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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 (1040 mg/day), or placebo (equivalent to 1040 rag/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 incremental 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 fluoxetine 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 $125,000/QALY). Fluoxetine is more cost-effective than combination therapy after 12 weeks of treatment.

To purchase or authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1744-6171.2007.00089.x Byline: Deborah Winders Davis (1), Barbara Burns (2), Elizabeth Snyder (3), Julia Robinson (4) Keywords: Attention networks; attention problems; prematurity; preschool children Abstract: PROBLEM: Children born prematurely have been shown to have a range of problems that often result in delayed academic achievement. METHODS: The current study assessed both attention problem scores (Child Behavior Checklist) and actual performance on tasks tapping three attention networks in a sample of children (n = 94) born with very low birth weights (VLBW; [less than or equal to] 1500 grams). FINDINGS: Attention problem scores were extremely low and did not predict children's actual attention performance. CONCLUSIONS: A body of research is developing that suggests VLBW children may have specific, yet subtle, attention problems that may differ from those of other children. Author Affiliation: (1)Department of Pediatrics (2)Department of Psychological and Brain Sciences, University of Louisville, Louisville, KY (3)The Center for Child and Family Policy, Duke University, Durham, NC (4)Department of Psychology, Eastern Kentucky University, Richmond, KY

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.

Objective: The goal of this study was to evaluate the effectiveness of involuntary outpatient commitment in reducing rehospitalizations among individuals with severe mental illnesses. Method: Subjects who were hospitalized involuntarily were randomly assigned to be released (N=135) or to continue under outpatient commitment (N=129) after hospital discharge and followed for 1 year. Each subject received case management services plus additional outpatient treatment. Outpatient treatment and hospital use data were collected. Results: In bivariate analyses, the control and outpatient commitment groups did not differ significantly in hospital outcomes. However, subjects who underwent sustained periods of outpatient commitment beyond that of the initial court order had approximately 57% fewer readmissions and 20 fewer hospital days than control subjects. Sustained outpatient commitment was shown to be particularly effective for individuals with nonaffective psychotic disorders, reducing hospital readmissions approximately 72% and requiring 28 fewer hospital days. In repeated measures multivariable analyses, the outpatient commitment group had significantly better hospital outcomes, even without considering the total length of court-ordered outpatient commitments. However, in subsequent repeated measures analyses examining the role of outpatient treatment among psychotically disordered individuals, it was also found that sustained outpatient commitment reduced hospital readmissions only when combined with a higher intensity of outpatient treatment. Conclusions: Outpatient commitment can work to reduce hospital readmissions and total hospital days when court orders are sustained and combined with intensive treatment, particularly for individuals with psychotic disorders. This use of outpatient commitment is not a substitute for intensive treatment; it requires a substantial commitment of treatment resources to be effective.

Objective: Violent behavior among individuals with severe mental illness has become all important focus in community-based care. This study examines the joint effect of substance abuse and medication noncompliance on the greater risk of serious violence among persons with severe mental illness. Method: Involuntarily admitted inpatients with severe mental illness who were awaiting a period of outpatient commitment were enrolled in a longitudinal outcome study. At baseline, 331 subjects underwent an extensive face-to-face interview. Complementary data were gathered by a review of hospital records and a telephone interview with a family member or other informant. These data included subjects' sociodemographic characteristics, illness history, clinical status, medication adherence, substance abuse, insight into illness, and violent behavior during the 4 months that preceded hospitalization. Associations between serious violent acts and a range of individual characteristics and problems were analyzed by using multivariable logistic regression. Results: The combination of medication noncompliance and alcohol or substance abuse problems was significantly associated with serious violent acts in the community, after sociodemographic and clinical characteristics were controlled. Conclusions: Alcohol or other drug abuse problems combined with poor adherence to medication may signal a higher risk of violent behavior among persons with severe mental illness. Reduction of such risk may require carefully targeted community interventions, including integrated mental health and substance abuse treatment.

Objective: Clinical services for psychiatrically impaired populations have only recently been studied with scientifically valid designs to explore innovations in structure, accessibility, and financing. Health systems reform in the United States has provided the impetus for better defining clinically effective and cost-sensitive models for mental health services. This article reviews assertive community treatment, used for adults with severe mental illnesses, and multisystemic therapy, used for adolescents with serious emotional disturbances, as examples of service system innovations that have been studied with controlled clinical trial designs and have demonstrated efficacy in treating difficult and costly clinical populations. Method: The authors reviewed the published controlled clinical trials of assertive community treatment and multisystemic therapy, focusing on the clinical and administrative elements that distinguish them from traditional service systems. Results: A qualitative assessment of these two approaches suggests that they share common elements, with important implications for mental health policy. Specifically, the use of an ecological model of behavior applied to mental health patients is critical to both systems. In addition, therapeutic principles emphasizing pragmatic (outcome-oriented) treatment approaches, home-based interventions, and individualized goals are key elements of their success. Most important, both systems embody a therapeutic philosophy demanding therapist accountability, in which personnel are rewarded for clinical outcomes and therapeutic innovation rather than for following a prescribed plan. Conclusions: As empirically tested approaches, assertive community treatment and multisystemic therapy provide a scientific foundation for continued reform and serve to illustrate critical elements in designing new community treatment initiatives for behavioral as well as medical conditions.

Objective: This study investigated 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. The authors used a representative community sample to compare the regression effects of insurance coverage on utilization of mental health services among these subjects. Method: Data are from the second wave of the Piedmont, North Carolina, site of the Epidemiologic Catchment Area project. These data contain DSM-III diagnostic measures derived from the National Institute of Mental Health Diagnostic Interview Schedule as well as measures of insurance coverage and utilization. Responses from 2,889 community residents were analyzed using both ordinary least squares and logistic regression. Results: In both models, insurance coverage was strongly associated with care among those with as well as among those without a psychiatric disorder. The association between coverage and the probability of care was strongest among those with a disorder. Conclusions: The findings are not consistent with the claim that failing to provide insurance coverage will reduce discretionary but not necessary mental health care utilization. They provide evidence that failing to provide insurance coverage will reduce utilization as much or more among those with a psychiatric disorder as among those without. This result has important implications for health care reform.

This study measured hospital utilization and residential status of 51 patients with chronic psychoses before and after a 1-year program of assertive community treatment. Time hospitalized was reduced by 94%, and 82% of the patients previously living in hospitals or group homes attained independent living status, suggesting that this form of clinical management may reduce institutional care and costs to mental health care systems.

Mental health variables, such as psychiatric diagnoses and medications, concerning youth that entered residential group home care in 1995 and 2004 are examined using their admissions data. Findings show that the youth's mental health needs in 2004 were greater than those in 1995.

The study examines the predictors and rates of mentally-ill youth moving back home and reunification stability. Findings show that race affects likelihood of reunification and instability, that boys and older youth are more likely to move back home, and that those from high-income families are likely to be in out-of-home placements.

Involuntary outpatient commitment (OPC) is a promising but controversial legal intervention that may reduce criminal justice contact in persons with severe mental illness (SMD. This article examines arrest outcomes in a 1-year randomized study of OPC in 262 participants with SMI in North Carolina. Extended OPC was found to be significantly associated with reduced arrest probability (12% vs. 45%) in a subgroup with a prior history of multiple hospitalizations combined with prior arrests and/or violent behavior. Reduction in risk of violent behavior was a significant mediating factor in the association between OPC and arrest. In persons with SMI whose history of arrests is related directly to illness relapse, OPC may reduce criminal justice contact by increasing participation in mental health services.