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People with co-occurring mental and substance use disorders experience poor outcomes and incur high costs in multiple domains. Efforts to develop and disseminate evidence-based integrated programs for people with such co-occurring disorders began to wane in the past decade as efforts shifted toward integrating primary health care. Several recent trends underscore the need to refocus efforts on providing integrated care for people with both mental and substance use disorders. The authors summarize what is known about integrated care for people with these co-occurring disorders and recommend advancing implementation and research on integration and improving outcomes with existing resources.

Tobacco use in people with behavioral health conditions remain two to three times higher than the general population causing premature death and impacting recovery negatively across several domains. Intermediary organizations can provide practical tools, training, and technical assistance to help programs improve capacity to treat tobacco use. This report describes the construction and application of the Tobacco Integration Self-Evaluation Tool (TiSET) for behavioral health programs, a 20-item scale inspired by the DDCMHT and additional content from the Facility Tobacco Policy and Treatment Practices Self-Evaluation tool that one of the study authors (JW) used previously with addiction treatment programs. Completing the TiSET is an important step for behavioral health programs to evaluate their ability to effectively treat people that use tobacco. An important next step is to use those results to facilitate a quality improvement process. We include large agency example illustrating how the TiSET can be applied in real-world practice.

This study examined the relationship between individual placement and support (IPS) employment specialists' time spent in the community and employment outcomes in the current digital age, featuring increased technology use and online hiring practices.The authors examined the relationship between employment outcomes and IPS employment specialists' time spent in the community at 78 sites in 2018 and 84 sites in 2019.The amount of time staff spent in the community was significantly and positively associated with better employment outcomes.These data support the continued importance of employment specialists' spending time in the community with employers and IPS recipients to achieve optimal outcomes for recipients.

Fidelity scales demonstrate whether practices are delivered as intended. Typically, these assessments are conducted by independent raters, which can be expensive and difficult to resource in large systems. We piloted whether an intermediary organization could (1) train programs to conduct a self-assessment using an established reliable and valid measure, the Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) Index, (2) use the results of that assessment to drive a quality improvement process through a six month learning collaborative, and (3) repeat the self-assessment to measure progress. To assess reliability of the second self-assessment, we invited programs to also participate in an objective DDCMHT assessment with an independent rater. Participating programs rated themselves similarly to the objective rater and demonstrated significant improvements following participation in a quality improvement process. These findings suggest that intermediary organizations may be positioned to provide expert training and technical assistance to help organizations integrate self-assessments with quality improvement activities.

Motivational interviewing (MI) is an empirically supported clinical method to help individuals make behavioral changes to achieve a personal goal. Through a set of specific techniques, MI helps individuals mobilize their own intrinsic values and goals to explore and resolve ambivalence about change. This article examines how MI-informed approaches can be applied to help staff adopt new evidence-based practices in organizational settings. Although the implementation science literature offers strategies for implementing new practices within organizations, leaders of quality improvement initiatives often encounter ambivalence about change among staff. Implementation approaches that require staff to make substantial changes may be facilitated by drawing from MI strategies. These include building a sense of collaboration from the beginning, eliciting "change talk," and addressing any ambivalence encountered. Motivational interviewing techniques may be particularly helpful in working with those in a stage of precontemplation (who have yet to see a reason for change) and those who are contemplating change (who see that a problem exists but are ambivalent about change). This article provides examples of how an MI-informed approach can be applied to help facilitate change in staff within organizations that are implementing quality improvement initiatives. These techniques are illustrated using a representative scenario.

Intermediary and purveyor organizations (IPOs) play a key role in disseminating and implementing behavioral health evidence-based practices. The COVID-19 pandemic created a time of crisis and disruption to behavioral health care delivery. Using the conceptual framework of basic, targeted, and intensive technical assistance (TA) from the Training and Technology Transfer Centers, case studies are used to describe how programs at The Center for Practice Innovations a state funded-intermediary organization, adapted its training and technical assistance to be delivered entirely remotely, to include content related to COVID-19 and to provide guidance on telehealth-based behavioral health care.

Mental health authorities in several states, often working with academic partners, have played important roles in disseminating evidence-based practices (EBPs) for adults diagnosed with serious mental illness. This work has been facilitated by intermediary organizations that work directly with providers to implement EBPs. This report uses two case studies to describe how the Center for Practice Innovations (CPI), an intermediary organization, has used the Active Implementation Research Network’s nine implementation drivers to successfully implement EBPs across the large state of New York. One case study focuses on supported employment and the second on integrated treatment for co-occurring mental health and substance use conditions. We provide these case studies to illustrate how intermediary organizations can use implementation science to organize and select effective support strategies to disseminate and implement a range of EBPs within a state system.

A growing body of literature demonstrates that high-fidelity implementation of the individual placement and support (IPS) model of supported employment increases the chances of achieving desired outcomes. This study examined the relationship between IPS fidelity, as self-reported by program sites, and employment outcomes and determined whether this relationship was maintained over time.A total of 78 outpatient programs in New York State provided data on self-reported IPS fidelity and employment outcomes. Pearson correlations were used to determine the relationship between fidelity scores and competitive employment rates. A mixed-effects model examined the relationship between repeated fidelity and employment measures over time.A significant positive relationship was found between better self-reported IPS fidelity and greater employment. The relationship between IPS fidelity and employment was sustained over time (up to one year).Higher-fidelity implementation of the IPS model, as self-assessed by program sites, was associated with higher employment rates, which were sustained over time.

Improved dissemination is critical to implementation of evidence-based practice in community behavioral healthcare settings. Web-based training modalities are a promising strategy for dissemination of evidence-based practice in community behavioral health settings. Initial and sustained engagement of these modalities in large, multidisciplinary community provider samples is not well understood. This study evaluates comparative engagement and user preferences by provider type in a web-based training platform in a large, multidisciplinary community sample of behavioral health staff in New York State. Workforce make-up among platform registrants was compared to the general NYS behavioral health workforce. Training completion by functional job type was compared to characterize user engagement and preferences. Frequently completed modules were classified by credit and requirement incentives. High initial training engagement across professional role was demonstrated, with significant differences in initial and sustained engagement by professional role. The most frequently completed modules across functional job types contained credit or requirement incentives. The analysis demonstrated that high engagement of a web-based training in a multidisciplinary provider audience can be achieved without tailoring content to specific professional roles. Overlap between frequently completed modules and incentives suggests a role for incentives in promoting engagement of web-based training. These findings further the understanding of strategies to promote large-scale dissemination of evidence-based practice in community behavioral health settings.

Objective:Fidelity assessments help ensure that evidence-based practices are implemented properly. Although assessments are typically conducted by independent raters, some programs have implemented self-assessments because of resource constraints. Self-assessments were compared with independent assessments of programs implementing individual placement and support supported employment.Methods:Eleven community-based outpatient programs in New York State completed both self- and independent assessments. Intraclass correlation coefficients and paired t tests were used to compare scores from self- and independent assessments.Results:For both assessment methods, mean scores for all programs were within the range of fair fidelity. Self- and independent assessment total scores were not significantly different; however, significant differences were found on some scale items in this small sample.Conclusions:Self-assessment may be valid for examining a program’s overall functioning and useful when resource constrain...

This study aimed to evaluate the effectiveness of Homefront, a six-session, peer-taught family education program by the National Alliance on Mental Illness (NAMI), delivered in person or online, for families or support persons of military service members or of veterans with mental illness.Program participants completed online surveys at baseline, at the end of the program (postprogram), and at 3-month follow-up, which measured subjective empowerment, burden, coping, psychological distress, family functioning, experience of caregiving, and knowledge of mental illness. A mixed-effects model examined change over time.A total of 119 individuals (in person, N=63 [53%]; online, N=56 [47%]) enrolled. Participants showed statistically significant improvement on all dimensions between baseline, postprogram, and follow-up, except for subjective burden, which improved between baseline and follow-up. Results for in-person and online formats did not differ.The six-session NAMI Homefront program was associated with benefits for military and veteran family members and support persons.

Scant evidence exists in the literature for best practices in training assertive community treatment (ACT) teams to deliver highly effective services to consumers. This column describes a blended training curriculum, which includes both face-to-face and distance learning strategies, developed by the ACT Training Institute in New York State to meet the ongoing training needs of teams across New York State. Data on training uptake, which has steadily increased over time, are reported. The role of the state is crucial in driving adoption of training activities. The column also describes how the ACT Training Institute uses fidelity and outcome data to identify training needs.

Objective This multisite randomized trial addressed risks and benefits of staying on long-acting injectable haloperidol or fluphenazine versus switching to long-acting injectable risperidone microspheres.

Objective: Integrated, evidence-based treatment for co-occurring severe mental illness and substance use disorder (co-occurring disorders) reduces substance use, hospitalization, homelessness, incarceration, and treatment costs and promotes individuals’ recovery, independent living, and employment. This report describes and characterizes early uptake of New York State's Web-based training and distance implementation supports to promote statewide dissemination of integrated, evidence-based co-occurring disorders services. Methods: Thirty-five half-hour online modules provide training on integrated evidence-based co-occurring disorders treatment. Distance supports for implementation include monthly webinars, phone calls, and virtual learning communities. The authors calculated the proportion of programs with one or more practitioners who accessed the Web-based resources and the cumulative number of modules completed as an indicator of the reach of the Web-based approach to scaling up an innovation. They als...

This randomized trial addressed the risks and benefits of staying on antipsychotic polypharmacy or switching to monotherapy.Adult outpatients with schizophrenia taking two antipsychotics (127 participants across 19 sites) were randomly assigned to stay on polypharmacy or switch to monotherapy by discontinuing one antipsychotic. The trial lasted 6 months, with a 6-month naturalistic follow-up. Kaplan-Meier and Cox regression analyses examined time to discontinuation of assigned antipsychotic treatment, and random regression models examined additional outcomes over time.Patients assigned to switch to monotherapy had shorter times to all-cause treatment discontinuation than those assigned to stay on polypharmacy. By month 6, 86% (N=48) of those assigned to stay on polypharmacy were still taking both medications, whereas 69% (N=40) of those assigned to switch to monotherapy were still taking the same medication. Most monotherapy discontinuations entailed returning to the original polypharmacy. The two groups did not differ with respect to psychiatric symptoms or hospitalizations. On average, the monotherapy group lost weight, whereas the polypharmacy group gained weight.Discontinuing one of two antipsychotics was followed by treatment discontinuation more often and more quickly than when both antipsychotics were continued. However, two-thirds of participants successfully switched, the groups did not differ with respect to symptom control, and switching to monotherapy resulted in weight loss. These results support the reasonableness of prescribing guidelines encouraging trials of antipsychotic monotherapy for individuals receiving antipsychotic polypharmacy, with the caveat that patients should be free to return to polypharmacy if an adequate trial on antipsychotic monotherapy proves unsatisfactory.

This column describes the Center for Practice Innovations (CPI), which was created in 2007 by the New York State Office of Mental Health and the Department of Psychiatry at Columbia University. CPI uses innovative approaches to build stakeholder collaborations, develop and maintain practitioners’ expertise, and build agency infrastructures that support implementing and sustaining evidence-based practices. CPI’s five core initiatives provide training in co-occurring mental and substance use disorders, assertive community treatment, supported employment and education, wellness self-management, and treatment of first-episode psychosis. Central to CPI’s activities are award-winning training modules, statewide learning collaboratives, and use of a learning management system.

Purpose:Previous analysis of data from CATIE showed that patients randomly assigned to switch to a new medication were more likely to discontinue study drug than those who stayed on the medication they had been taking prior to randomization. This study addresses additional outcomes measures evaluating symptoms, neurocognition, quality of life, neurological side effects, weight, and health costs. First, considering patients randomized to olanzapine or risperidone, outcomes among patients who had been on the drug to which they were randomized prior to CATIE (N = 129 “stayers”) were compared to outcomes of those who switched to either of these two drugs (N = 269 “switchers”). A second set of analyses considered patients on baseline monotherapy with olanzapine (N = 297); risperidone (N = 252) or quetiapine (n = 87) and compared those randomly assigned to stay on each of these medications with those assigned to switch to any of the other five phase 1 medications in CATIE. In mixed models of each outcome the in...

526 Mental health services research provides a critical bridge between efficacy demonstrated in randomized controlled trials and treatment effectiveness in real-world settings. It does so by taking into account multiple influences—for example, characteristics of service systems, consumers, and providers—that influence the effectiveness of treatments in service delivery settings (1). One way to understand the impact of these multiple influences is by developing a program theory (2,3) or heuristic model (1) to guide an effectiveness evaluation from inception to interpretation. The heuristic model proposed by Shern and Evans (1) provides a framework for guiding mental health services research by identifying five domains that affect both consumer and service outcomes: consumer characteristics, such as demographic characteristics, clinical status, and functional status; organizational characteristics, such as rules that govern behavior in an organization; practitioner behavior, such as prescribing, and practitioner characteristics, including training, values, beliefs, and therapeutic orientation; services environment, such as attitudes, values, and beliefs of staff; and service system characteristics, such as external laws and regulations influencing service delivery and reimbursement. From the perspective of this heuristic model, we discuss the implications that the findings of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) have for monitoring and influencing the behavior of prescribers through changes in the service system that should have an impact on both consumer outcomes (for example, change in clinical status or side effect burden) and system outcomes (for example, changes in resources devoted to different prescribing patterns).

We examined prevalence and perceived distress resulting from self-reported side effects (SEs) attributed to psychotropic medications among individuals with severe mental illness participating in a study of consumer-operated services. We examined gender and racial differences using logistic regression, conducted factor analyses of SEs, and examined correlations between distress and self-reported symptoms. Over 90% reported at least one SE, and nearly two-thirds reported a high level of distress with at least one SE. The most distressing SEs reported were embarrassment from weight gain, weight gain, dry mouth, and sedation. The likelihood of distress by particular SEs varied by gender and race.

In a large (n = 1,827) multi-site study examining effectiveness of consumer operated service programs as an adjunct to traditional mental health services, we examined individuals' preferred term describing their status as service recipients, and we applied logistic regression to examine whether preference varied by gender, race or diagnosis. Preferred terms were client (39%), patient (22%), consumer (16%), survivor (11%), other (11%) and ex-patient (1%), varying by site. Controlling for site, preferences did not vary by gender, race, or diagnosis. The lack of consensus suggests clinicians, researchers, program administrators, and policymakers should be sensitive to individuals' preferences.

This report describes experiences and outcomes of an online learning collaborative focused on implementation of stagewise treatment.Eleven participating programs convened online monthly for a year. Between meetings, program staff created an implementation plan and programs collected performance indicator data, including assessment of staff knowledge of integrated treatment for people with co-occurring disorders, whether a person's current stage of treatment was documented in his or her chart, and whether the treatments were appropriate for the stage of treatment. Descriptive statistics were used to characterize performance indicators and feedback. Wilcoxon matched-pairs signed-rank tests examined changes in performance indicators over time.Program staff generally demonstrated significant improvements in performance indicators over time and rated the distance learning collaborative favorably.Distance learning collaboratives can be structured to provide opportunities for program staff to interact and learn from one another and to implement and sustain changes.

Changing antipsychotics is common despite the dearth of information on risks and benefits associated with medication changes. The authors examined phase 1 findings from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study to explore whether it was more advantageous to continue taking the medication being received at baseline or to switch to a different antipsychotic.First, for patients randomly assigned to treatment with olanzapine (N=314) or risperidone (N=321), the authors assessed the impact of being assigned to stay with the medication they were receiving at entry into the study versus being assigned to switch to these medications from a different antipsychotic. Second, for patients whose baseline antipsychotic was olanzapine (N=319), risperidone (N=271), or quetiapine (N=94), the authors examined the impact of being randomly assigned to stay with the same antipsychotic versus switch. Finally, the authors assessed the impact of removing the data of 209 patients whose random assignment was to stay with their baseline antipsychotic. The authors followed analysis strategies for CATIE; primary outcome was time until all-cause treatment discontinuation.Individuals randomly assigned to olanzapine and risperidone who were continuing with their baseline medication had significantly longer times until discontinuation than did those assigned to switch antipsychotics. When these "stayers" were removed, differences seen in the original CATIE phase 1 analyses were attenuated, although the original pattern of results remained.Comparisons of medication effectiveness should take into account whether medications being compared were each newly initiated. Further, unless the clinical situation requires a medication change, prescribers may want to take steps to optimize current medication regimens (e.g., dosage adjustments, behavioral or psychosocial interventions) before switching medications.

The authors examined alternative methods for obtaining feedback from people receiving anonymous mental health services via Project Liberty, an initiative that provided free counseling to residents of the New York City area after the 2001 attacks on the World Trade Center.Counselors offered all English-speaking and Spanish-speaking adults who used Project Liberty crisis counseling services the opportunity to evaluate Project Liberty via a telephone interview (eight sites) or a brief questionnaire (four sites).A total of 107 service recipients provided feedback via a brief 32-item questionnaire, and 153 gave feedback via a 45-minute telephone interview. Although the overall participation rates were modest (less than 20 percent), nearly three-quarters of those who volunteered to participate in the telephone interview (for which they received $20) did so. Neither gender nor racial or ethnic group was associated with a greater likelihood of participating in one method over another.Responses to items on the brief questionnaire and in the telephone interview were similar, and offering multiple response methods increased participation rates. Although telephone interviews were more costly than the questionnaire to administer, they provided important additional information about ongoing symptoms and problems that individuals experienced after the attacks. The modest response rates obtained in the evaluation indicate that future evaluations of postdisaster services need to use methodstomaximizeresponse rates and provider adherence to administrative tasks that are critical to the evaluation.

Objective: This study examined outcomes associated with clinicians' fidelity to key elements of a cognitive-behavioral treatment intervention developed for Project Liberty's enhanced services counseling program. Methods: In telephone interviews 60 individuals reported how often their clinicians provided six components considered central to the intervention by the intervention developers. Respondents received services at sites where some (25 to 50 percent) or all clinicians had received training in the intervention. Results: Compared with respondents who received services where only some clinicians had received training (N=19), those who received services where all clinicians had received training (N=41) were significantly more likely to report that their clinicians applied techniques central to the intervention (p

OBJECTIVES: This study examined service utilization and event reaction patterns among children who used crisis counseling services provided under Project Liberty for 27 months after the September 11, 2001, terrorist attacks on the World Trade Center. METHODS: The authors analyzed logs of 681,318 service encounters submitted by Project Liberty counselors, paying particular attention to demographic characteristics and reported event reactions. RESULTS: Nine percent of service recipients reached by community-based Project Liberty providers were children, whereas census data for the 15 counties and boroughs served by Project Liberty indicated that children constituted 25 percent of the population. Service use as a function of race or ethnicity and of gender was consistent with census data. Similar to findings for adults, the most common emotional event reactions reported for children were experiencing sadness and tearfulness, being anxious and fearful, having difficulty concentrating, experiencing irritability and anger, having intrusive thoughts or images, and having difficulty sleeping. Behavioral event reactions listed on service logs suggested that older children (12 to 17 years) were more likely to use drugs whereas elementary school-age children were more likely to display signs of anxiety, isolation and withdrawal, and difficulties with concentration and memory. CONCLUSIONS: Sensitivity to differences in the event reaction patterns shown by younger and older children may be useful in refining treatments to help reduce the psychological impact of children's trauma after terrorist incidents. Language: en

This study determined the likelihood and predictors of Project Liberty counseling recipients' reporting their return to satisfactory life functioning 16 to 26 months after the September 11, 2001, attacks.Using anonymous brief paper-and-pencil questionnaires or structured telephone interviews, 452 respondents provided retrospective ratings of their functioning in five life domains during the month before the World Trade Center attacks and the month immediately before the assessment. Information on demographic characteristics and exposure to risk during the World Trade Center attacks also was obtained and used in logistic regression models. The 153 respondents who were interviewed by telephone also rated helpfulness of various coping strategies.In the five domains, 77 to 87 percent of the sample reported good to excellent functioning in the month before the attacks; 55 to 68 percent reported returning to at least the same level of daily functioning after the attacks. African Americans were two to four times more likely than respondents of all other races to report a return to good or excellent functioning after the attack in four domains. Compared with respondents who did not lose their job as a result of the attacks, those who did lose their job were less likely to return to good preattack functioning in two domains. Project Liberty counseling reportedly helped 90 percent of respondents return to predisaster levels of functioning.Responses to future terrorist attacks should consider demographic characteristics and the impact of the attack because they can affect return to preattack functioning. Counselors should support activities that facilitate positive responses and ameliorate negative psychological responses.

Formerly homeless mentally ill veterans are at an important crossroads when they move from living in an institutional setting such as a shelter or supportive residential facility to independent living. We hypothesized that peer advisors, veterans with severe mental illness who had been homeless previously, graduated from a Healthcare for Homeless Veterans program, and subsequently maintained independent, stable housing could assist other veterans make a successful transition to independent living. Pilot data suggests that participants who received peer advisors were more likely to follow up with assessments than were controls. In this report, we describe a pilot peer advisor program, its implementation, and pilot data on program administration.

Objectives: The validity of self-reports of drug use from individuals who abuse substances has been questioned. Results from studies examining the accuracy of such self-reports have been mixed, indicating the need for closer examinations of the factors associated with concordance between self-reported drug use and results of urine screens. Methods: As part of a larger study examining the effectiveness of interventions for people with co-occurring mental health and substance use disorders, we examined the agreement between self-report and urine screens for recent drug use. Results: Overall, the concordance between self-report and results from urine screens was high (80-84% agreement overall and 75–79% for the subset where the urine screen indicated recent drug use). Estimates for the likelihood of use of marijuana and cocaine within the past 30 days were 15% and 32%, respectively, based on urine screens, 25% and 35% based on self-report, and 28% and 43% based on information from both sources combi...

The use of standardized patient assessments (SPAs) in psychiatry is an emerging best practice. This column describes a survey of resident and faculty supervisors at a large academic department examining current practices, attitudes, and perceived barriers to incorporating SPAs into clinical practice. Although the study found that SPAs were not routinely used in clinical practice or supervision, residents and faculty were fairly optimistic about their potential value. The results suggest that educational initiatives should be integrated into clinical practice, start early within training, include both trainees and faculty supervisors, and set use of SPAs as an expected standard of care.

Schizophrenia is associated with several chronic physical illnesses and a shorter life expectancy, compared with life expectancy in the general population. One approach to improving the health of patients with schizophrenia is to improve the monitoring of physical health that occurs in psychiatric settings. The authors discuss a consensus panel's recommendations for improving the physical health monitoring of patients with schizophrenia who are treated in outpatient settings.A consensus meeting including psychiatric and other medical experts assembled on October 17-18, 2002, to evaluate the existing literature and to develop recommendations for physical health monitoring of patients with schizophrenia. Conference participants reviewed the literature in the following areas: 1) weight gain and obesity; 2) diabetes; 3) hyperlipidemia; 4) prolongation of the QT interval on the ECG; 5) prolactin elevation and related sexual side effects; 6) extrapyramidal side effects, akathisia, and tardive dyskinesia; 7) cataracts; and 8) myocarditis. Experts for each topic area formulated monitoring recommendations that were discussed by all of the participants until a consensus was reached.Consensus recommendations included regular monitoring of body mass index, plasma glucose level, lipid profiles, and signs of prolactin elevation or sexual dysfunction. Information from monitoring should guide the selection of antipsychotic agents. Specific recommendations were made for cardiac monitoring of patients who receive medications associated with QT interval prolongation, including thioridazine, mesoridazine, and ziprasidone, and for monitoring for signs of myocarditis in patients treated with clozapine. Patients who receive both first- and second-generation antipsychotic medications should be examined for extrapyramidal symptoms and tardive dyskinesia. Patients with schizophrenia should receive regular visual examinations.The conference participants recommended that mental health care providers perform physical health monitoring that typically occurs in primary care settings for their patients who do not receive physical health monitoring in those settings. This change in usual practice is recommended on the basis of the conference participants' belief that this additional monitoring will result in the earlier detection of common, serious risk factors that could, without detection and intervention, contribute to impaired health of patients with schizophrenia.

Few studies have examined gender differences in the propensity to gain weight on clozapine. Weight gain increases risk for many medical illnesses and is of particular concern for people with schizophrenia who are more overweight than the general population. Long-stay patients in Connecticut state hospitals were randomly assigned to switch to open-label treatment with clozapine (n = 138) or to continue receiving first generation (conventional) antipsychotic medications (n = 89). Using survival and random regression models, we examined percentage of body weight gained during 2 years for patients assigned to clozapine versus those who continued taking first generation antipsychotic medications. We also examined the impact of gender on weight gain. Patients who switched to clozapine gained a greater percentage of weight (13 pounds, 7%) than did patients remaining on first generation medications (5 pounds, 4%) at the end of 2 years. Normal-weight patients on clozapine were more likely to become obese (body mass index [BMI] > or = 30). Patients gained weight whether they switched to clozapine or remained on first generation antipsychotic medications, but weight gain was significantly greater (1 BMI unit) in the clozapine-treated group, particularly among women.

We characterized prescribing in Connecticut's State public mental health system to assess the feasibility of implementing an evidence-based medication algorithm. Medication records for a random sample of outpatients with diagnoses of schizophrenia spectrum disorders showed prescribing patterns similar to the entire United States. The base rate of changing antipsychotic medications was moderate. Over half of patients received decanoate medications, polypharmacy was nontrivial, and there was variability in prescribing patterns across physicians. Caucasian patients were more likely to receive an atypical antipsychotic and less likely to have a decanoate medication, and Latino patients were less likely to change medications. Because the base rate of changing medications was moderate and a considerable proportion of patients were prescribed newer antipsychotic medications, introducing a research-derived medication algorithm with newer atypical antipsychotics as first line agents may fit well with current practice. Further, implementing such an algorithm may reduce racial and ethnic disparities in prescribing patterns.

We examined the utility of drugs versus urine to detect drugs of abuse by characterizing the number of hair and urine samples provided and the agreement between hair, urine, and self-reported drug use. Of 40 participants, 39 (97.5%) provided urine, whole only 31 (77.5%) agreed to provide hair (3 (7.5%) declined, 6 (15%) were not able). Hair detected more drug use than urine and self-report, and concordance between urine and self-report was 90% or greater. The advantage of hair to detect drug use, particularly cocaine, may warrant inclusion of hair samples to document cocaine or drug use during longer retrospective periods; if documenting recent use of drugs other than cocaine, self-report may suffice.

People with severe mental illness and a co-occurring substance use disorder (co-occurring disorders) who live in urban areas experience high rates of incarceration. This study examined sociodemographic, clinical, economic, and community integration factors as predictors of incarceration among people with co-occurring disorders.This secondary analysis used data from a randomized controlled trial of assertive community treatment versus standard case management. In the parent study, researchers interviewed 198 people with co-occurring disorders from two urban mental health centers in Connecticut at baseline and every six months for three years. Researchers tracked incarceration, clinical engagement and status, employment, living situation, social relationships, and substance use. The study reported here used bivariate analyses and logistic regression analyses to compare individuals who were incarcerated during the study period with those who were not.The overall incarceration rate was 38% during the study period. In multivariate analyses, prior incarceration predicted incarceration during the study period (odds ratio [OR]=3.26). Two factors were associated with a reduced likelihood of incarceration: friendships with individuals who did not use substances (OR=.19) and substance use treatment engagement (OR=.60).Positive social relationships and engagement in substance use treatment are promising service and policy targets to prevent incarceration in this high-risk population.

This column describes the Center for Practice Innovations (CPI), which was created in 2007 by the New York State Office of Mental Health and the Department of Psychiatry at Columbia University. CPI uses innovative approaches to build stakeholder collaborations, develop and maintain practitioners' expertise, and build agency infrastructures that support implementing and sustaining evidence-based practices. CPI's five core initiatives provide training in co-occurring mental and substance use disorders, assertive community treatment, supported employment and education, wellness self-management, and treatment of first-episode psychosis. Central to CPI's activities are award-winning training modules, statewide learning collaboratives, and use of a learning management system.

TOPIC A growing research literature indicates that cognitive enhancement (CE) interventions for people with schizophrenia can improve cognitive functioning and may benefit psychosocial functioning (e.g., competitive employment, quality of social relationships). Debate continues regarding the strength of evidence for CE and related policy implications, such as the appropriateness of funding CE services. PURPOSE This paper summarizes and updates a meeting of experts and stakeholders convened in 2008 by the New York Office of Mental Health to review evidence on the impact of CE for people with schizophrenia and other serious mental illnesses, and addresses whether the evidence base for CE interventions is sufficient to warrant funding. SOURCES USED Specific recommendations based on the extant literature are provided regarding the structure and components of CE programs that should be present in order to improve cognitive and psychosocial outcomes and therefore merit consideration of funding. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE These recommendations may serve as a starting point in developing standards for CE programs. Establishing evidence-based practice standards for implementing CE interventions for people with serious mental illnesses may facilitate dissemination of programs that have the greatest potential for improving individuals' functional outcomes while minimizing incremental costs associated with providing CE services. Important open questions include how the performance of CE programs should be monitored and which individuals might be expected to benefit from CE as evidenced by improved functioning in their everyday lives.

The use of standardized patient assessments (SPAs) in psychiatry is an emerging best practice. This column describes a survey of resident and faculty supervisors at a large academic department examining current practices, attitudes, and perceived barriers to incorporating SPAs into clinical practice. Although the study found that SPAs were not routinely used in clinical practice or supervision, residents and faculty were fairly optimistic about their potential value. The results suggest that educational initiatives should be integrated into clinical practice, start early within training, include both trainees and faculty supervisors, and set use of SPAs as an expected standard of care.

FROM: Subotnik KL, Casaus LR, Ventura J, et al . Long-acting injectable risperidone for relapse prevention and control of breakthrough symptoms after a recent first episode of schizophrenia: a randomized clinical trial. JAMA Psychiatry 2015;72:822–9. Appropriate use of antipsychotic medications for people experiencing early episode psychosis is critical for symptom control and for shaping attitudes towards medication as a support to recovery.1 Risperidone is an effective medication in treating early episode psychosis2 and long-acting injectable risperidone may increase early (12-week) adherence rates.3 However, long-acting medications are rarely used following a first episode of schizophrenia4 and the aim of the present study was to compare the clinical efficacy of the long-acting injectable formulation of risperidone with the oral formulation in the early course of schizophrenia. Eighty-three people with early episode schizophrenia (Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV)) in the Los Angeles area participated between …

OBJECTIVE: This study analyzed data from a randomized trial to examine the impact on medication adherence of integrated treatment delivered via assertive community treatment (ACT) versus standard clinical case management (SCCM). METHOD: Data from the original study included 198 study participants with co-occurring psychotic and substance use disorders who were randomly assigned to receive integrated treatment via ACT or SCCM and were followed for 3 years. We applied mixed-effects logistic regression to estimate group (ACT vs. SCCM) by time effects on a self-report measure of medication adherence. Adherence was dichotomized as 20% or more missed medication days (“poor adherence”) versus less than 20% missed medication days (“adequate adherence”). RESULTS: Participants who were assigned to ACT reported significant improvement in medication adherence compared with those assigned to SCCM. CONCLUSIONS: Integrated treatment delivered via ACT may benefit persons with co-occurring psychotic and substance use disorders who are poorly adherent to medications.

Objective: This study sought to identify and characterize rates of clinically questionable prescribing in New York State. Methods: As part of a quality improvement initiative, 34 national psychopharmacology experts identified a set of questionable prescribing practices recognizable from pharmacy claims data. Indicators of such practices were applied to Medicaid claims data for 217,216 beneficiaries in New York State who had an active psychotropic prescription on April 1, 2008. Results: A total of 156,103 (72%) of these beneficiaries had one or more continuing (>90 days) prescriptions for a psychotropic. About 10% of adults were prescribed four or more psychotropics concurrently, and 13% of children and 2% of older adults were prescribed three or more concurrently. Prescribing an antipsychotic with a moderate-to-high risk of causing metabolic abnormalities approached 50% (46%) among individuals who had existing cardiometabolic conditions. Among beneficiaries prescribed second-generation antipsychotics with a moderate-tohigh risk of causing metabolic abnormalities, over half (60%) had not received a metabolic screening test in the past year. Among women of reproductive age prescribed mood stabilizers, over one-quarter (30%) were prescribed a valproic acid–based formulation despite its potential for teratogenicity. Only 2% of youths under age 18 were prescribed benzodiazepines; however, about half (48%) had trials over 90 days’ duration. Conclusions: Examination of pharmacy claims from Medicaid beneficiaries in New York State indicated that prescribing practices deemed clinically questionable by pharmacology experts are common. Aggregated pharmacy claims data can identify such practices, and reviews of these data can be a core component of efforts to improve prescribing practices. (Psychiatric Services 60:1595–1602, 2009)