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

is a consultation model with the goal of enhancing communication between two of the most important stakeholders in children's lives – parents and teachers. Using a single–group pre–post design, this preliminary study examined the effect of Partners in School on parent–teacher communication outcomes and the factors associated with these outcomes. Participants were 26 teachers and 49 parents of children with autism spectrum disorder (ASD). Parents and teachers completed surveys before and after participating in Partners in School. Teachers reported an increase in their communication to parents. However, parents did not report an increase in their communication to teachers. Teachers' self–efficacy, expectations, and intervention fidelity were associated with increased communication to parents. Parental self–efficacy and teacher experience were associated with parents' reports of communication to teachers. Our findings suggest that family–school consultation services may be used to enhance teachers' communication with parents. [ABSTRACT FROM AUTHOR]

Few studies examine the effectiveness of community-based early interventions in unselected samples of autistic children, especially those from minoritized backgrounds. These types of studies require attention to strategies for recruitment, retention, data collection, and support for community providers beyond those used in university-based trials. We conducted a pilot trial of Project ImPACT, a promising caregiver-mediated naturalistic developmental behavioral intervention, in partnership with the early intervention system in a poor, large city. We assessed recruitment and retention strategies, training protocol, and measurement battery. We recruited representative provider and family samples, and had good measure completion among retained participants. Retention varied by study arm, providers had relatively poor fidelity to the intervention despite substantial support, and our measures did not appear sensitive to change. Lessons learned include the need for (a) a ramp-up training period prior to starting the study, (b) intensive implementation supports, and (c) additional strategies for family retention. [ABSTRACT FROM AUTHOR]

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

Background: Triptans are the most commonly used acute treatment for migraine. This study evaluated real-world treatment patterns following an initial triptan prescription to understand refill rates and use of non-triptan medications for the acute treatment of migraine. Methods: Commercially-insured adult patients over 18 years of age with a triptan prescription between 1/1/2013 to 31/12/2013 were identified from the Optum Clinformatics™ Data Mart database, with date of the first triptan fill designated as index date. Inclusion was limited to those with no fills for a triptan in the 12 months prior to index date (i.e. new users or initiators of triptans) and continuous enrollment in the 12 months pre- and 24 months post-index date. Fills for index triptan, non-index triptan, and other acute treatments for migraine were assessed for up to 24 months post-index. Results: Among 10,509 patients, 50.8% did not refill the initial triptan within 12 months and 43.6% did not refill within 24 months. In the 12 months post-index, 90.5% of patients used only one type of triptan, 8.4% used two different triptans, and 1.0% used three or more triptans. Among patients with and without a triptan refill, use of opioids (39% vs. 42%), non-steroidal anti-inflammatory drugs (22% vs. 22%), and butalbital-containing products (9% vs. 10%) were similar. Conclusion: More than half of those who newly initiated a triptan did not refill their initial prescription, and less than 1 in 10 used two or more triptans within 12 months. High rates of non-triptan acute medication use were found over 12 and 24 months of follow-up, most commonly opioids. [ABSTRACT FROM AUTHOR]

Background: Triptans are the most commonly used acute treatment for migraine. This study evaluated real-world treatment patterns following an initial triptan prescription to understand refill rates and use of non-triptan medications for the acute treatment of migraine.Methods: Commercially-insured adult patients over 18 years of age with a triptan prescription between 1/1/2013 to 31/12/2013 were identified from the Optum Clinformatics™ Data Mart database, with date of the first triptan fill designated as index date. Inclusion was limited to those with no fills for a triptan in the 12 months prior to index date (i.e. new users or initiators of triptans) and continuous enrollment in the 12 months pre- and 24 months post-index date. Fills for index triptan, non-index triptan, and other acute treatments for migraine were assessed for up to 24 months post-index.Results: Among 10,509 patients, 50.8% did not refill the initial triptan within 12 months and 43.6% did not refill within 24 months. In the 12 months post-index, 90.5% of patients used only one type of triptan, 8.4% used two different triptans, and 1.0% used three or more triptans. Among patients with and without a triptan refill, use of opioids (39% vs. 42%), non-steroidal anti-inflammatory drugs (22% vs. 22%), and butalbital-containing products (9% vs. 10%) were similar.Conclusion: More than half of those who newly initiated a triptan did not refill their initial prescription, and less than 1 in 10 used two or more triptans within 12 months. High rates of non-triptan acute medication use were found over 12 and 24 months of follow-up, most commonly opioids. [ABSTRACT FROM AUTHOR]

Objective: Computer-assisted interventions (CAIs) are popular for educating children with autism, but their effectiveness is not well established. This study evaluated the effectiveness of 1 CAI designed to improve children's language, cognitive, and academic skills, TeachTown: Basics, in a large urban school district.Method: Teachers (n = 59) in autism support classrooms and their consented students in kindergarten through second grade (n = 154) were randomized to TeachTown: Basics or waitlist control. Child outcome was measured at baseline and after 1 academic year using the Bracken Basic Concepts Scale-Receptive and Expressive versions and the Differential Ability Scales, Second Edition (DAS-II). Random effects regression models that included clustering of time within students and students within classrooms were used to test whether the change over time in each outcome differed between groups.Results: There were no statistically significant differences in outcomes for children who received TeachTown: Basics or treatment as usual. Increased time spent using TeachTown: Basics was associated with worse receptive language outcomes for children in the experimental group after 1 academic year. However, there was no association between minutes spent using TeachTown and changes in expressive language or DAS-II score.Conclusion: Despite growing enthusiasm for CAIs in autism treatment, the present findings indicate that CAI might not be effective at improving language and cognitive outcomes for children with autism spectrum disorder. The decision to implement CAIs in schools should be carefully balanced against the evidence for effectiveness of these programs. Schools might be better served by investing in treatment strategies with established evidence.Clinical Trial Registration Information: RCT of TeachTown in Autism Support Classrooms: Innovation and Exnovation; https://clinicaltrials.gov/; NCT02695693. [ABSTRACT FROM AUTHOR]

Medicaid is a major insurer of autistic people. However, during the transition to adulthood, autistic individuals are more likely than people with intellectual disability to lose their Medicaid benefits. Individuals with intellectual disability may have greater success maintaining Medicaid coverage during this time because most states provide coverage to individuals with intellectual disability throughout adulthood, which is not the case for autism. Using national Medicaid data from 2008 to 2016, we estimated the probability of intellectual disability diagnosis accrual among autistic Medicaid beneficiaries. Medicaid beneficiaries ages 8 to 25 with 1+ inpatient or 2+ outpatient autism spectrum disorder claims, but no intellectual disability claim, in a 12-month eligibility period were included. We used a person-month discrete-time proportional hazards model. Disruptions in Medicaid coverage were operationalized as 2+ consecutive months of no coverage before coverage resumed (yes/no). One in five autistic individuals ages 8–25 accrued an intellectual disability diagnosis. The probability of accruing an intellectual disability diagnosis was higher among autistic individuals who had disruptions in Medicaid coverage compared to those without disruptions, and peaked at age 21 (during the transition to adulthood). Expanding Medicaid to cover autistic people of all ages could decrease the need for intellectual disability diagnosis accrual and improve health outcomes for autistic adults. What is known? In most states, Medicaid waivers provide individuals with an intellectual disability diagnosis generous healthcare coverage throughout adulthood. By comparison, fewer Medicaid programs are available for autistic individuals, and they are more likely to experience disruptions, or gaps, in Medicaid coverage and subsequently not re-enroll. What this paper adds? One in five autistic individuals with Medicaid coverage between ages 8 and 25 accrued a new intellectual disability diagnosis. The probability of a new intellectual disability diagnosis was higher among those who had previous disruptions in Medicaid coverage. Implications for research and policy. Expanding Medicaid to cover autistic people of all ages could decrease the need for intellectual disability diagnosis accrual. Input from autistic individuals and their families regarding their health insurance access and healthcare experiences is critically important to understanding next steps for research. [ABSTRACT FROM AUTHOR]

Little research examines the best ways to improve communication between parents and teachers of children with autism spectrum disorder (ASD) and its effect on child outcomes. The present study tests an innovative parent-teacher consultation model, entitled Partners in School. The goal of Partners in School is to improve parent-teacher communication about evidence-based practices (EBPs) and, subsequently, outcomes for children with ASD. Participants were 26 teachers and 49 parents of children with ASD from a large urban public school district. Parents and teachers completed measures of their communication and child outcomes prior to and after receiving consultation through Partners in School. Results indicated that parents and teachers perceived improvements in child outcomes after participation in Partners in School. Changes in parent-teacher communication also were associated with changes in some child outcomes. Discussion highlights the important role of communication in consultations targeting family-school partnerships for children with ASD. [ABSTRACT FROM AUTHOR]

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

Women veterans experience high rates of lifetime intimate partner violence (IPV) and suffer a variety of trauma-related health conditions. The purpose of this study was to identify health status and health risk behaviors associated with experiences of psychological, physical, or sexual IPV among women veterans receiving care at a Veterans Affairs (VA) medical center. We conducted surveys with 249 women veteran patients and examined health factors associated with each form of violence. Sexual IPV victimization had the most pronounced associations with adverse health. In multivariate analysis, controlling for age, race, and income, women veterans who experienced sexual violence victimization were close to or more than three times as likely as those who experienced no IPV to report poor or fair overall health, a diagnosis of post-traumatic stress disorder or depression, bipolar disorder, or anxiety, difficulty sleeping, cigarette smoking, and problem drinking. Those who reported psychological violence only (without physical or sexual violence) also reported greater odds of self-rated poor or fair health. These findings are consistent with findings from studies with non-veteran populations and serve to further identify the unique contributions of sexual IPV to health outcomes. The integrated VA health care system offers opportunities for IPV identification and response including a coordinated team-based care model with social work integrated within primary care. [ABSTRACT FROM AUTHOR]

We examined (a) the associations between Medicaid home and community-based waiver participation and service use and expenditures among children with ASD; and (b) how states' waiver spending moderates these effects. We used 2005 Medicaid claims to identify a sample of children with autism spectrum disorder (ASD). We selected two comparison groups who had no waiver participation: (a) children who were eligible for Medicaid through disability (disability group), and (b) children who had at least one inpatient/long-term care (IP/LT) episode (IP/LT group). Waiver participants were less likely to use IP/LT services and had lower associated expenditures than the disability group. As states' waiver spending increased, waiver participants became increasingly less likely to use IP/LT services. Waiver participants had more outpatient visits and associated expenditures; this difference increased as state waiver spending increased. Compared with the IP/LT group, waiver participants had lower IP/LT expenditures, more outpatient visits, and associated expenditures. Higher state waiver generosity increased this effect on outpatient visits and expenditures. [ABSTRACT FROM AUTHOR]

Objective: The authors sought to characterize the short-term risks of repeat self-harm and psychiatric hospital admission for deliberate self-harm patients discharged from emergency departments to the community, focusing on recognition of mental disorders in the emergency department. Method: A retrospective longitudinal cohort analysis of national Medicaid claims data was conducted of adults 21-64 years of age with deliberate self-harm who were discharged from emergency departments (N=5,567). Rates and adjusted risk ratios are presented of repeat self-harm visits and inpatient psychiatric admission during the 30 days following the initial emergency visit. Results: Approximately 9.7% of self-harm visits were followed by repeat self-harm visits and 13.6% by inpatient psychiatric admissions within 30 days after the initial emergency visit. The rate of repeat self-harm visits was inversely related to recognition of a mental disorder in the emergency department (adjusted risk ratio [ARR]=0.66, 95% 0=0.55-0.79) and directly related to recent diagnosis of anxiety disorders (ARR=1.56, 95% 0=1.30-1.86) or personality disorders (ARR=1.67,95% Cl=1.19-2.34). Recognition of a mental disorder in the emergency department was inversely related to repeat self-harm among patients with no recent mental disorder diagnosis (ARR=0.57, 95% 0=0.41-0.79); any recent mental disorder diagnosis (ARR=0.70, 95%=0.57-0.87); and depressive (ARR=0.71, 95% 0=0.54-0.94), bipolar (ARR=0.70, 95% 0=0.51-0.94), and substance use (ARR=0.71, 95% 0=0.53-0.96) disorder diagnoses. Recognition of a mental disorder was also inversely related to subsequent inpatient psychiatric admission (ARR=0.81, 95% 0=0.71-0.93). Conclusions: Adults who are discharged to the community after emergency visits for deliberate self-harm are at high short-term risk of repeat deliberate self-harm and hospital admission, although these risks may be attenuated by clinical recognition of a mental disorder in the emergency department. [ABSTRACT FROM AUTHOR]

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

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

OBJECTIVE: To examine changes in parental labor force participation, hours of work, and annual earnings associated with childhood autism spectrum disorders (ASD). METHODS: We used the 2002-2008 Medical Expenditure Panel Survey to examine parental labor market outcomes of children with ASD relative to children with another health limitation and children without health limitations. A logit model was used to estimate parental labor force participation. A tobit model was used to estimate parental hours of work and earnings. RESULTS: On average, mothers of children with ASD earn 35% ($7189) less than the mothers of children with another health limitation and 56% ($14 755) less than the mothers of children with no health limitation. They are 6% less likely to be employed and work 7 hours less per week, on average, than mothers of children with no health limitation. There were no statistically significant differences in fathers' labor market outcomes across 3 groups. On average, children with ASD are 9% less likely to have both parents working. Family earnings of children with ASD are 21% ($10 416) less than those of children with another health limitation and 28% ($17 763) less than those of children with no health limitation. Family weekly hours of work are an average of 5 hours less than those of children with no health limitation. CONCLUSIONS: Families of children with ASD face significant economic burden. Given the substantial health care expenses associated with ASD, the economic impact of having lower income in addition to these expenses is substantial. It is essential to design universal health care and workplace policies that recognize the full impact of autism. [ABSTRACT FROM AUTHOR]

The article presents a medical research study on the follow-up outpatient mental health care of youth who suffered episodes of deliberate self-harm. Predictors of emergency department discharge, mental health assessments and follow-up care for Medicaid-covered youth are examined through a retrospective longitudinal cohort analysis from 2006 Medicaid claims data.

Objective: This analysis assessed whether stimulant adherence was associated with improvement in academic grade point average (GPA) among children diagnosed with and treated for attention-deficit/hyperactivity disorder (ADHD). Method: Medicaid claims were merged with academic records from Philadelphia public schools of Medicaid-eligible children in first through eighth grades who were diagnosed with ADHD and who had filled one or more stimulant prescription. Students diagnosed with mental retardation, autism, or speech, hearing, visual, or language impairments were excluded. Marking periods were scored for GPA (range: 0-4.0) based on English, mathematics, social studies, and science grades and for stimulant adherence (medication possession ratio > 0.70). Random and fixed-effects models estimated the effects of stimulant adherence on GPA, between all adherent and nonadherent marking periods in aggregate and within individual student's marking periods, respectively. Results: A total of 3,543 students contributed 29,992 marking periods, of which 18.6% were adherent. Mean GPA was significantly higher during stimulant-adherent (2.18) than stimulant-nonadherent (1.99) marking periods in aggregate (p < .0001). The regression coefficient representing within-student association between stimulant adherence and GPA over time was 0.108 (p < .0001), indicating that adherence was associated with a 0.108 increase in GPA. In stratified analyses, analogous coefficients were 0.106 for boys, 0.111 for girls, 0.078 for elementary students, and 0.118 for middle school students (all p < .0001). The association was stronger among students with (0.139) than without (0.088) comorbid disruptive behavior disorders (both p < .0001). Conclusions: Stimulant adherence, although found to be low among urban elementary and middle school students diagnosed with ADHD, was associated with a marginal improvement in GPA. J. Am. Acad. Child Adolesc. Psychiatry, 2011;50(5):480-489. Key words: stimulant, adherence, academic performance, school, ADHD [ABSTRACT FROM AUTHOR]

Abstract: Persons with former alcohol or drug use disorders are protected from labor market discrimination by the Americans with Disabilities Act of 1990. They have been neglected, however, in empirical studies of labor market discrimination following implementation of the Act. We apply econometric techniques used to study other disabled groups to determine if there are significant differences in employment outcomes for persons with and without former substance use disorders and, if so, what part of these differences potentially can be attributed to employer discrimination. There are no significant differences in employment rates between persons with and without former substance use disorders, and among those who are employed no significant differences in rates of full-time employment. But persons with former substance use disorders report significantly higher rates of involuntary job loss within the previous year. Part of the differential remains unexplained after controlling for other factors that affect employment outcomes, suggesting employer discrimination may be one cause of poor job stability among this group. Certain identifiable subgroups with low levels of human capital are particularly susceptible to substance-related discrimination. [Copyright &y& Elsevier]

Research indicates that knowing someone with HIV/ AIDS is associated with greater perceived risk of contracting HIV and changes in sexual risk behaviors. The current study with a sample of 1,172 examined whether knowing someone with HIV/AIDS influenced sexual risk communication and youth engagement in sexual intercourse using the Philadelphia Educational Longitudinal Study (PELS). Adolescents who reported personally knowing someone with AIDS were more likely to be female (p < .001) and Black (p < .007) or Hispanic (p < .019). These adolescents were 1.5 times more likely to report ever having had sex and 1.3 times more likely to have ever talked to their parent about how to avoid STDs and AIDS compared to youth who did not know someone with AIDS. Understanding if and how knowing someone with HIV/AIDS influences sexual activity may be an important approach in reducing new HIV infections. [ABSTRACT FROM AUTHOR]

Focusing on the reported growing use of firearms to complete suicide among African Americans, this article analyzes the 1993 National Mortality Followback Survey to examine the association of firearm suicide with race, education, geographic region, access to a firearm, depressive symptoms, and mental health service utilization on decedents aged 15 years and older. After controlling for demographic, socioeconomic, and clinical variables, the analysis indicates that African American men were twice as likely as White men to use a firearm to complete suicide. The findings suggest the importance for clinicians to screen for the presence of firearms in depressed African Americans and to reduce their access to firearms. In addition, clinicians, social workers, and public health professionals should consider racial differences in correlates of firearm suicide when designing prevention and intervention initiatives. [ABSTRACT FROM AUTHOR]

Objective: This study attempted to estimate the relative risk of developing hyperlipidemia after treatment with antipsychotics in relation to no antipsychotic treatment. Method: A matched case-control analysis was performed with pharmacy and claims data from California Medicaid (Medi-Cal). Patients were excluded if they were treated for medical disorders or prescribed medications known to increase their risk of hyperlipidemia. Cases were ages 18 to 64 years with schizophrenia, major depression, bipolar disorder, or other affective psychoses and incident hyperlipidemia. Cases were matched to up to six control subjects by age, sex, race, and psychiatric diagnosis. Both groups were prescribed either no antipsychotic medication or had two or more prescriptions for one and only one antipsychotic medication during the 60 days prior to the first indication of hyperlipidemia (cases) or matched index date (controls) in the billing record. Conditional logistic regressions were used to derive odds ratios and 95% confidence intervals (95% Cls) of each antipsychotic medication in relation to no antipsychotic medication. Results: A total of 13,133 incident cases of hyperlipidemia were matched to 72,140 control subjects. As compared with no antipsychotic medication, treatment with clozapine (odds ratio: 1.82, 95% CI: 1.61-2.05), risperidone (odds ratio: 1.53, 95% CI: 1.43–1.64), quetiapine (odds ratio: 1.52, 95% CI: 1.40-I .65), olanzapine (odds ratio: 1.56, 95% CI: 1.47–1.67), ziprasidone (odds ratio: 1.40, 95% CI: 1.19–1.65), and first-generation antipsychotics (odds ratio: 1.26, 95% CI: 1.14–1.39), but not aripiprazole (odds ratio: 1.19, 95% CI: 0.94–1.52) was associated with a significant increase in risk of incident hyperlipidemia. Conclusions: These findings suggest that most commonly prescribed antipsychotic medications increase the risk of developing hyperlipidemia in patients with schizophrenia or mood disorders. [ABSTRACT FROM AUTHOR]

This research note examines patterns of denominational switching and the characteristics of switchers within Judaism in the United States. Viewing orthodox, conservative, and reform Judaism and a fourth “nonspecific” group as categories that range from the most traditional to the least traditional, respectively, we focus on the movement of individuals toward or away from a more traditional denomination in comparison with remaining in the same denomination in which they were raised. The data were drawn from the National Jewish Population Survey (NJPS) 2000–2001 (NJPS 2003). We found that 62 percent stay within the same group, 29 percent move away from tradition, and 9 percent move to a more traditional denomination. Multivariate logistic regression analyses show that a lower level of Jewish background, higher previous travel to Israel, a greater extent of organizational affiliation, and a higher level of spiritual feelings and beliefs are associated with moving to a more traditional denomination whereas a higher level of Jewish background, lower previous travel to Israel, and a lower level of spiritual feelings and beliefs are associated with moving to a less traditional denomination. In addition, a few sociodemographic factors (previously married, has a child at home, lives in a western state) are associated with movement toward tradition whereas others (older age, female, not living in the northeast or west) are associated with movement in the other direction. [ABSTRACT FROM AUTHOR]

Medical inpatients often suffer from comorbid psychiatric illness, which has been shown in previous studies to be associated with longer hospital stays. The present analysis used a large representative dataset to examine the impact of patient demographic and clinical characteristics on the relationship between psychiatric comorbidity and hospital length of stay. Analyses showed the existence of a psychiatric comorbidity predicted longer hospital stays for medical inpatients. However, in comparison to previous research, this effect was attenuated in this sample. Patients with mental disorders who were elderly, on Medicare, and those with schizophrenia or mood disorders were especially at risk for slightly longer lengths of stay. [ABSTRACT FROM AUTHOR]

Medical errors in the general medical sector result in significant patient deaths and injuries, as well as high costs to the health care system. Despite the growing literature on errors in medical and surgical specialties, few studies have examined the incidence, nature, predictors, and prevention of errors that may occur in mental health treatment settings. The purpose of the current review is to examine the lessons learned from patient-safety research in the general medical sector, provide examples of types of errors in psychiatry, review the errors identified in the literature, offer a discussion of error-reduction strategies for improving patient safety, and provide recommendations for future research. Increased attention to medical errors in psychiatry is necessary in order to build safer health systems and promote a culture of safety among providers, thereby producing better care for patients with mental disorders. [ABSTRACT FROM AUTHOR]

Objective: Continuation of antidepressant treatment for depression beyond the first months helps to consolidate treatment response and to reduce the risk of early relapse. The authors sought to characterize the rate and pattern of antidepressant discontinuation among adults initiating antidepressant treatment for depression. Method: Data were drawn from the household component of the Medical Expenditure Panel Survey for 1996-2001. Analysis was limited to data for adults age 18 years and older (N=829) who initiated antidepressant treatment for depression and who 1) discontinued treatment during the first 30 days of treatment, 2) completed the first 30 days of treatment and then discontinued treatment during the following 60 days, or 3) continued treatment for more than 90 days after treatment initiation. Results: A majority of the patients discontinued antidepressant therapy during the first 30 days (42.4%). Only 27.6% of the patients continued antidepressant therapy for more than 90 days. Antidepressant discontinuation during the first 30 days of treatment was significantly more common among Hispanics (53.8%) than non-Hispanics (41.3%); patients with fewer than 12 years of education (50.8%), compared with those with 12 or more years (39.3%); and patients with low family incomes (50.2%), compared with those with medium or high family incomes (38.6%). Patients were significantly more likely to continue anti-depressant treatment beyond 30 days if they received psychotherapy (68.0% versus 43.7%), completed 12 or more years of education (64.8% versus 52.0%), or had private health insurance (60.1% versus 50.8%). Among those who continued antidepressants beyond 30 days, antidepressant continuity during the subsequent 60 days was significantly associated with fair or poor pretreatment self-rated mental health and physical health, treatment with a selective serotonin reuptake inhibitor or serotonin-norepinephrine reuptake inhibitor, and psychotherapy. Conclusions: Early discontinuation of antidepressant therapy is widespread in the community treatment of depression, especially among socioeconomically disadvantaged patients. Provision of psychotherapy and selection of an appropriate antidepressant medication may reduce the risk of discontinuation during the first 3 months of antidepressant treatment for depression. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: The peer-review literature is the primary medium through which the findings of funded research are evaluated by and disseminated to the broader scientific community. This study examines when and how grants funded by the National Institutes of Health (NIH) lead to publications. Methods: Data on all investigator-initiated R01 grants funded during 1996 (n = 18211) were extracted from the NIH’s Computer Retrieval of Information on Scientific Projects Web site. These data were linked with all MEDLINE articles published during and up through 4 years after completion of each grant using NIH grant numbers reported in the manuscript. Analyses examined the number, timing, and correlates of all linked publications and publications in core journals (179 journals, comprising the top 100 Institute for Scientific Information or 120 Abridged Index Medicus journals). Results: On average, each grant produced 7.6 MEDLINE manuscripts (95% confidence interval [CI]: 7.47 to 7.69) and 1.61 publications in a core journal (95% CI: 1.56 to 1.65). In multivariable analyses among universities, more manuscripts and publications in core journals were seen for competing renewals versus new grants, for projects reviewed by basic science study sections, for full professors, and for universities with graduate programs ranked in the top 10 by US News and World Report. However, all grant, investigator, and institutional strata produced substantial numbers of publications per grant. Conclusions: The findings support the feasibility and potential utility of efforts to study the link between grant funding and research findings, an early step in the process by which funded science leads to improved clinical and public health. [Copyright &y& Elsevier]

This study tracks the diffusion of generic fluoxetine after its release in August 2001 within the largest U.S. pharmacy benefit manager (PBM). Within two weeks of the generic's release, prescriptions exceeded those of brand-name Prozac. The main winners proved to be Barr Laboratories, the first entrant to the generic market; large purchasers, who reaped substantial cost savings after Barr's period of exclusivity expired; and the PBM. The major loser was Eli Lilly, the manufacturer of Prozac. Consumers and makers of other antidepressants largely remained on the sidelines, with surprisingly little short-term impact evident from Prozac's patent expiration. [ABSTRACT FROM AUTHOR]

Objective: This study examined patterns of psychotropic medication use after the Sept. 11, 2001, terrorist attacks. Method: It drew from two large pharmacy data sets, one providing nationally representative aggregate projections for all U.S. prescriptions (156.9 million claims for psychotropic medications during the study period) and a second from the nation's largest pharmacy benefit management organization (36.4 million enrollees per month), 4.1% of whom had a prescription for a psychotropic medication during the study period. Analyses examined use of antidepressant, antipsychotic, anxiolytic, and hypnotic medications in the 12 weeks before and after Sept. 11, 2001, compared with the same weeks during 2000. Results: Nationally and in Washington, D.C., there was no evidence of an increase in overall prescriptions, new prescriptions, or daily doses for psychotropic medications. In New York City, there was an in- crease in the proportion of existing users with psychotropic dose increases in the weeks after the attacks (16.9% in 2001 versus 13.6% in 2000) but no significant increase in the rate of new psychotropic prescriptions. Conclusions: For most of the nation, the distress associated with the terrorist attacks was not accompanied by a commensurate increase in the use of psychotropic medications. In New York City, there was a statistically significant but modest increase in the proportion of individuals with dose increases in their psychotropic medications. [ABSTRACT FROM AUTHOR]

Objective: This study examined the relationship between utilization management techniques and psychiatrists' treatment plan modifications. Method: Nationally representative data on 1,843 patients treated by 615 psychiatrists participating in the American Psychiatric Institute for Research and Education's Practice Research Network were used to examine the demographic and clinical characteristics of patients whose care was subjected to utilization management and to assess the association between utilization management and psychiatrists' treatment plan modifications. Results: Approximately half of all patients had treatment that was subject to utilization management (52.6%). For the patients whose treatment was not subject to utilization management, 15.5% had their treatment plan changed compared to the 31.5% who were subject to utilization management. Overall, after adjustment for differences in patients, settings, and psychiatrist characteristics, the patients subject to utilization management were 2.6 times more likely to have their treatment changed than the patients who were not subject to utilization management. These patients were 3.7 times more likely to have their type of treatment changed and 2.3 times more likely to have their frequency or number of visits changed. Psychiatrists in individual practice settings and those with nonsalaried income sources were more likely to modify treatment decisions for their patients when subject to utilization management. Conclusions: The presence of utilization management is highly associated with changes in psychiatrists' treatment decisions. When compared to evidence-based treatment recommendations, these changes seem likely to result in less than optimal care. [ABSTRACT FROM AUTHOR]

: Background contextFew empirical data are available that document changes in population-based rates for the evaluation and treatment of nonspecific back pain.: PurposeTo determine the extent of change in the pattern of outpatient evaluation and treatment of nonspecific low back pain in the United States between 1987 and 1997.: Study design and settingThe 1987 National Medical Expenditure Survey and the 1997 Medical Expenditure Panel Survey, two nationally representative surveys with similar sampling methods and questions, were used.: Patient sampleNoninstitutionalized adults in the United States.: Outcome measuresChanges in rates of any health service for nonspecific back pain and occurrence of provider-specific care and types of services provided. Changes in the prescription of specific medication classes (ie, nonsteroidal anti-inflammatory drugs [NSAIDs], muscle relaxants, nonnarcotic and narcotic analgesics) were also investigated.: ResultsOverall rate for outpatient treatment for nonspecific back pain in the US population was relatively stable over the decade (4.48% in 1987, 4.53% in 1997, p = .85). Among those receiving care, the proportion receiving physician care increased from 64% in 1987 to 74% in 1997 (p<.001), whereas those obtaining care from physical therapists increased from 5% to 9% during the same time period (p<.01). The proportion of respondents receiving NSAIDs, muscle relaxants, nonnarcotic analgesics and narcotic analgesics remained stable. However, the mean number of patient visits in which these medications were prescribed increased from 2.0 to 3.9 over the decade (p<.001). The proportion of individuals receiving chiropractic care (p<.01) and X- rays (p<.001) were lower in 1997 than 1987.: ConclusionsThe national pattern of health care for nonspecific low back pain observed in the present study serves as a basis for future investigations into the management of this major public health problem. Findings suggest that perhaps a duplication of care is partly responsible for the high degree of health care utilization in this population. [Copyright &y& Elsevier]

Objective: This article reports recent trends in the use of outpatient psychotherapy in the United States. Method: Data from the household sections of the 1987 National Medical Expenditure Survey and the 1997 Medical Expenditure Panel Survey were analyzed. Trends in the rate of psychotherapy use from these nationally representative samples are presented by age, sex, race/ethnicity, marital status, education, employment status, and income. Psychotherapy users are compared over time by provider specialty, concomitant psychotropic medication use, number of annual visits, and costs. In addition, trends in payment source and primary diagnosis are assessed for psychotherapy visits. Results: Between 1987 and 1997, there was no statistically significant change in the overall rate of psychotherapy use (3.2 per 100 persons in 1987 and 3.6 per 100 in 1997). However, significant increases were observed in psychotherapy use by adults aged 55-64 years and by unemployed adults. Among psychotherapy patients, there was a marked increase in the use of antidepressant medications (14.4% to 48.6%), mood stabilizers (5.3% to 14.5%), stimulants (1.9% to 6.4%), and psychotherapy provided by physicians (48.1% to 64.7%). A smaller proportion of patients made more than 20 psychotherapy visits in 1997 (10.3%) than in 1987 (15.7%). Over this period, psychotherapy visits for mood disorders became more common. In 1997, 9.7 million Americans spent $5.7 billion on outpatient psychotherapy. Conclusions: From 1987 to 1997, access to psychotherapy in the United States remained constant overall but was characterized by increased use by some socioeconomically disadvantaged groups. However, the number of visits per user markedly decreased during this period. Psychotherapy was increasingly administered by physicians and provided in conjunction with psychotropic medications. These changes occurred during a period of expansion in the number of available psychotropic medications and growth in managed... [ABSTRACT FROM AUTHOR]

Discusses the most expensive medical conditions in the U.S. Association between spending and disability; Role of the cost-of-illness and burden-of-disease estimates in setting priorities.

Objectives: Little information exists on national trends in the use of psychotropic medication by children and adolescents. The objective of this report is to compare patterns and predictors of psychotropic medication use by children and adolescents in the United States in 1987 and 1996.Method: An analysis of medication use data is presented from two nationally representative surveys of the general population focusing on children 18 years of age and younger who used one or more prescribed psychotropic medication during the survey years. Rates of stimulant, antidepressant, and other psychotropic medication use are reported.Results: The overall annual rate of psychotropic medication use by children increased from 1.4 per 100 persons in 1987 to 3.9 in 1996 (p < .0001). Significant increases were found in the rate of stimulant use (0.6 per 100 persons to 2.4 per 100 persons), antidepressant use (0.3 per 100 persons to 1.0 per 100 persons), other psychotropic medications (0.6 per 100 persons to 1.2 per 100 persons), and coprescription of different classes of psychotropic medications (0.03 per 100 persons to 0.23 per 100 persons), especially antidepressants and stimulants. Rates of antipsychotic and benzodiazepine use remained stable. In 1996, stimulant use was especially common in children aged 6 to 14 years (4.1 per 100), and antidepressant use was common in children aged 15 to 18 years (2.1 per 100 persons).Conclusion: Between 1987 and 1996, there was a marked expansion in use of psychotropic medications by children, especially stimulants and antidepressants. [ABSTRACT FROM AUTHOR]

Compares trends in outpatient treatment of depressive disorders in the United States in 1987 and 1997. Design, setting, and participants; Main outcome measures; Results; Conclusion there was in increase in outpatient treatment with psychotropic medications, but fewer outpatient visits and less use of psychotherapy; Indication that these changes coincided with the introduction of better-tolerated antidepressants, the expansion of third-party payment, and the development of rapid diagnostic procedures.

Examines the patterns of economic burden across five chronic conditions in the United States. Costs of health care; Characteristics and patterns of service on driving the costs; Comprehension on the needs and improvement of care.

Examines the prevalence, characteristics and impact of mental and general medical disabilities in the United States. Association of disabilities attributed to a mental condition with social and cognitive difficulties; Estimated number of Americans who reported that a mental condition contributes to their disability.

Enrollment in Medicaid facilitates access to needed services among transition-age youth on the autism spectrum and youth with intellectual disability (ID). There are long-standing programs to ensure that individuals with ID remain enrolled as they age; similar programs for autistic youth are newer, not as widespread, and may not be as effective. We compared Medicaid disenrollment and re-enrollment between transition-age youth on the autism spectrum, youth with ID, and youth with both diagnoses using a national claims-based prospective cohort study from 2008 through 2012. Autistic youth were most likely to disenroll and least likely to re-enroll. Disenrollment peaked for all three groups at ages 19 and 21. Transition-age youth on the autism spectrum experience more disruptions in access to Medicaid-reimbursed services than youth with ID. More equitable Medicaid enrollment options for autistic individuals are needed to ensure their access to critical health care as they age. [ABSTRACT FROM AUTHOR]

Attempts to determine the extent and pattern of blood serum monitoring of mood stabilizers in Medicaid patients with bipolar disorder. Demographic and service use characteristics; Likelihood of therapeutic drug monitoring and case management services; Likelihood that lithium users will receive the recommended serum level test.

Examines trends in the composition and duration of visits to psychiatrists in office-based psychiatric practice. Use of physician-reported data from the 1985 and 1995 National Ambulatory Medical Care Surveys; Secular changes in visit characteristics; Factors affecting changes in practice style.

Background: In addition to symptoms, DSM-IV criteria for major depression require clinical significance, operationalized via reports of receipt of care or interference in functioning. The authors examined whether this confounding of symptoms with receipt of care and/or impairment affected racial differences in rates of major depression in the community. Method: Analysis of data from the 1999 National Health Interview Survey for a nationally representative community sample of 30,801 adults administered the depression module of the Composite International Diagnostic Interview-Short Form. Results: There were no differences between African American subjects and white/other subjects when diagnosis was based solely on symptoms. Symptomatic African American individuals were less likely to endorse either receipt of care or interference in functioning, so that the clinical significance criterion served to reduce their rates of DSM-IV diagnosis. Conclusions: The clinical significance criterion underestimates of the rate of depression for African American individuals relative to white/other subjects, which may in turn underestimate their need for services. [ABSTRACT FROM AUTHOR]

This article examines trends in the volume, authorship, content, and funding of MEDLINE articles between 1978 and 2001, a time of great change in medical research and medical practice. The authors examine these trends as a means of identifying opportunities and challenges for using this information to guide practice. A total of 8.1 million journal articles were published in MEDLINE between 1978 and 2001. Between 1978 to 1985 and 1994 to 2001, the annual number of MEDLINE articles increased 46%, from an average of 272,344 to 442,756 per year, and the total number of pages increased from 1.88 million pages per year during 1978 to 1985 to 2.79 million pages per year between 1994 to 2001. The growing number of articles, the shift toward clinical topics, and the growth of randomized trials point to an increasingly rich source of information available for guiding treatment decisions. However, this stunning growth in medical information also brings challenges and risks. Furthermore, MEDLINE-indexed journals represent an increasingly small portion of the broader universe of medical information.

Background: Theory and correlational research indicate organizational leadership and climate are important for successful implementation of evidence-based practices (EBPs) in healthcare settings; however, experimental evidence is lacking. We addressed this gap using data from the WISDOM (Working to Implement and Sustain Digital Outcome Measures) hybrid type III effectiveness-implementation trial. Primary outcomes from WISDOM indicated the Leadership and Organizational Change for Implementation (LOCI) strategy improved fidelity to measurement-based care (MBC) in youth mental health services. In this study, we tested LOCI's hypothesized mechanisms of change, namely: (1) LOCI will improve implementation and transformational leadership, which in turn will (2) mediate LOCI's effect on implementation climate, which in turn will (3) mediate LOCI's effect on MBC fidelity. Methods: Twenty-one outpatient mental health clinics serving youth were randomly assigned to LOCI plus MBC training and technical assistance or MBC training and technical assistance only. Clinicians rated their leaders' implementation leadership, transformational leadership, and clinic implementation climate for MBC at five time points (baseline, 4-, 8-, 12-, and 18-months post-baseline). MBC fidelity was assessed using electronic metadata for youth outpatients who initiated treatment in the 12 months following MBC training. Hypotheses were tested using longitudinal mixed-effects models and multilevel mediation analyses. Results: LOCI significantly improved implementation leadership and implementation climate from baseline to follow-up at 4-, 8-, 12-, and 18-month post-baseline (all ps <.01), producing large effects (range of ds = 0.76 to 1.34). LOCI's effects on transformational leadership were small at 4 months (d = 0.31, p =.019) and nonsignificant thereafter (ps >.05). LOCI's improvement of clinic implementation climate from baseline to 12 months was mediated by improvement in implementation leadership from baseline to 4 months (proportion mediated [pm] = 0.82, p =.004). Transformational leadership did not mediate LOCI's effect on implementation climate (p = 0.136). Improvement in clinic implementation climate from baseline to 12 months mediated LOCI's effect on MBC fidelity during the same period (pm = 0.71, p =.045). Conclusions: LOCI improved MBC fidelity in youth mental health services by improving clinic implementation climate, which was itself improved by increased implementation leadership. Fidelity to EBPs in healthcare settings can be improved by developing organizational leaders and strong implementation climates. Trial registration: ClinicalTrials.gov identifier: NCT04096274. Registered September 18, 2019. [ABSTRACT FROM AUTHOR]

Presents a study which examines the effect of self-reported anxiety on the days persons with various general medical conditions spend in bed owing to disability. Analysis of the data collected; Method used in this study; Results of the study; Discussions on the results.

The extent to which mental health services for youths embody system-of-care (SOC) principles is an important quality indicator. This study tested whether youth and family experiences of SOC principles varied depending on youths' level of need after adjusting for sociodemographic and treatment factors. The relationship to caregiver-reported clinical outcomes was also examined. Using administrative data and cross-sectional surveys from a stratified random sample of 1124 caregivers of youths ages 5–20 within a statewide system, adjusted analyses indicated caregivers of youths with the most intensive needs were significantly less likely to report receiving care that embodied SOC principles, with deficits on six of nine items. Youths whose services embodied SOC principles experienced significantly greater improvement in caregiver-reported functioning even after adjusting for level of need. Results highlight disparities in SOC principles for youths with intensive needs and the need for policy and intervention development to improve care for this population. [ABSTRACT FROM AUTHOR]

The article highlights the need for greater focus on those at high risk of suicide at a time when the overall annual suicide rate in the U.S. increased to 12.1 per 100,000 persons. Topics discussed include results observed from promising suicide prevention strategies, the opportunity for improvement in patient transitions from inpatient to outpatient psychiatric care in the U.S. and the benefits presented by consolidation of healthcare delivery into larger organizational entities.

BACKGROUND: The health care costs associated with treating autism spectrum disorder (ASD) in children can be substantial. State-level mandates that require insurers to cover ASD-specific services may lessen the financial burden families face by shifting health care spending to insurers. METHODS: We estimated the effects of ASD mandates on out-of-pocket spending, insurer spending, and the share of total spending paid out of pocket for ASD-specific services. We used administrative claims data from 2008 to 2012 from 3 commercial insurers, and took a difference-in-differences approach in which children who were subject to mandates were compared with children who were not. Because mandates have heterogeneous effects based on the extent of children's service use, we performed subsample analyses by calculating quintiles based on average monthly total spending on ASD-specific services. The sample included 106 977 children with ASD across 50 states. RESULTS: Mandates increased out-of-pocket spending but decreased the share of spending paid out of pocket for ASD-specific services on average. The effects were driven largely by children in the highest-spending quintile, who experienced an average increase of $35 per month in out-of-pocket spending (P < .001) and a 4 percentage point decline in the share of spending paid out of pocket (P < .001). CONCLUSIONS: ASD mandates shifted health care spending for ASD-specific services from families to insurers. However, families in the highest-spending quintile still spent an average of >$200 per month out of pocket on these services. To help ease their financial burden, policies in which children with higher service use are targeted may be warranted. [ABSTRACT FROM AUTHOR]

Purpose: Parent coaching is a complex, psychosocial intervention with multiple core components. Clinicians' use of these core components may be influenced by distinct factors; no research has examined whether clinician perceptions of parent coaching vary across core coaching components. This study aimed to examine the extent to which clinicians working with families of young autistic children in publicly funded early intervention intend to use core parent coaching components, and to examine how closely psychological factors relate to providers' intentions to use each component. Methods: Using the Theory of Planned Behavior as a framework, this study compared the strength of clinicians' intentions across five core parent coaching components: collaboration with parents, delivering the intervention within daily routines, demonstrating the intervention, providing in-vivo feedback, and reflection and problem solving. We examined the associations between intentions and psychological determinants of intentions (i.e., attitudes, norms, and self-efficacy) for each component. Results: Clinicians' average intentions varied by core component, with strongest intentions for demonstrating the intervention strategy for a parent. The associations between intentions and psychological determinants also varied by core component. Attitudes, injunctive norms, and self-efficacy, but not descriptive norms, significantly related to clinicians' intentions to use collaboration and daily routines, whereas attitudes and descriptive norms, but not injunctive norms and self-efficacy, significantly related to clinicians' intentions to use feedback and reflection and problem solving. Conclusion: These results suggest that implementation strategies should be tailored to the specific intervention component to be most efficient and effective. The results also provide examples of potentially malleable factors that implementation strategies can strategically target. [ABSTRACT FROM AUTHOR]

Presents a letter to the editor in response to the article "Who cares about academic medicine?" by J. Clark and P. Tugwell, in the October 2, 2004 issue.

Forty-six states and the District of Columbia have enacted insurance mandates that require commercial insurers to cover treatment for children with autism spectrum disorder (ASD). This study examined whether implementing autism mandates altered service use or spending among commercially insured children with ASD. We compared children age twenty-one or younger who were eligible for mandates to children not subject to mandates using 2008-12 claims data from three national insurers. Increases in service use and spending attributable to state mandates were detected for all outcomes. Mandates were associated with a 3.4-percentage-point increase in monthly use and a $77 increase in monthly spending on ASD-specific services. Effects were larger for younger children and increased with the number of years since mandate implementation. These increases suggest that state mandates are an effective tool for broadening access to autism treatment under commercial insurance. [ABSTRACT FROM AUTHOR]