Search

Objective: To determine the effectiveness of an on-site modular intervention in improving access to mental health services and outcomes for children with behavioral problems in primary care relative to enhanced usual care. The study includes boys and girls from six primary care offices in metropolitan Pittsburgh, PA., Methods: One hundred sixty-three clinically referred children who met a modest clinical cutoff (75th percentile) on the externalizing behavior scale of the Pediatric Symptom Checklist-17 were randomized to a protocol for on-site, nurse-administered intervention or to enhanced usual care. Protocol for on-site, nurse-administered intervention applied treatment modules from an evidence-based specialty mental health treatment for children with disruptive behavior disorders that were adapted for delivery in the primary care setting; enhanced usual care offered diagnostic assessment, recommendations, and facilitated referral to a specialty mental health provider in the community. The main outcome measures such as standardized rating scales, including the Pediatric Symptom Checklist-17, individualized target behavior ratings, treatment termination reports, and diagnostic interviews were collected., Results: Protocol for on-site, nurse-administered intervention cases were significantly more likely to receive and complete mental health services, reported fewer service barriers and more consumer satisfaction, and showed greater, albeit modest, improvements on just a few clinical outcomes that included remission for categorical behavioral disorders at 1-year follow-up. Both conditions also reported several significant improvements on several clinical outcomes over time., Conclusions: A psychosocial intervention for behavior problems that was delivered by nurses in the primary care setting is feasible, improves access to mental health services, and has some clinical efficacy. Options for enhancing clinical outcome include the use of multifaceted collaborative care interventions in the pediatric practice.

Objective: Despite the existence of effective and relatively cost-effective depression treatments, many depressed patients do not receive appropriate care. The authors assessed opportunities for increasing the rate of effective depression treatment by investigating the market for such treatment in the Pittsburgh area., Methods: A conceptual framework was developed to evaluate the market for effective depression care. On the basis of the conceptual framework, interviews were conducted with representatives from seven large employers, two medical health insurance carriers, two behavioral health insurance carriers, four primary care providers, and four behavioral health care providers. Respondents were asked to assess the barriers to and opportunities for increasing the rates of depression treatment from their perspectives., Results: The findings suggest that there is currently little demand among purchasers for improving depression care and little interest among insurers and providers for improving care in the absence of purchaser demand. Even stakeholders who identified depression as an important problem could not come to a consensus about who should be responsible for addressing the problem. Employers reported that they look primarily to their vendors to initiate quality improvement efforts, whereas insurers reported that such improvement efforts were more likely to occur if they were initiated by employers who purchase their health plans; providers, in turn, reported feeling powerless to initiate change., Conclusions: The absence of a clear locus of responsibility for improving depression care lends considerable inertia to the status quo. Because the currently low treatment rates are likely to be socially inefficient, researchers and policy makers should consider strategies to help overcome this inertia.