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Background: Given the low usage of virtual health care prior to the COVID‐19 pandemic, it was unclear whether those living in rural locations would benefit from increased availability of virtual mental health care. The rapid transition to virtual services during the COVID‐19 pandemic allowed for a unique opportunity to examine how the transition to virtual mental health care impacted psychotherapy disruption (i.e., 45+ days between appointments) among individuals living in rural locations compared with those living in nonrural locations. Methods: Electronic health record and insurance claims data were collected from three health care systems in the United States including rurality status and psychotherapy disruption. Psychotherapy disruption was measured before and after the COVID‐19 pandemic onset. Results: Both the nonrural and rural cohorts had significant decreases in the rates of psychotherapy disruption from pre‐ to post‐COVID‐19 onset (32.5–16.0% and 44.7–24.8%, respectively, p < 0.001). The nonrural cohort had a greater reduction of in‐person visits compared with the rural cohort (96.6–45.0 vs. 98.0–66.2%, respectively, p < 0.001). Among the rural cohort, those who were younger and those with lower education had greater reductions in psychotherapy disruption rates from pre‐ to post‐COVID‐19 onset. Several mental health disorders were associated with experiencing psychotherapy disruption. Conclusions: Though the rapid transition to virtual mental health care decreased the rate of psychotherapy disruption for those living in rural locations, the reduction was less compared with nonrural locations. Other strategies are needed to improve psychotherapy disruption, especially among rural locations (i.e., telephone visits). [ABSTRACT FROM AUTHOR]

Objective: The authors sought to describe patterns of health care use prior to first diagnosis of a psychotic disorder in a population-based sample.Method: Electronic health records and insurance claims from five large integrated health systems were used to identify 624 patients 15-29 years old who received a first diagnosis of a psychotic disorder in any care setting and to record health services received, diagnoses assigned, and medications dispensed during the previous 36 months. Patterns of utilization were compared between patients receiving a first diagnosis of a psychotic disorder and matched samples of general health system members and members receiving a first diagnosis of unipolar depression.Results: During the year before a first psychotic disorder diagnosis, 29% of patients had mental health specialty outpatient care, 8% had mental health inpatient care, 24% had emergency department mental health care, 29% made a primary care visit with a mental health diagnosis, and 60% received at least one mental health diagnosis (including substance use disorders). Compared with patients receiving a first diagnosis of unipolar depression, those with a first diagnosis of a psychotic disorder were modestly more likely to use all types of health services and were specifically more likely to use mental health inpatient care (odds ratio=2.96, 95% CI=1.97-4.43) and mental health emergency department care (rate ratio=3.74, 95% CI=3.39-4.53).Conclusions: Most patients receiving a first diagnosis of a psychotic disorder had some indication of mental health care need during the previous year. General use of primary care or mental health services, however, does not clearly distinguish people who later receive a diagnosis of a psychotic disorder from those who later receive a diagnosis of unipolar depression. Use of inpatient or emergency department mental health care is a more specific indicator of risk. [ABSTRACT FROM AUTHOR]

Objective: To identify space-time clusters of changes in prescribing aripiprazole for bipolar disorder among providers in the VA.Data Sources: VA administrative data from 2002 to 2010 were used to identify prescriptions of aripiprazole for bipolar disorder. Prescriber characteristics were obtained using the Personnel and Accounting Integrated Database.Study Design: We conducted a retrospective space-time cluster analysis using the space-time permutation statistic.Data Extraction Methods: All VA service users with a diagnosis of bipolar disorder were included in the patient population. Individuals with any schizophrenia spectrum diagnoses were excluded. We also identified all clinicians who wrote a prescription for any bipolar disorder medication.Principal Findings: The study population included 32,630 prescribers. Of these, 8,643 wrote qualifying prescriptions. We identified three clusters of aripiprazole prescribing centered in Massachusetts, Ohio, and the Pacific Northwest. Clusters were associated with prescribing by VA-employed (vs. contracted) prescribers. Nurses with prescribing privileges were more likely to make a prescription for aripiprazole in cluster locations compared with psychiatrists. Primary care physicians were less likely.Conclusions: Early prescribing of aripiprazole for bipolar disorder clustered geographically and was associated with prescriber subgroups. These methods support prospective surveillance of practice changes and identification of associated health system characteristics. [ABSTRACT FROM AUTHOR]

Objective: To learn if a quality of care Medicaid child psychiatric consultation service implemented in three different steps was linked to changes in statewide child antipsychotic utilization.Data Sources/study Setting: Washington State child psychiatry consultation program primary data and Medicaid pharmacy division antipsychotic utilization secondary data from July 1, 2006, through December 31, 2013.Study Design: Observational study in which consult program data were analyzed with a time series analysis of statewide antipsychotic utilization.Data Collection/extraction Methods: All consultation program database information involving antipsychotics was compared to Medicaid pharmacy division database information involving antipsychotic utilization.Principal Findings: Washington State's total child Medicaid antipsychotic utilization fell from 0.51 to 0.25 percent. The monthly prevalence of use fell by a mean of 0.022 per thousand per month following the initiation of elective consults (p = .004), by 0.065 following the initiation of age/dose triggered mandatory reviews (p < .001), then by another 0.022 following the initiation of two or more concurrent antipsychotic mandatory reviews (p = .001). High-dose antipsychotic use fell by 57.8 percent in children 6- to 12-year old and fell by 52.1 percent in teens.Conclusions: Statewide antipsychotic prescribing for Medicaid clients fell significantly at different rates following each implementation step of a multilevel consultation and best-practice education service. [ABSTRACT FROM AUTHOR]

Objectives: The objectives of this study were to ascertain the relative importance of scientific "approval" versus U.S. Food and Drug Administration (FDA) regulatory approval regarding changes in aripiprazole prescribing rates for treating bipolar disorder and to identify systemlevel covariates associated with faster regional uptake of aripiprazole. Methods: Medication use data for 2002-2009 were obtained from the Veterans Health Administration (VHA) National Psychosis Registry for 106,547 patients with diagnoses of bipolar disorder, aggregated at the level of the Veterans Integrated Service Nehvork (VISN). VISN-level independent variables were obtained from several VHA organizational databases. Interrupted time-series analysis was used to examine changes in rates of prescribing aripiprazole, and logistic regression was used to model aboveversus below-median growth in aripiprazole prescribing across VISNs. Results: Three inflections were observed, corresponding to the publication of two positive studies and FDA approval of aripiprazole for the treatment of bipolar mania. No significant VISN-level policy, administrative, or staffing predictors of the growth rate in aripiprazole prescribing were identified. Exploratory analyses showed that access to care may play a role in uptake, whereas competing demands, such as substance abuse treatment needs, may retard adoption. Conclusions: Early published evidence may have a strong impact on practice for low-barrier innovations, such as newly marketed medications or changes in indication for approved medications. Regional targeting of prescriber behavior interventions may maximize efficiency in efforts to change prescribing; further delineation of factors associated with regional heterogeneity in prescribing would support such efforts. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The uptake of new antipsychotic medications among children has not been studied adequately. Although ziprasidone received Food and Drug Administration approval for the treatment of psychotic disorders among children in June 2009, it first became available for off-label use by children in 2001 and presented an excellent case study for off-label market entry. The objective of this study was to determine the pattern of initiation and switching for off-label use of ziprasidone among Michigan children who were insured by Medicaid in the first year that ziprasidone was available. METHODS: We conducted a retrospective study by using Michigan Medicaid data for patients who were aged <21 years and had 2 years of continuous enrollment and at least 1 prescription for ziprasidone in the first year the medication was available. The main outcome mea- sures were proportion of children prescribed ziprasidone as their first antipsychotic, with evidence of treatment resistance, and by a psychiatrist. RESULTS: In the first year, 292 individuals who met criteria were prescribed ziprasidone. Approximately 53% had a diagnosis of psychosis. Explosive personality disorder and oppositional defiant disorder were the next most common diagnoses. For 33% of individuals, this was the first antipsychotic medication. Only 12% of individuals showed evidence of treatment resistance to other antipsychotic medications before switching to ziprasidone. CONCLUSIONS: During the period when ziprasidone had no approved pediatric usages, a small percentage of patients who were prescribed ziprasidone showed evidence of treatment resistance, the primary expected indication. Some prescribing for ziprasidone in the first year in this population could be considered inappropriate considering what was known about the safety and efficacy of ziprasidone in children and adolescents atthetime. "Fail first" and prior authorization policies may be appropriate in the first year a medication is available so as to protect children from potential serious harm. [ABSTRACT FROM AUTHOR]

To characterize the US national level healthcare utilization patterns of patients with commercial insurance plans before and after a psychiatric hospitalization admitted through the emergency department (ED) using insurance claims data. We identified 34,250 patients from multiple commercial health insurance providers across the US who meet our eligibility criteria. We summarized their healthcare encounters and used logistic regression models to study the patterns of healthcare utilization including prior visits, outpatient follow-ups, and hospital- or ED-readmissions. Suicidal ideation was highly prevalent at the time of the index event (29.88%). Almost half of the patients (48.28%) had healthcare encounters with the same primary diagnosis one year before admission, about 5% had outpatient follow-ups or were readmitted to the hospital or ED 7 days post discharge. The post 30-day follow-ups and readmission rates were slightly higher. In general, older patients were less likely to have prior visits, follow-ups, or readmissions, and patients with SUDs, specifically alcohol dependence, opioid dependence/abuse, and stimulant dependence, were more likely to have outpatient follow-ups. Patterns of patients' prior visits, follow-ups, and readmissions varied by demographics and psychiatric comorbidity. Additional studies are needed to further explain the spatial variations of utilization patterns. [ABSTRACT FROM AUTHOR]

Importance: An improved understanding of autism spectrum disorder (ASD) prevalence over time and across the lifespan can inform health care service delivery for the growing population of autistic children and adults., Objective: To describe trends in the prevalence of ASD diagnoses using electronic records data from a large network of health systems in the US., Design, Setting, and Participants: This cross-sectional study examined annual diagnosis rates in health records of patients in US health systems from January 1, 2011, to December 31, 2022. Eligible individuals were included in the study sample for a given calendar year if they were enrolled in a participating health system for at least 10 months out of the year. Data were extracted from 12 sites participating in the Mental Health Research Network, a consortium of research centers embedded within large, diverse health care systems., Main Outcome and Measures: Diagnoses of ASD were ascertained using International Classification of Diseases, Ninth Revision (ICD-9) and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) revision codes. Annual diagnosis rates were calculated as the number of unique members diagnosed, divided by the total members enrolled., Results: A total of 12 264 003 members were enrolled in 2022 (2 359 359 children aged 0 to 17 years [19.2%]; 6 400 222 female [52.2%]; 93 002 American Indian or Alaska Native [0.8%], 1 711 950 Asian [14.0%], 952 287 Black or African American [7.8%], 2 971 355 Hispanic [24.2%], 166 144 Native Hawaiian or Pacific Islander [1.4%], and 6 462 298 White [52.7%]). The ASD diagnosis rate was greatest among 5-to-8-year-olds throughout the study period and increased by 175% among the full sample, from 2.3 per 1000 in 2011 to 6.3 per 1000 in 2022. The greatest relative increase in diagnosis rate from 2011 to 2022 occurred among 26-to-34-year-olds (450%) and increases were greater for female vs male individuals among children (305% [estimated annual percentage change (EAPC), 13.62 percentage points; 95% CI, 12.49-14.75 percentage points] vs 185% [EAPC, 9.63 percentage points; 95% CI, 8.54-10.72 percentage points], respectively) and adults (315% [EAPC, 13.73 percentage points; 95% CI, 12.61-14.86 percentage points] vs 215% [EAPC, 10.33 percentage points; 95% CI, 9.24-11.43 percentage points]). Relative increases were greater in racial and ethnic minority groups compared with White individuals among children, but not adults., Conclusions and Relevance: In this cross-sectional study of children and adults in the US, ASD diagnosis rates increased substantially between 2011 and 2022, particularly among young adults, female children and adults, and children from some racial or ethnic minority groups. Diagnosis prevalence trends generated using health system data can inform the allocation of resources to meet the service needs of this growing, medically complex population.

Background: Antipsychotics carry a higher-risk profile than other psychotropic medications and may be prescribed for youth with conditions in which other first-line treatments are more appropriate. This study aimed to evaluate the population-level effect of the Safer Use of Antipsychotics in Youth (SUAY) trial, which aimed to reduce person-days of antipsychotic use among participants. Methods: We conducted an interrupted time series analysis using segmented regression to measure changes in prescribing trends of antipsychotic initiation rates pre-SUAY and post-SUAY trial at four U.S. health systems between 2013 and 2020. Results: In our overall model, adjusted for age and insurance type, antipsychotic initiation rates decreased by 0.73 (95% confidence interval [CI]: 0.30, 1.16, p = 0.002) prescriptions per 10,000 person-months before the SUAY trial. In the first quarter following the start of the trial, there was an immediate decrease in the rate of antipsychotic initiations of 6.57 (95% CI: 0.99, 12.15) prescriptions per 10,000 person-months. When comparing the posttrial period to the pretrial period, there was an increase of 1.09 (95% CI: 0.32, 1.85) prescriptions per 10,000 person-months, but the increasing rate in the posttrial period alone was not statistically significant (0.36 prescriptions per 10,000 person-months, 95% CI: -0.27, 0.99). Conclusion: The declining trend of antipsychotic initiation seen between 2013 and 2018 (pre-SUAY trial) may have naturally reached a level at which prescribing was clinically warranted and appropriate, resulting in a floor effect. The COVID-19 pandemic, which began in the final three quarters of the posttrial period, may also be related to increased antipsychotic medication initiation.

Objective: This study examined atypical antipsychotic prescribing by Food and Drug Administration (FDA) approved-use (on-label) status for adolescents before and during the COVID-19 pandemic., Methods: Retrospective data were collected from electronic health records (EHRs) of adolescents aged 10-17 years in Kaiser Permanente Northern California. New outpatient atypical antipsychotic prescription orders during 2013-2021 were evaluated. Prescriptions were categorized as on-label if linked in EHRs to autism, psychosis, bipolar disorder, or Tourette's diagnoses; otherwise, they were potentially off-label (herein, off-label). Trend analysis of monthly prescribing rates assessed slope change at pandemic onset for the cohort and by sex and age groups., Results: Among 5828 patients, 74.5% of new antipsychotic orders were off-label in 2021. Overall prescribing decreased significantly until early 2020 (slope = -0.045, P < .01) but then significantly increased through 2021 (post-March 2020 slope change = 0.211, P = .01). Off-label prescriptions increased at a similar rate during the COVID-19 time period, but on-label prescriptions did not change significantly. Males and younger adolescents (ages 10-14 years) showed significant decreases until early 2020, while females and older adolescents (ages 15-17 years) did not. Females and younger adolescents exhibited significant increases in overall and off-label prescribing rates following pandemic onset; older adolescents exhibited increases in overall prescriptions while males had no detectable changes., Conclusions: Antipsychotic prescribing declined slightly but then increased significantly following COVID-19 onset for overall and off-label prescriptions. Pandemic onset differentially impacted antipsychotic prescribing by sex and age, with overall and off-label prescribing driven by increases among female and younger adolescents., Competing Interests: Declaration of Competing Interest Dr. Costales reports grant support from the National Institute of Mental Health (T32MH125792) during the conduct of this study. Dr. Penfold reports receiving research funding to his institution from Janssen Research & Development, Otsuka Pharmaceuticals, and SAGE Therapeutics., (Copyright © 2024 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: The authors measured implementation of Zero Suicide (ZS) clinical practices that support identification of suicide risk and risk mitigation, including screening, risk assessment, and lethal means counseling, across mental health specialty and primary care settings., Methods: Six health care systems in California, Colorado, Michigan, Oregon, and Washington participated. The sample included members ages ≥13 years from 2010 to 2019 (N=7,820,524 patients). The proportions of patients with suicidal ideation screening, suicide risk assessment, and lethal means counseling were estimated., Results: In 2019, patients were screened for suicidal ideation in 27.1% (range 5.0%-85.0%) of mental health visits and 2.5% (range 0.1%-35.0%) of primary care visits among a racially and ethnically diverse sample (44.9% White, 27.2% Hispanic, 13.4% Asian, and 7.7% Black). More patients screened positive for suicidal ideation in the mental health setting (10.2%) than in the primary care setting (3.8%). Of the patients screening positive for suicidal ideation in the mental health setting, 76.8% received a risk assessment, and 82.4% of those identified as being at high risk received lethal means counseling, compared with 43.2% and 82.4%, respectively, in primary care., Conclusions: Six health systems that implemented ZS showed a high level of variation in the proportions of patients receiving suicide screening and risk assessment and lethal means counseling. Two opportunities emerged for further study to increase frequency of these practices: expanding screening beyond patients with regular health care visits and implementing risk assessment with lethal means counseling in the primary care setting directly after a positive suicidal ideation screening., Competing Interests: The authors report no financial relationships with commercial interests.

Importance: Given that the Patient Health Questionnaire (PHQ) item 9 is commonly used to screen for risk of self-harm and suicide, it is important that clinicians recognize circumstances when at-risk adolescents may go undetected., Objective: To understand characteristics of adolescents with a history of depression who do not endorse the PHQ item 9 before a near-term intentional self-harm event or suicide., Design, Setting, and Participants: This was a retrospective cohort study design using electronic health record and claims data from January 2009 through September 2017. Settings included primary care and mental health specialty clinics across 7 integrated US health care systems. Included in the study were adolescents aged 13 to 17 years with history of depression who completed the PHQ item 9 within 30 or 90 days before self-harm or suicide. Study data were analyzed September 2022 to April 2023., Exposures: Demographic, diagnostic, treatment, and health care utilization characteristics., Main Outcome(s) and Measure(s): Responded "not at all" (score = 0) to PHQ item 9 regarding thoughts of death or self-harm within 30 or 90 days before self-harm or suicide., Results: The study included 691 adolescents (mean [SD] age, 15.3 [1.3] years; 541 female [78.3%]) in the 30-day cohort and 1024 adolescents (mean [SD] age, 15.3 [1.3] years; 791 female [77.2%]) in the 90-day cohort. A total of 197 of 691 adolescents (29%) and 330 of 1024 adolescents (32%), respectively, scored 0 before self-harm or suicide on the PHQ item 9 in the 30- and 90-day cohorts. Adolescents seen in primary care (odds ratio [OR], 1.5; 95% CI, 1.0-2.1; P = .03) and older adolescents (OR, 1.2; 95% CI, 1.0-1.3; P = .02) had increased odds of scoring 0 within 90 days of a self-harm event or suicide, and adolescents with a history of inpatient hospitalization and a mental health diagnosis had twice the odds (OR, 2.0; 95% CI, 1.3-3.0; P = .001) of scoring 0 within 30 days. Conversely, adolescents with diagnoses of eating disorders were significantly less likely to score 0 on item 9 (OR, 0.4; 95% CI, 0.2-0.8; P = .007) within 90 days., Conclusions and Relevance: Study results suggest that older age, history of an inpatient mental health encounter, or being screened in primary care were associated with at-risk adolescents being less likely to endorse having thoughts of death and self-harm on the PHQ item 9 before a self-harm event or suicide death. As use of the PHQ becomes more widespread in practice, additional research is needed for understanding reasons why many at-risk adolescents do not endorse thoughts of death and self-harm.

Introduction: People enrolled in Medicaid managed care who struggle with diabetes control often have complex medical, behavioral, and social needs. Here the authors report the results of a program designed to partner with primary care teams to address those needs., Methods: A nonprofit organization partnered with a Medicaid managed care plan and a Federally Qualified Health Center in California to enroll people with A1cs > 9% in a 12-month program. The program team included a community health worker, certified diabetes care and education specialist/registered dietitian, behavioral health counselor, and registered nurse. They developed patient-led action plans, connected patients to community resources, and supported behavior changes to improve diabetes control. Baseline assessments of behavioral health conditions and social needs were collected. Monthly A1c values were tracked for participants and a comparison group., Results: Of the 51 people enrolled, 83% had at least 1 behavioral health condition. More than 90% reported at least 1 unmet social need. The average monthly A1c among program participants was 0.699 lower than the comparison group post-enrollment ( P = .0008), and the disparity in A1c between Hispanic and non-Hispanic White participants at enrollment declined., Discussion: Participants had high levels of unmet medical, behavioral, and social needs. Addressing these needs resulted in a rapid and sustained improvement in A1c control compared to non-enrollees and a reduction in disparity of control among Hispanic participants., Conclusion: By partnering with a primary care team, a program external to Federally Qualified Health Center primary care can improve clinical outcomes for people with complex needs living with diabetes., Competing Interests: Conflicts of InterestDr Penfold reports receiving research funding to his institution from SAGE Therapeutics, Biogen, Janssen Research and Development, and The Lundbeck Foundation. Avni C Shah, MD, is the founder and CEO of Vayu Health. No conflicts of interest exist for Michael L Parchman, MD, MPH, Kelsey Stefanik-Guizlo, MPH, or Erika Holden, BA.

Objective: Children with low income and minority race and ethnicity have worse hospital outcomes due partly to systemic and interpersonal racism causing communication and system barriers. We tested the feasibility and acceptability of a novel inpatient communication-focused navigation program., Methods: Multilingual design workshops with parents, providers, and staff created the Family Bridge Program. Delivered by a trained navigator, it included 1) hospital orientation; 2) social needs screening and response; 3) communication preference assessment; 4) communication coaching; 5) emotional support; and 6) a post-discharge phone call. We enrolled families of hospitalized children with public or no insurance, minority race or ethnicity, and preferred language of English, Spanish, or Somali in a single-arm trial. We surveyed parents at enrollment and 2 to 4 weeks post-discharge, and providers 2 to 3 days post-discharge. Survey measures were analyzed with paired t tests., Results: Of 60 families enrolled, 57 (95%) completed the follow-up survey. Most parents were born outside the United States (60%) with a high school degree or less (60%). Also, 63% preferred English, 33% Spanish, and 3% Somali. The program was feasible: families received an average of 5.3 of 6 components; all received >2. Most caregivers (92%) and providers (81% [30/37]) were "very satisfied." Parent-reported system navigation improved from enrollment to follow-up (+8.2 [95% confidence interval 2.9, 13.6], P = .003; scale 0-100). Spanish-speaking parents reported decreased skills-related barriers (-18.4 [95% confidence interval -1.8, -34.9], P = .03; scale 0-100)., Conclusions: The Family Bridge Program was feasible, acceptable, and may have potential for overcoming barriers for hospitalized children at risk for disparities., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships that may be considered as potential competing interests: K. Casey Lion reports financial support was provided by the National Institutes of Health., (Copyright © 2023 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: To develop a new approach to prescribing guidelines as part of a pragmatic trial, Safer Use of Antipsychotics in Youth (SUAY; ClinicalTrials.gov Identifier: NCT03448575), which supports prescribers in delivering high-quality mental health care to youths., Method: A nominal group technique was used to identify first- to nth-line treatments for target symptoms and potential diagnoses. The panel included US pediatricians, child and adolescent psychiatrists, and psychopharmacology experts. Meeting materials included information about Medicaid review programs, systematic reviews, prescribing guidelines, and a description of the pragmatic trial. Afterward, a series of 4 webinar discussions were held to achieve consensus on recommendations., Results: The panel unanimously agreed that the guideline should focus on target symptoms rather than diagnoses. Guidance included recommendations for first- to nth-line treatment of target mental health symptoms, environmental factors to be addressed, possible underlying diagnoses that should first be considered and ruled out, and general considerations for pharmacological and therapeutic treatments., Conclusion: Prescribing guidelines are often ignored because they do not incorporate the real-world availability of first-line psychosocial treatments, comorbid conditions, and clinical complexity. Our approach addresses some of these concerns. If the approach proves successful in our ongoing pragmatic trial, Safer Use of Antipsychotics in Youth (SUAY), it may serve as a model to state Medicaid programs and health systems to support clinicians in delivering high-quality mental health care to youths., Clinical Trial Registration Information: Safer Use of Antipsychotics in Youth; http://clinicaltrials.gov/; NCT03448575., (Copyright © 2021 American Academy of Child & Adolescent Psychiatry. All rights reserved.)

Objectives: Antipsychotic prescribing in children and adolescents increased sharply beginning in the 1990s, but recent reports among Medicaid enrollees suggest declining trends. However, few studies have included both commercially and publicly insured patients or focused on trends in new antipsychotic medications in children without documented psychotic disorders or other indicated conditions. The objective of the study was to report trends in new antipsychotic prescribing for pediatric patients (age 3-17 years) in a large children's health care system. Methods: Data were abstracted from electronic medical records (January 1, 2013 to December 31, 2017). New antipsychotic medication orders were defined as antipsychotic orders for patients without an order in the 180 days prior. Patients were excluded if the order was initiated in an emergency department or inpatient setting; they were diagnosed with psychotic disorder, mania, autism spectrum disorder, or intellectual disability; or the order was for prochlorperazine. The crude rate of new antipsychotic prescribing is reported quarterly with Poisson 95% confidence intervals in the total sample and by demographic subgroups (child vs. adolescent, female vs. male, public vs. private insurance, and white vs. nonwhite). Results: Antipsychotic orders decreased from 54.9 prescriptions per 10,000 person months in the first quarter of 2013 to 34.1 per 10,000 person months in the last quarter of 2017. Rates of antipsychotic prescribing were significantly higher for adolescents compared with children, patients who were commercially insured compared with Medicaid insured, and at most time points for white compared with non-white patients. However, prescribing rates did not differ significantly based on gender. Conclusions: Antipsychotic prescribing declined for both commercially and Medicaid-insured children in a pediatric hospital-based system, although white and commercially insured patients were more likely to be prescribed antipsychotics. More attention may be needed for reducing potentially avoidable prescribing of antipsychotics in previously understudied subgroups, such as commercially insured patients. Clinical Trial Registration Number: NCT03448575.

Background: Children from socially disadvantaged families experience worse hospital outcomes compared with other children. We sought to identify modifiable barriers to care to target for intervention., Methods: We conducted a prospective cohort study of hospitalized children over 15 months. Caregivers completed a survey within 3 days of admission and 2 to 8 weeks after discharge to assess 10 reported barriers to care related to their interactions within the health care system (eg, not feeling like they have sufficient skills to navigate the system and experiencing marginalization). Associations between barriers and outcomes (30-day readmissions and length of stay) were assessed by using multivariable regression. Barriers associated with worse outcomes were then tested for associations with a cumulative social disadvantage score based on 5 family sociodemographic characteristics (eg, low income)., Results: Of eligible families, 61% ( n = 3651) completed the admission survey; of those, 48% ( n = 1734) completed follow-up. Nine of 10 barriers were associated with at least 1 worse hospital outcome. Of those, 4 were also positively associated with cumulative social disadvantage: perceiving the system as a barrier (adjusted β = 1.66; 95% confidence interval [CI] 1.02 to 2.30), skill barriers (β = 3.82; 95% CI 3.22 to 4.43), cultural distance (β = 1.75; 95% CI 1.36 to 2.15), and marginalization (β = .71; 95% CI 0.30 to 1.11). Low income had the most consistently strong association with reported barriers., Conclusions: System barriers, skill barriers, cultural distance, and marginalization were significantly associated with both worse hospital outcomes and social disadvantage, suggesting these are promising targets for intervention to decrease disparities for hospitalized children., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Objective: To examine the association between thoughts of death or self-harm reported on item 9 of the Patient Health Questionnaire (PHQ) depression module and the risk of suicide attempt or suicide death over the following 2 years., Method: In 4 health care systems participating in the Mental Health Research Network, electronic records identified 509,945 adult outpatients completing 1,228,308 PHQ depression questionnaires during visits to primary care, specialty mental health, and other outpatient providers between January 1, 2007 and December 31, 2012. 9,203 nonfatal suicide attempts were identified using health system records of inpatient or outpatient encounters for self-inflicted injury. 484 suicide deaths were identified using cause-of-death codes from state mortality data., Results: Cumulative hazard of suicide attempt during 2 years ranged from approximately 0.5% among those reporting thoughts of death or self-harm "not at all" to 3.5% among those reporting such thoughts "nearly every day." Cumulative hazard of suicide death during 2 years ranged from approximately 0.04% among those responding "not at all" to 0.19% among those responding "nearly every day." The excess hazard associated with thoughts of death or self-harm declined with time, but remained 2- to 5-fold higher for at least 18 months. Nevertheless, 39% of suicide attempts and 36% of suicide deaths within 30 days of completing a PHQ occurred among those responding "not at all" to item 9., Conclusions: In community practice, response to PHQ item 9 is a strong predictor of suicide attempt and suicide death over the following 2 years. For patients reporting thoughts of death or self-harm, suicide prevention efforts must address this enduring vulnerability., Competing Interests: The authors have no relevant financial interests to disclose., (© Copyright 2016 Physicians Postgraduate Press, Inc.)

Introduction: Knowledge of the factors affecting the adoption of new medications can enhance mental health care and guide quality improvement and policy development. Food and Drug Administration indications for treating bipolar disorder with several second-generation antipsychotics (SGAs) in the 2000s represent an opportunity to identify factors that impact the spread of a then-innovative treatment through a new population., Methods: Analysis of Department of Veterans Affairs administrative data identified the population of 170,811 veterans diagnosed with bipolar disorder from 2003 to 2010. We analyzed time trends and predictors of antimanic choice (SGA vs other) among the 40,512 outpatients with bipolar disorder who initiated their first VA outpatient antimanic prescription, using multinomial logistic regression in month-by-month analyses. We conducted classwise analyses and investigated prespecified predictors among specific agents., Results: In classwise analyses, SGAs supplanted lithium, valproate, and carbamazepine/oxcarbazepine as the most commonly initiated antimanics by 2007. Psychosis, but not other indices of severity, predicted SGA initiation. Demographic analyses did not identify substantial disparities in initiation of SGAs. Drug-specific analyses revealed some consideration of medical comorbidities in choosing among specific antimanic agents, although effect sizes were small. Most patients initiating an antimanic had received an antidepressant in the previous year., Discussion: Second-generation antipsychotics quickly became the frontline antimanic treatment for bipolar disorder, although antidepressants most commonly predated antimanic prescriptions. Second-generation antipsychotics were used for a broad range of patients rather than being restricted to a severely ill subpopulation. The modest association of antimanic choice with relevant medical comorbidities suggests that continued attention to quality prescribing practices is warranted.

Background: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) carry a high mortality risk. While identifying clinical and genetic risk factors for these conditions has been hindered by their rarity, large electronic health databases hold promise for identifying large numbers of cases for study, especially with the introduction in 2008 of ICD-9 codes more specific for these conditions., Objective: The objective of this study is to estimate the validity of ICD-9 codes for ascertaining SJS/TEN in 12 collaborating research units in the USA, covering almost 60 million lives., Methods: From the electronic databases at each site, we ascertained potential cases of SJS/TEN using ICD-9 codes. At five sites, a subset of medical records was abstracted and standardized criteria applied by board-certified dermatologists to adjudicate diagnoses. Multivariate logistic regression was used to identify factors independently associated with validated SJS/TEN cases., Results: A total of 56 591 potential cases of SJS/TEN were identified. A subset of 276 charts was selected for adjudication and 39 (of the 276) were confirmed as SJS/TEN. Patients with the ICD-9 codes introduced after 2008 were more likely to be confirmed as cases (OR 3.32; 95%CI 0.82, 13.47) than those identified in earlier years. Likelihood of case status increased with length of hospitalization. Applying the probability of case status to the 56 591 potential cases, we estimated 475-875 to be valid SJS/TEN cases., Conclusion: Newer ICD-9 codes, along with length of hospitalization, identified patients with a high likelihood of SJS/TEN. This is important for identification of subjects for future pharmacogenomics studies., (Copyright © 2015 John Wiley & Sons, Ltd.)

Objectives: Studies of serious mental illnesses that use administrative databases have employed various criteria to establish diagnoses of interest. Several studies have assessed the validity of diagnostic inclusion criteria against research diagnoses. However, no studies have examined the effect of diagnostic inclusion criteria on prevalence and population characteristics across such groups., Methods: Administrative data for 2003-2010 from the Department of Veterans Affairs were used to calculate prevalence rates and assess effects of varying the diagnostic inclusion criteria on population composition for bipolar disorder, schizophrenia, and posttraumatic stress disorder (PTSD). Specifically, for each diagnosis, mutually exclusive subpopulations were compared on the basis of the following inclusion criteria for a given diagnosis: one treatment encounter, two outpatient encounters or one inpatient encounter, and any two encounters. For bipolar disorder and schizophrenia, effects of excluding individuals who had a competing diagnosis of, respectively, schizophrenia or bipolar disorder in the prior 12 months and since 2002 were also determined., Results: In 2010, moving from the broadest definitions of bipolar disorder (N=120,382), schizophrenia (N=91,977), and PTSD (N=554,028) to the most restrictive definitions reduced prevalence rates by, respectively, 28.7%, 34.9%, and 25.7%, with temporal trends for 2003-2010 paralleling results in 2010. Population composition changes with changing diagnostic inclusion criteria were variable, with predominantly small odds ratios., Conclusions: Population composition was relatively robust across common diagnostic inclusion criteria for each condition. Thus choice of criteria can focus on considerations of diagnostic validity and case-finding needs. Three mechanisms for the impact of diagnostic criteria on population composition in administrative data sets are discussed.

Objectives: To determine the relationship of child behavioral health (BH) screening results to receipt of BH services in Massachusetts Medicaid (MassHealth) children., Methods: After a court decision, Massachusetts primary care providers were mandated to conduct BH screening at well-child visits and use a Current Procedural Terminology code along with a modifier indicating whether a BH need was identified. Using MassHealth claims data, a cohort of continuously enrolled (July 2007-June 2010) children was constructed. The salient visit (first use of the modifier, screening code, or claim in fiscal year 2009) was considered a reference point to examine BH history and postscreening BH services. Bivariate and multivariate logistic regression analyses were performed to determine predictors of postscreening BH services., Results: Of 261,160 children in the cohort, 45% (118,464) were screened and 37% had modifiers. Fifty-seven percent of children screening positive received postscreening BH services compared with 22% of children screening negative. However, only 30% of newly identified children received BH services. The strongest predictors of postscreening BH services for children without a BH history were being in foster care (odds ratio, 10.38; 95% confidence interval, 9.22-11.68) and having a positive modifier (odds ratio, 3.79; 95% confidence interval, 3.53-4.06)., Conclusions: Previous BH history, a positive modifier, and foster care predicted postscreening BH services. Only one-third of newly identified children received services. Thus although screening is associated with an increase in BH recognition, it may be insufficient to improve care. Additional strategies may be needed to enhance engagement in BH services., (Copyright © 2014 by the American Academy of Pediatrics.)

Objective: To investigate if the widely publicized warnings in 2003 from the US Food and Drug Administration about a possible increased risk of suicidality with antidepressant use in young people were associated with changes in antidepressant use, suicide attempts, and completed suicides among young people., Design: Quasi-experimental study assessing changes in outcomes after the warnings, controlling for pre-existing trends., Setting: Automated healthcare claims data (2000-10) derived from the virtual data warehouse of 11 health plans in the US Mental Health Research Network., Participants: Study cohorts included adolescents (around 1.1 million), young adults (around 1.4 million), and adults (around 5 million)., Main Outcome Measures: Rates of antidepressant dispensings, psychotropic drug poisonings (a validated proxy for suicide attempts), and completed suicides., Results: Trends in antidepressant use and poisonings changed abruptly after the warnings. In the second year after the warnings, relative changes in antidepressant use were -31.0% (95% confidence interval -33.0% to -29.0%) among adolescents, -24.3% (-25.4% to -23.2%) among young adults, and -14.5% (-16.0% to -12.9%) among adults. These reflected absolute reductions of 696, 1216, and 1621 dispensings per 100,000 people among adolescents, young adults, and adults, respectively. Simultaneously, there were significant, relative increases in psychotropic drug poisonings in adolescents (21.7%, 95% confidence interval 4.9% to 38.5%) and young adults (33.7%, 26.9% to 40.4%) but not among adults (5.2%, -6.5% to 16.9%). These reflected absolute increases of 2 and 4 poisonings per 100,000 people among adolescents and young adults, respectively (approximately 77 additional poisonings in our cohort of 2.5 million young people). Completed suicides did not change for any age group., Conclusions: Safety warnings about antidepressants and widespread media coverage decreased antidepressant use, and there were simultaneous increases in suicide attempts among young people. It is essential to monitor and reduce possible unintended consequences of FDA warnings and media reporting., (© Lu et al 2014.)

Recent reports of antipsychotic medication use in pediatric populations describe large increases in rates of use. Much interest in the increasing use has focused on potentially inappropriate prescribing for non-Food and Drug Administration-approved uses and use amongst youth with no mental health diagnosis. Different studies of antipsychotic use have used different time periods, geographic and insurance populations of youth, and aggregations of diagnoses. We review recent estimates of use and comment on the similarities and dissimilarities in rates of use. We also report new data obtained on 11 health maintenance organizations that are members of the Mental Health Research Network in order to update and extend the knowledge base on use by diagnostic indication. Results indicate that most use in pediatric populations is for disruptive behaviors and not psychotic disorders. Differences in estimates are likely a function of differences in methodology; however, there is remarkable consistency in estimates of use by diagnosis.

Interrupted time series (ITS) analysis is arguably the strongest quasi-experimental research design. ITS is particularly useful when a randomized trial is infeasible or unethical. The approach usually involves constructing a time series of population-level rates for a particular quality improvement focus (eg, rates of attention-deficit/hyperactivity disorder [ADHD] medication initiation) and testing statistically for a change in the outcome rate in the time periods before and time periods after implementation of a policy/program designed to change the outcome. In parallel, investigators often analyze rates of negative outcomes that might be (unintentionally) affected by the policy/program. We discuss why ITS is a useful tool for quality improvement. Strengths of ITS include the ability to control for secular trends in the data (unlike a 2-period before-and-after t test), ability to evaluate outcomes using population-level data, clear graphical presentation of results, ease of conducting stratified analyses, and ability to evaluate both intended and unintended consequences of interventions. Limitations of ITS include the need for a minimum of 8 time periods before and 8 after an intervention to evaluate changes statistically, difficulty in analyzing the independent impact of separate components of a program that are implemented close together in time, and existence of a suitable control population. Investigators must also be careful not to make individual-level inferences when population-level rates are used to evaluate interventions (though ITS can be used with individual-level data). A brief description of ITS is provided, including a fully implemented (but hypothetical) study of the impact of a program to reduce ADHD medication initiation in children younger than 5 years old and insured by Medicaid in Washington State. An example of the database needed to conduct an ITS is provided, as well as SAS code to implement a difference-in-differences model using preschool-age children in California as a comparison group., (Copyright © 2013 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: The Veterans Health Administration (VHA) has undergone significant organizational transformation as part of a comprehensive strategic plan to enhance mental health services. Organizational change can create stress and decrease employee morale, even if the change is beneficial for patients and the organization. The study examined whether psychiatrists' work satisfaction and work environment perceptions changed during a period of transformation. Facility-level turnover rate was also examined., Methods: Data were analyzed from 7,218 psychiatrists who responded to an annual organizational survey between 2004 and 2010 (excluding 2005) conducted with 139 facilities. Survey ratings were regressed on individual and facility-level characteristics in a multilevel model. Adjusted mean scores for the measures were compared with Tukey post hoc tests to identify significant differences by year., Results: Most satisfaction ratings on measures improved after the initial actions for strategic reform and stabilized in 2006. Turnover rates and intention to leave were also consistent during this time. Positive linear trends over time were observed for pay satisfaction, management for achievement, skill development, workplace civility, and satisfaction with senior management., Conclusions: Extensive reorganization of VHA mental health services was associated with improvements in psychiatrists' workplace satisfaction, and these increases were sustained over time. In the current climate of rapid transformation under health care reform nationally, the VHA experience may inform the broader national process and organizational strategies to improve and maintain the morale of the health care workforce.

Background: Recommendations for annual seasonal influenza vaccination have expanded to now include >300 million children and adults each year. Community settings have become increasingly important venues for influenza vaccination. We sought to identify barriers to and solutions for expanding influenza vaccination in community settings., Methods: Semi-structured telephone interviews were conducted from 01/09 to 06/10 with a range of stakeholders involved in influenza vaccination, including health plans, medical services firms, retail based clinics, pharmacies, schools, and state and local public health immunization programs. Participants (n=65) were asked about barriers and feasible solutions to influenza vaccine delivery to children and adults in community settings. Key themes were identified through iterative coding using a grounded theory approach., Results: Stakeholders identified specific financial barriers to influenza vaccine delivery in 3 major areas: purchase and distribution, delivery, and reimbursement. Limited purchasing power, the uncertain nature of public demand, and unpredictable timing of influenza vaccine supply were important barriers to enhance delivery in community settings. Barriers to delivery included complexities in running off-site clinics, especially in school settings, the need to manage publicly vs. privately purchased vaccines separately, and state-to-state variability in requirements for credentialing, physician oversight, and reporting. Reimbursement barriers included a protracted credentialing process, the need to determine insurance eligibility at point-of-service, and lack of a billing infrastructure in off-site clinics. Opportunities to mitigate financial barriers to influenza vaccine delivery in community settings focused on coordination across providers and the role of public health as a "trusted broker" to overcome existing challenges., Conclusions: Financial and systems barriers hamper the optimal use of community settings to effectively deliver influenza vaccines. Public health partners at the federal, state, and local levels are well-positioned to facilitate the engagement of all stakeholders in this important and complex vaccine delivery system., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: Recent increases in patient cost-sharing for health care have lent increasing importance to monitoring cost-related changes in health care use. Despite the widespread use of survey questions to measure changes in health care use and related behaviors, scant data exists on the reliability of such questions., Methods: We administered a cross-sectional survey to a stratified random sample of families in a New England health plan's high deductible health plan (HDHP) with ≥ $500 in annualized out-of-pocket expenditures. Enrollees were asked about their knowledge of their plan, information seeking, behavior change associated with having a deductible, experience of delay in care due in part to cost, and hypothetical delay in care due in part to cost. Initial respondents were mailed a follow-up survey within two weeks of each family returning the original survey. We computed several agreement statistics to measure the test-retest reliability for select questions. We also conducted continuity adjusted chi-square, and McNemar tests in both the original and follow-up samples to measure the degree to which our results could be reproduced. Analyses were stratified by self-reported income., Results: The test-retest reliability was moderate for the majority of questions (0.41 - 0.60) and the level of test-retest reliability did not differ substantially across each of the broader domains of questions. The observed proportions of respondents with delayed or foregone pediatric, adult, or any family care were similar when comparing the original and follow-up surveys. In the original survey, respondents in the lower-income group were more likely to delay or forego pediatric care, adult care, or any family care. All of the tests comparing income groups in the follow-up survey produced the same result as in the original survey., Conclusions: In this population of HDHP beneficiaries, we found that survey questions concerning plan knowledge, information seeking, and delayed or foregone care were moderately reliable. Our results offer reassurance for researchers using survey information to study the effects cost sharing on health care utilization.