The impact of managed care on children's outpatient treatment: a comparison study of treatment outcome before and after managed care

This study examined treatment outcome pre- and post-managed care in 3 samples of patients (N = 885; ages 5 to 18 years) at an urban-based children's psychiatric outpatient clinic. Although the post-managed care groups were seen for fewer sessions than the pre-managed care group, there was no difference between the pre- and post-managed care groups in clinical outcome.     

Comorbidity of schizophrenia and cancer: clinical recommendations for treatment

The paper analyzes some issues on the comorbidity between schizophrenia and cancer. Epidemiological studies have reported contradictory results, but it is certain that patients with schizophrenia are more likely to suffer from risk factors for cancer development, such as increased alcohol abuse, obesity, nicotine dependence and decreased physical activity. The paper gives guidelines for the treatment of cancer in patients with schizophrenia, and discusses possible interactions between chemotherapy and psychotropic drugs. Particular attention is paid to the use of antipsychotics which increase the level of prolactin, in view of the possible risk of breast and endometrial cancer in patients with schizophrenia.     

Improving the care of individuals with schizophrenia and substance use disorders: consensus recommendations

National attention continues to focus on the need to improve care for individuals with co-occurring mental illnesses and substance use disorders, as emphasized in the 2003 President's New Freedom Commission Report on Mental Health and recent publications from the Substance Abuse and Mental Health Services Administration (SAMHSA). These reports document the need for best practice recommendations that can be translated into routine clinical care. Although efforts are underway to synthesize literature in this area, few focused recommendations are available that include expert opinion and evidence-based findings on the management of specific co-occurring disorders, such as schizophrenia and addiction. In response to the need for user-friendly recommendations on the treatment of schizophrenia and addiction, a consensus conference of experts from academic institutions and state mental health systems was organized to 1) frame the problem from clinical and systems-level perspectives; 2) identify effective and problematic psychosocial, pharmacological, and systems practices; and 3) develop a summary publication with recommendations for improving current practice. The results of the consensus meeting served as the foundation for this publication, which presents a broad set of recommendations for clinicians who treat individuals with schizophrenia. "Integrated treatment" is the new standard for evidence-based treatment for this population and recommendations are given to help clinicians implement such integrated treatment. Specific recommendations are provided concerning screening for substance use disorders in patients with schizophrenia, assessing motivation for change, managing medical conditions that commonly occur in patients with dual diagnoses (e.g., cardiovascular disease, liver complications, lung cancer, HIV, and hepatitis B or C infections) and selecting the most appropriate medications for such patients to maximize safety and minimize drug interactions, use of evidence-based psychosocial interventions for patients with dual diagnoses (e.g., Dual Recovery Therapy, modified cognitive-behavioral therapy, modified motivational enhancement therapy, and the Substance Abuse Management Module), and key pharmacotherapy principles for treating schizophrenia, substance use disorders, and comorbid anxiety, depression, and sleep problems in this population. Finally the article reviews programmatic and systemic changes needed to overcome treatment barriers and promote the best outcomes for this patient population. An algorithm summarizing the consensus recommendations is provided in an appendix.     

Some distinctive features of the impact of managed care on psychiatry

Past research suggests that the spread of managed care is affecting the treatment of mental and physical illnesses differently. This article develops six hypotheses that could explain the differential effects of managed behavioral health care, based on characteristics of mental disorders, professional norms of treatment, and the broader societal consequences of untreated mental illness. Using data from the 1998 Socioeconomic Monitoring System fielded by the American Medical Association, we tested these hypotheses by comparing the experiences of psychiatrists under managed care with those of primary care providers and medical specialists. We found the following: (1) psychiatrists face substantially more aggressive external review than do primary care providers and are less successful in overturning denials; (2) psychiatrists feel significantly more at risk for disaffiliation from health plans; (3) psychiatrists report facing review protocols that are more confusing than those for primary care physicians, but psychiatrists' staff spend less time on external review; (4) psychiatrists are more likely than other physicians to report that their patients have difficulty making informed choices about managed care; and (5) psychiatrists evidence greater time commitment to advocacy on behalf of their patients with respect to managed care.     

Improving community-based care for the treatment of schizophrenia: lessons from native Africa

Recent innovations in the treatment of schizophrenia reflect a growing trend towards community-based care, such as Assertive Community Treatment (ACT). These programs reduce psychiatric hospitalization rates, improve residential stability, and result in improved satisfaction with care; however, they fail to show any consistent reduction in psychiatric symptoms or long-term improvement in social adjustment. As growing evidence suggests that the course and outcome of schizophrenia is significantly more favorable in undeveloped countries where community interventions are primary, this paper is an attempt to identify key factors in native African healing practices and their potential application to community-based treatment in the West.     

The schizophrenia PORT pharmacological treatment recommendations: conformance and implications for symptoms and functional outcome

This cross-sectional study examines conformance to four of the Schizophrenia Patient Outcomes Research Team (PORT) antipsychotic treatment recommendations, patient and treatment setting characteristics assocated with conformance, and the relationship of conformance with outcome. Two hundred twenty-four inpatients and 358 outpatients with schizophrenia underwent an interview and review of their medical records. Demographic, clinical, and role function data were collected. Almost all inpatients and outpatients with schizophrenia or schizoaffective disorder were prescribed an antipsychotic. The majority of inpatients were prescribed an antipsychotic within the recommended dose range, whereas the majority of outpatients were prescribed an antipsychotic either below or above the recommended dose range. There were no consistent relationships between patient, geographic, and treatment characteristics and antipsychotic dose. Patients treated with conventional antipsychotic doses below the recommended dose range had significantly better role function. Prospective longitudinal studies are required to delineate the factors that may underlie this relationship.     

Services to families of adults with schizophrenia: from treatment recommendations to dissemination

OBJECTIVE: Data from the Schizophrenia Patient Outcomes Research Team project were examined to determine the extent to which families of adults with schizophrenia receive services and whether training staff in the provision of family services increases service availability. METHODS: For patients with a diagnosis of schizophrenia, paid claims for family therapy were identified in 1991 in a nationally representative sample of Medicare data and one state's Medicaid data. In a field study in two states, 530 patients were asked about services received by their families. A quasiexperimental dissemination of a family intervention was done at nine agencies; staff at four agencies received a standard didactic presentation, and staff at five received that standard presentation paired with intensive training. RESULTS: In the representative national Medicare sample of 15,425 persons with schizophrenia, .7 percent (N=108) had an outpatient claim for family therapy. This figure was 7.1 percent in the Medicaid sample of 5,393 persons with schizophrenia in one state. Of the 530 patients in the field study who reported having contact with their families, 159 (30 percent) reported that their families had received information, advice, or support about their illness, and 40 (8 percent) responded that their families had attended an educational or support program. At the four agencies where staff received only didactic training, no changes in family services were found after one year. Three of the five agencies where staff participated in intensive training enhanced their family services. CONCLUSIONS: A minority of families of persons with schizophrenia receive information about the illness from providers. Implementation of model family interventions is possible with considerable technical assistance. A gap exists between best practices and standard practices for families of persons with schizophrenia.     

Stroke care in the ICU: general supportive treatment. Experts' recommendations

The French Society of Intensive Care (SRLF) requested medical experts to publish recommendations on the management of stroke in the ICU for adult and pediatric patients. The following article describes the underlying evidence used by the experts to elaborate recommendations for general supportive treatment. Such treatment is fundamental for victims of acute stroke to avoid neurological worsening. Oxygen delivery in a normoxic patient is useless. However, if saturation is below 92 %, oxygen supplementation is needed. Hyper- and hypoglycemia worsen the neurological prognosis. As no glycemic target is known, administration of insulin is required for glucose levels higher that 10 mmol/l. Body temperature above 37.5° is associated with poorer outcome. In the acute phase of stroke, high blood pressure should not be lowered except in life-threatening situations, and if so the lowering should be done cautiously. The current consensus is to lower blood pressure if the systolic pressure is above 220 mmHg or if the diastolic pressure is above 120 mmHg for ischemic stroke. For hemorrhagic stroke and after thrombolysis, treatment is needed if systolic pressure rises above 180 mmHg and if diastolic pressure is above 105 mmHg. Small doses of heparin decrease the risk of deep venous thrombosis and pulmonary embolism without increasing cerebral bleeding. There is no consensus on the treatment of epileptic crises after stroke and no dedicated treatment. Further studies are needed to define adequate blood pressure and glycemic target values in order to limit secondary worsening after an acute stroke as well as the appropriate modalities for the treatment of epilepsy.     

Substance abuse day treatment and managed health care

Day treatment for substance abusers has been viewed by many as a viable treatment modality, particularly in light of the success of psychiatric day treatment programs. The available research also supports the efficacy of day treatment versus inpatient treatment for substance abusers. Nevertheless, day treatment programs for substance abusers have had difficulty gaining acceptance with treatment providers and patients alike. This paper offers several explanations for this lack of acceptance and proposes that managed care settings are ideally suited to pioneer substance abuse day treatment programs. Practical suggestions will also be offered to help market this treatment modality and minimize patient resistance.     

Social cognition in schizophrenia: recommendations from the measurement and treatment research to improve cognition in schizophrenia new approaches conference

This article summarizes the discussion from a breakout group at the National Institute of Mental Health-Measurement and Treatment Research to Improve Cognition in Schizophrenia New Approaches Conference on social cognition in schizophrenia. During this discussion, the reasons for the recent growth of research on social cognition in schizophrenia were examined. The discussion group established consensus on several points, including the importance of viewing social cognition from interdisciplinary perspectives (including outcomes research, social psychology, cognitive psychology, cognitive neuroscience, and animal models) and the need for clearer definition of terms. There was also general agreement that social cognition is a valuable construct for understanding the nature and disability of schizophrenia. One of the objectives of this group was to generate recommendations for subsequent human and animal studies, and these research agendas are summarized in this report.     

Quality of health care for people with developmental disabilities: the challenge of managed care

Health care quality issues for people with developmental disabilities under managed care were explored. Health-related quality was defined in terms of four domains: structure, process, outcome, and satisfaction. Three general problems in the assessment of health care quality were identified: lack of quality measures, patient response problems, and lack of system elements. Selected current measurement systems were described in relation to their use for people with developmental disabilities. An approach to developing quality measures was outlined using Healthy People 2000, Health Plan Employer Data Information Set, and clinical practice issues. The movement toward quality improvement was examined and recommendations presented for steps in developing and measuring health care quality.     

Specific treatment for intracerebral hemorrhage. Experts' recommendations: stroke management in the intensive care unit

Spontaneous intracerebral hemorrhages represent from 10 to 15% of strokes. They can be defined by the eruption of arterial blood within the cerebral parenchyma. Clinical signs are not specific and the diagnosis can only be made using brain imaging techniques (CT or magnetic resonance imaging). Management of intracerebral hemorrhage combines general measures (neurovascular intensive care unit, treatment of high blood pressure and of neurotoxic factors) with more specific measures including correction of coagulation abnormalities and, in some cases, neurosurgical treatment.