; and psychiatric hospitalization rate.Education and employment rates increased from 40% to 80% by six months, hospitalization rates decreased from 70% to 10% by three months, and improvement in GAF scores continued for 12 months. Female gender, non-Hispanic white race-ethnicity, and more education at baseline predicted better education and employment status at follow-up.Individuals with early psychosis receiving CSC achieved significant improvements in education and employment and experienced a decrease in hospitalization rate. Demographic variables and baseline education predicted education and employment outcomes. CSC teams should make particular effort to support the occupational goals of individuals at increased risk of not engaging in work or school, including male participants and participants from racial and ethnic minority groups.

Individuals with serious mental illness face multiple barriers to accessing care and experience disproportionately poor health outcomes. Starting in 2011, New York State undertook a series of major reforms of its Medicaid system designed to address these concerns. In this commentary we review three reforms that aim to change the way New York Medicaid is delivered and experienced, especially for underserved individuals with SMI: Health Homes, Behavioral Health Managed Care, and the Delivery System Reform Incentive Payment Program. We describe the history of these reforms' and their core themes: coordination and collaboration, cross-sector collaborations to address social determinants of health, prevention and early intervention, and financial reform. We describe the challenges and opportunities these reforms present for improving the health and health care of Medicaid members with SMI, both in New York and as models for change elsewhere.

Purpose: This study examined the effectiveness of an abstinence education program that was sensitive to federally mandated curriculum and measures. Methods: The intervention was delivered to 5,772 middle school and high school students. Effectiveness was assessed by a measure that was anchored on A-H themes, which are components of federally mandated curricular components of abstinence education. To better understand the relationship of different variables and determine the significance of student’s improvements on the A-H measure scores, the ANCOVA was used with the pretest score and age as covariates and the use of gender and ethnicity as fixed factors in the analysis. Results: While controlling for the effects of the pretest, the analyses showed that age and gender were main effects but that ethnicity did not prove to be related to the outcome scores. Results demonstrated that the effectiveness of the program decreased as adolescent boys aged. There were no significant interactions in the gender and ethnicity variables. Conclusions: The findings of this study will be beneficial to program developers in understanding what variations and demographics are most receptive to this particular abstinence-only education model. Further studies in this area are needed to evaluate the effectiveness of currently available programs., info:eu-repo/semantics/publishedVersion

As health information technology advances, efforts to use administrative data to inform real-time treatment planning for individuals are increasing, despite few empirical studies demonstrating that such administrative data predict subsequent clinical events. Medicaid claims for individuals with frequent psychiatric hospitalizations were examined to test how well patterns of service use predict subsequent high short-term risk of continued psychiatric hospitalizations.Medicaid claims files from New York and Pennsylvania were used to identify Medicaid recipients ages 18-64 with two or more inpatient psychiatric admissions during a target year ending March 31, 2009. Definitions from a quality-improvement initiative were used to identify patterns of inpatient and outpatient service use and prescription fills suggestive of clinical concerns. Generalized estimating equations and Markov models were applied to examine claims through March 2011, to see what patterns of service use were sufficiently predictive of additional hospitalizations to be clinically useful.A total of 11,801 individuals in New York and 1,859 in Pennsylvania identified met the cohort definition. In both Pennsylvania and New York, multiple recent hospitalizations, but not failure to use outpatient services or failure to fill medication prescriptions, were significant predictors of high risk of continued frequent hospitalizations, with odds ratios greater than 4.0.Administrative data can be used to identify individuals at high risk of continued frequent hospitalizations. Payers and system administrators could use such information to authorize special services (such as mobile outreach) for such individuals to promote service engagement and prevent rapid rehospitalizations.

The study determined rates of reengagement in services for individuals with serious mental illness who had discontinued services.As part of a quality assurance program in New York City involving continuous review of Medicaid claims and other administrative data, clinician care monitors identified 2,834 individuals with serious mental illness who were apparently in need of care but disengaged from services. The care monitors reviewed monthly updates of Medicaid claims, encouraged outreach from providers who had previously worked with identified individuals, and determined whether individuals had reengaged in services.Reengagement rates over a 12-month follow-up period were low, particularly for individuals who had been incarcerated or for whom no service provider was available to provide outreach.Subgroups of disengaged individuals with serious mental illness have different rates of reengagement. Active outreach by providers might benefit some, but such targeting is inefficient when the individual cannot be located.

In 2007 to 2008, there were several incidents of violence in New York City (NYC) involving individuals with serious mental illness. Some were dramatic and shocking; all were life-threatening or fatal, and subsequent media coverage and public outcry escalated with calls for a return to greater coercion and institutionalization of people with mental illness. Then New York State (NYS) Governor Eliot Spitzer informed the press there would be an investigation of these events. Governor Spitzer and NYC Mayor Michael Bloomberg called for relevant state and city agency heads and experts to review the incidents of violence and provide recommendations about what might limit future similar incidents. In all, a dozen agencies were convened with a 90-day time frame to produce their report. A list of the members of the panel is included in its report1 (available at: http://www.omh.state.ny.us/omhweb/justice_panel_report/). The panel was chaired by Michael F. Hogan, PhD (Commissioner, NYS Office of Mental Health), Linda I. Gibbs (NYC Deputy Mayor for Health and Human Services), Denise E. O’Donnell (NYS Commissioner for Criminal Justice), and John Feinblatt (NYC Criminal Justice Coordinator). Circumstances like these place enormous demand on public health and safety officials. Diverse stakeholders insist upon immediate action and often have conflicting agendas. Elected officials may support needed action but may lack the resources to realize their aims. Public health and mental health leadership need to represent scientific evidence in the face of emotionally charged claims. Criminal justice leadership needs to ensure the public safety. Critical decisions with far-reaching implications can be made on short notice, with limited time for consultation and deliberation before issuing a public document with meaningful and actionable recommendations. These situations represent unique, if tragic, opportunities for significant social service system improvement and reform.2 The following “case history” describes how NYS and NYC public mental health leaders organized information, experts, and resources to create panel recommendations specific to mental health that established new policies, avoided ineffective escalations in coercive interventions, clarified longstanding regulations, and created a new service to enhance accountability and coordination of services for NYC’s most vulnerable mentally ill individuals.

Individuals with serious mental illness often are unable to access consumer- and family-oriented community care, resulting in repeated hospitalizations, incarceration, and homelessness. The “medical home” concept was developed in primary care to provide accessible and accountable services for individuals with chronic medical conditions. Building on the work done in primary care, the authors propose a “mental health home.” The model of care incorporates medical home characteristics, such as access to and coordination of services, integration of primary and preventive care, adoption of recovery orientation and evidence-based practices, and family and community outreach. Barriers to and strategies for implementation of mental health homes are discussed. (Psychiatric Services 60:528–533, 2009)

This study explores the nature of clinical therapeutic relationships between mental health treatment providers and high-need clients with serious mental illness who had recently discontinued treatment. Semi-structured qualitative interviews of 56 clients with serious mental illness who had recently discontinued care and 25 mental health treatment providers were completed. Both clients with serious mental illness and treatment providers emphasized the importance of client-focused goal setting, time and availability of treatment providers, a caring approach, and trust and honesty in the relationship. However, clients with serious mental illness placed greater emphasis on goals involving tangible services, a notable area of discord between the two groups. Individuals with serious mental illness and treatment providers agreed regarding several key elements to a positive clinical relationship. Further attention to client goals related to tangible services may serve to improve relationships between treatment providers and high-need clients with serious mental illness.

It has been suggested that learning potential (LP), a patient's ability to benefit from training and practice, may mediate the relationship between cognition and functional outcome. Aims of this study were to (1) assess whether performance on a verbal memory-based measure of LP is associated with readiness for psychosocial rehabilitation; and (2) assess whether explicit cognitive training in memory strategies improves task performance beyond any implicit learning of organizational strategies that occurs with repeated exposure to to-be-learned material. Fifty outpatients with schizophrenia or schizoaffective disorder were administered three different versions of a list-learning test, the California Verbal Learning Test (CVLT-II). Some patients also received explicit training in semantic memory strategies before administration of the second word list. Based on performance across the three assessments, participants were categorized as "learners", "high scorers", and "non-learners". Participants were also administered the Micromodule Learning Test (MMLT), a measure that predicts performance in manualized skill training groups. LP categorization was associated with performance on the MMLT. High scorers performed better than the other two groups, and as found in earlier studies, education level was associated with performance for the learners. Explicit semantic clustering training was associated with increases in the use of the trained strategy.

Chronic schizophrenia patients have previously demonstrated performance deficits in contour integration tasks. The purpose of this study was to investigate whether schizophrenia patients, spanning a range of illness severity, would demonstrate responsiveness to manipulations that recruit top-down processing strategies involving learning and sequencing effects in a contour integration task.We administered a contour integration test over four consecutive days and in two different presentation conditions each day. In one condition, the stimuli were administered in order of increasing difficulty, and in the other they were presented in random order. The order in which these two conditions were presented was counterbalanced across days and participants. In addition, a nonschizophrenia psychotic disorders control group was included to determine if past findings of a contour integration deficit in schizophrenia could be replicated in the presence of a symptomatically similar control group.All groups demonstrated similar learning curves across the four days and generally similar overall levels of performance, with the exception of the group of the most chronic schizophrenia patients. In addition, the order in which the stimuli were presented to subjects affected their performance, with higher scores achieved for all groups in the condition where the stimuli were presented in increasing order of difficulty. Interaction effects revealed that the effects of order presentation were greater for nonpatient than for psychotic patients.These data are further evidence that perceptual organization impairments in schizophrenia are illness severity-related, and that schizophrenia patients as a whole are less sensitive to top-down manipulations in this type of task.

The construct of self-efficacy has been hypothesized to mediate the relationship between efforts at coping with psychiatric illness and functional outcome. This study examined whether self-efficacy mediated the relationships between psychosocial functioning and important predictors of functioning: premorbid functioning, negative symptoms, and cognitive functioning. Although self-efficacy was positively associated with psychosocial functioning, it did not mediate the relationships between functioning and the other established predictors. Rather, negative symptoms were the strongest predictor of functioning and mediated the relationship between self-efficacy and functioning. The findings suggest that negative symptoms, and not self-efficacy, are the most critical determinants of psychosocial functioning in schizophrenia, and that psychosocial treatment should focus on the amelioration of these symptoms.

ObjectiveTo examine the interaction of specific anxiety subtypes and psychosis.IntroductionAccumulating evidence suggests that anxiety and its disorders play a significant role in patients with schizophrenia, but few studies have examined multiple types of anxiety and how they interact with different symptoms of schizophrenia.MethodsThirty-two patients diagnosed with schizophrenia or schizoaffective disorder were assessed through self-report measures and interviewer rating scales to examine symptoms of psychosis and anxiety.ResultsA majority of patients (62%) were diagnosed with at least one comorbid anxiety disorder. Obsessive-compulsive symptoms and social anxiety symptoms were related to positive symptoms, bizarre behavior, and quality of life (QOL). Furthermore, panic and social anxiety were related to suspiciousness/paranoia. No consistent relationship was found with negative symptoms. Finally, severity of anxiety disorders was negatively correlated with the severity of formal thought disorder.DiscussionThis is one of the first studies to simultaneously examine the interrelationships of different types of anxiety symptoms and psychotic symptoms. The present findings are consistent with the studies that have suggested relationships between panic and paranoia and comorbid anxiety disorders and impaired QOL. These data suggest that further research into anxiety in schizophrenia, including the cognitive and neurobiological correlates, may help elucidate the mechanisms involved in the manifestation of these psychopathologiesConclusionAnxiety disorders are common in patients with schizophrenia. The presence of such symptoms may influence the presence of core psychotic symptoms and QOL. More information is needed in terms of the relationship between treatment of these symptoms and changes in psychotic symptoms and/or relapse prevention.

The purpose of this article is to identify, assess, and offer solutions to common measurement errors found in sexual abstinence education evaluation. A critical review of the methodology of adolescent sexuality research was performed. “Gold standards” of their measurement strategy were derived and applied against 14 selected studies. Many of the articles reviewed had substantial limitations in their measurement strategies. However, several articles demonstrated excellence and serve as models for future efforts. Sexual abstinence education evaluation is plagued by the inherent weaknesses of self-report and health outcome measures. However, with careful adherence to the gold standards proposed, it is possible to limit the threat from these weaknesses, maximizing the benefit of self-report surveys and county-level health indicators.

There is conflicting evidence regarding the presence and direction of gender differences in verbal memory capacity in schizophrenia. We examined gender differences in verbal memory performance in schizophrenia and their interactions with repeated assessments and psychiatric symptoms. California Verbal Learning Test (CVLT) data were collected from 28 outpatients diagnosed with schizophrenia. The CVLT was administered on five occasions, 3 months apart. CVLT data were examined using repeated measures analyses, using maximum likelihood estimates, with Brief Psychiatric Rating Scale (BPRS) scores at assessments 1-5 as a time-varying covariate. There were significant main effects of time and gender, with scores improving over time, and women performing better than men. There was also a significant time by gender interaction. The BPRS covariate effect was not significant. Results are discussed in terms of implications for gender-informed approaches to rehabilitation treatments.

Neurocognitive deficits are believed to be important predictors of functional outcome in chronic psychotic disorders, but few supporting studies have utilized prospective designs and adequate control. The aim of this study was to estimate the relative influence of symptoms and neurocognitive deficits on the development of social behavior skills in a cohort of individuals with schizophrenia or schizoaffective disorder recovering from acute symptom exacerbations. Forty-six individuals were recruited upon discharge from an inpatient unit and completed assessments of symptoms, neurocognitive function, and social behavior at 3-month intervals for 1 year. Correlational analyses and random regression models were used to model social behavioral capacities longitudinally. Social behavior improved modestly (10% improvements in ratings) over the follow-up period for the group as a whole. Disorganized and negative symptoms, as well as neurocognitive deficits in short-term and working memory predicted changes in social behavior over time. Individuals with better working memory function showed significantly greater abilities to recover social behavior skills, whereas those with working memory deficits showed no functional improvement over time. Both symptoms and neurocognitive deficits are important determinants of functional outcome in schizophrenia. It is proposed that clinicians should consider neurocognitive thresholds for treatment response when developing rehabilitation plans.

This study examined whether Medicaid claims and other administrative data could identify high-need individuals with serious mental illness in need of outreach in a large urban setting. A claims-based notification algorithm identified individuals belonging to high-need cohorts who may not be receiving needed services. Reviewers contacted providers who previously served the individuals to confirm whether they were in need of outreach. Over 10,000 individuals set a notification flag over 12-months. Disengagement was confirmed in 55 % of completed reviews, but outreach was initiated for only 30 %. Disengagement and outreach status varied by high-need cohort.

This study investigated whether the association between low level benzene exposure and shortened gestation is modified by two susceptibility genes, CYP1A1 and GSTT1. This report includes 542 (302 nonexposed, 240 benzene-exposed) nonsmoking and nondrinking mothers of singleton live births at Beijing Yanshan Petrochemical Corporation between June 1995 and June 1997. Epidemiologic and clinical data and blood samples were obtained from mothers. Multiple linear regression models were used to estimate the associations of benzene exposure and genetic susceptibility with gestational age, adjusting for maternal age, education, parity, stress, passive smoking, prepregnancy weight and height, and infant's sex. Without consideration of genotype, benzene exposure was associated with a decrease in mean gestational age of 0.29 (standard error (SE), 0.12) week. When stratified by the maternal CYP1A1 genotype, the estimated decrease was 0.54 (SE, 0.12) week for the AA group, which was significantly greater (p = 0.003) than that for the Aa/aa group, which showed no decrease in gestational age. When both CYP1A1 and GSTT1 were considered, the greatest decrease was found among exposed mothers with the CYP1A1 AA-GSTT1 absent group (0.79 (SE, 0.25) week) and the CYP1A1 AA-GSTT1 present group (0.50 (SE, 0.22) week). Among the nonexposed, genetic susceptibility alone did not confer a significant adverse effect. This study provides evidence of gene-environment interaction and supports further assessment of the role of genetic susceptibility in the evaluation of reproductive toxins.

In this study, we investigated the ethical decision making of 30 individual and 30 family therapists in order to detect the types of decision making used by practicing therapists. Informants responded to three ethical dilemmas. Two of the situations were hypothetical. The third dilemma was a situation the informant had experienced in practice. Each interview was assessed for decision-making style, using content analysis. Kohlberg's justice reasoning and Gilligan's care reasoning provided the conceptual foundations for this analysis. The results suggest that both family and individual therapists prefer care reasoning on all dilemma types. There was significantly more care reasoning demonstrated on the personal dilemma than on the hypothetical dilemmas. Characteristics of informants did not provide clear explanations for the differences found in reasoning.