Publications by authors named "John S Lyons"

36 Publications

The pediatric inflammatory bowel disease INTERMED: A new clinical tool to assess psychosocial needs.

J Psychosom Res 2019 04 6;119:26-33. Epub 2019 Feb 6.

CHEO Research Institute, Ottawa, ON, Canada; Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada; CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology & Nutrition, Ottawa, ON, Canada. Electronic address:

Objective: The adult INTERMED is used to determine case complexity and psychosocial needs. We developed and validated a pediatric version of the INTERMED for children and adolescents with inflammatory bowel disease (IBD) and assessed its utility in predicting healthcare utilization.

Methods: We performed a cross-sectional study of children (aged 8-17 y) with IBD (n = 148) and their parents, seen in a hospital-based clinic. Subjects completed semi-structured interviews that were scored on the 34 pIBD-INTERMED items. To assess inter-rater reliability, 40 interviews were videotaped and scored by a second assessor. Convergent and predictive validity were assessed by examining the relation of the pIBD-INTERMED to standardized measures of psychological, social, and family functioning, disease activity, and healthcare utilization.

Results: Correlational analyses supported the validity of all five pIBD-INTERMED domains with very good inter-rater reliability (median r = 0.87) and internal consistency (α = 0.91) for the total complexity index. Ratings of 2-3 on the pIBD-INTERMED "mental health/cognitive threat" item were associated with greater odds of behavior and social problems (CBCL-Internalizing scale OR = 7.27, 95% CI 2.17-24.36); CBCL-Externalizing scale OR = 24.79, 95% CI 5.00-122.84), depression (Children's Depression Inventory OR = 8.52, 95% CI 1.70-43.02) and anxiety (Multidimensional Anxiety for Children OR = 11.57, 95% CI 3.00-45.37). The pIBD-INTERMED complexity index added significantly to the prediction of healthcare utilization, beyond the contribution of disease severity.

Conclusions: The pIBD-INTERMED is a reliable and valid tool for identifying psychosocial risks and needs of children with IBD. It can be used to guide planning of individualized care and enhance interdisciplinary pediatric IBD care.
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http://dx.doi.org/10.1016/j.jpsychores.2019.02.002DOI Listing
April 2019

Evaluating mental health service use during and after emergency department visits in a multisite cohort of Canadian children and youth.

CJEM 2019 01 4;21(1):75-86. Epub 2017 Dec 4.

¶Department of Pediatrics,University of Alberta,Edmonton, AB.

Objectives: The goal of this study was to examine the mental health needs of children and youth who present to the emergency department (ED) for mental health care and to describe the type of, and satisfaction with, follow-up mental health services accessed.

Methods: A 6-month to 1.5-year prospective cohort study was conducted in three Canadian pediatric EDs and one general ED, with a 1-month follow-up post-ED discharge. Measures included 1) clinician rating of mental health needs, 2) patient and caregiver self-reports of follow-up services, and 3) interviews regarding follow-up satisfaction. Data analysis included descriptive statistics and the Fisher's exact test to compare sites.

Results: The cohort consisted of 373 children and youth (61.1% female; mean age 15.1 years, 1.5 standard deviation). The main reason for ED presentations was a mental health crisis. The three most frequent areas of need requiring action were mood (43.8%), suicide risk (37.4%), and parent-child relational problems (34.6%). During the ED visit, 21.6% of patients received medical clearance, 40.9% received a psychiatric consult, and 19.4% were admitted to inpatient psychiatric care. At the 1-month post-ED visit, 84.3% of patients/caregivers received mental health follow-up. Ratings of service recommendations were generally positive, as 60.9% of patients obtained the recommended follow-up care and 13.9% were wait-listed.

Conclusions: Children and youth and their families presenting to the ED with mental health needs had substantial clinical morbidity, were connected with services, were satisfied with their ED visit, and accessed follow-up care within 1-month with some variability.
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http://dx.doi.org/10.1017/cem.2017.416DOI Listing
January 2019

Out-of-home placement decision-making and outcomes in child welfare: a longitudinal study.

Adm Policy Ment Health 2015 Jan;42(1):70-86

Department of Child and Adolescent Psychiatry, Center for Mental Health Implementation and Dissemination Science in States for Children, Adolescents, and Families (IDEAS Center), New York University Child Study Center, New York University School of Medicine, 1 Park Avenue, 7th Floor, New York, NY, 10016, USA,

After children enter the child welfare system, subsequent out-of-home placement decisions and their impact on children's well-being are complex and under-researched. This study examined two placement decision-making models: a multidisciplinary team approach, and a decision support algorithm using a standardized assessment. Based on 3,911 placement records in the Illinois child welfare system over 4 years, concordant (agreement) and discordant (disagreement) decisions between the two models were compared. Concordant decisions consistently predicted improvement in children's well-being regardless of placement type. Discordant decisions showed greater variability. In general, placing children in settings less restrictive than the algorithm suggested ("under-placing") was associated with less severe baseline functioning but also less improvement over time than placing children according to the algorithm. "Over-placing" children in settings more restrictive than the algorithm recommended was associated with more severe baseline functioning but fewer significant results in rate of improvement than predicted by concordant decisions. The importance of placement decision-making on policy, restrictiveness of placement, and delivery of treatments and services in child welfare are discussed.
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http://dx.doi.org/10.1007/s10488-014-0545-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4407360PMC
January 2015

Patterns of out-of-home placement decision-making in child welfare.

Child Abuse Negl 2013 Oct 12;37(10):871-82. Epub 2013 Jun 12.

Mental Health Services and Policy Program, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 710 North Lake Shore Drive, Suite 1200, Chicago, IL 60611, USA.

Out-of-home placement decision-making in child welfare is founded on the best interest of the child in the least restrictive setting. After a child is removed from home, however, little is known about the mechanism of placement decision-making. This study aims to systematically examine the patterns of out-of-home placement decisions made in a state's child welfare system by comparing two models of placement decision-making: a multidisciplinary team decision-making model and a clinically based decision support algorithm. Based on records of 7816 placement decisions representing 6096 children over a 4-year period, hierarchical log-linear modeling characterized concordance or agreement, and discordance or disagreement when comparing the two models and accounting for age-appropriate placement options. Children aged below 16 had an overall concordance rate of 55.7%, most apparent in the least restrictive (20.4%) and the most restrictive placement (18.4%). Older youth showed greater discordant distributions (62.9%). Log-linear analysis confirmed the overall robustness of concordance (odd ratios [ORs] range: 2.9-442.0), though discordance was most evident from small deviations from the decision support algorithm, such as one-level under-placement in group home (OR=5.3) and one-level over-placement in residential treatment center (OR=4.8). Concordance should be further explored using child-level clinical and placement stability outcomes. Discordance might be explained by dynamic factors such as availability of placements, caregiver preferences, or policy changes and could be justified by positive child-level outcomes. Empirical placement decision-making is critical to a child's journey in child welfare and should be continuously improved to effect positive child welfare outcomes.
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http://dx.doi.org/10.1016/j.chiabu.2013.04.016DOI Listing
October 2013

The Emergency Department Sickle Cell Assessment of Needs and Strengths (ED-SCANS): reliability and validity.

Adv Emerg Nurs J 2013 Apr-Jun;35(2):143-53

School of Nursing and Medicine, Duke University, Durham, NC 27713, USA.

Emergency department (ED) management of adults with sickle cell disease (SCD) is complex and frustrating. The Emergency Department Sickle Cell Assessment of Needs and Strengths (ED-SCANS) is a research-based decision support and quality improvement (QI) tool to guide management of individual patients with SCD and can also be used to guide the development of ED protocols and other QI initiatives for this population. The study evaluated ED-SCANS' inter-rater reliability, face and utility validity among clinicians, and construct validity of anxiety, depression, and psychiatric or social service needs among patients. ED nurses and physicians found the ED-SCANS to be useful, relevant, and easy to use. Nurse practitioners can use the ED-SCANS to assess and manage individual patients. Clinical nurse specialists can use the ED-SCANS as a framework to guide departmental QI efforts.
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http://dx.doi.org/10.1097/TME.0b013e31828ecbd5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4140092PMC
December 2013

Growth trajectories of maintenance variables related to refractory eating disorders in youth.

Psychother Res 2013 13;23(3):265-76. Epub 2013 Mar 13.

Eating Disorders Program, Children's Hospital of Eastern Ontario, Ottawa, Ontario K1H 8L1, Canada.

Despite decades of eating disorder (ED) research, studies of factors involved in long-term EDs are still lacking. This longitudinal study investigated the role of maintenance variables in a transdiagnostic adolescent ED sample. Participants included 275 adolescents who underwent specialized ED treatment. Hierarchical linear modeling confirmed a significant growth pattern of maintenance factors, wherein there was initial increase, then a decline during treatment, followed by a slight rebound post-treatment. Refractory status did not predict the variability in maintenance curves, suggesting that although this growth pattern existed, requiring a second treatment encounter did not explain the differences found in these patterns.
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http://dx.doi.org/10.1080/10503307.2013.775529DOI Listing
February 2014

Growth trajectories of maintenance variables related to refractory eating disorders in youth.

Psychother Res 2013 13;23(3):265-76. Epub 2013 Mar 13.

Eating Disorders Program, Children's Hospital of Eastern Ontario, Ottawa, Ontario K1H 8L1, Canada.

Despite decades of eating disorder (ED) research, studies of factors involved in long-term EDs are still lacking. This longitudinal study investigated the role of maintenance variables in a transdiagnostic adolescent ED sample. Participants included 275 adolescents who underwent specialized ED treatment. Hierarchical linear modeling confirmed a significant growth pattern of maintenance factors, wherein there was initial increase, then a decline during treatment, followed by a slight rebound post-treatment. Refractory status did not predict the variability in maintenance curves, suggesting that although this growth pattern existed, requiring a second treatment encounter did not explain the differences found in these patterns.
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http://dx.doi.org/10.1080/10503307.2013.775529DOI Listing
February 2014

Emergency Department Sickle Cell Assessment of Needs and Strengths (ED-SCANS), a focus group and decision support tool development project.

Acad Emerg Med 2010 Aug;17(8):848-58

Department of Emergency Medicine and the Institute for Health care Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.

Objectives: A decision support tool may guide emergency clinicians in recognizing assessment, analgesic and overall management, and health service delivery needs for patients with sickle cell disease (SCD) in the emergency department (ED). We aimed to identify data and process elements important in making decisions regarding evaluation and management of adult patients in the ED with painful episodes of SCD.

Methods: Qualitative methods using a series of focus groups and grounded theory were used. Eligible participants included adult clients with SCD and emergency physicians and nurses with a minimum of 1 year of experience providing care to patients with SCD in the ED. Patients were recruited in conjunction with annual SCD meetings, and providers included clinicians who were and were not affiliated with sickle cell centers. Groups were conducted until saturation was reached and included a total of two patient groups, three physician groups, and two nurse groups. Focus groups were held in New York, Durham, Chicago, New Orleans, and Denver. Clinician participants were asked the following three questions to guide the discussion: 1) what information would be important to know about patients with SCD in the ED setting to effectively care for them and help you identify patient analgesic, treatment, and referral needs? 2) What treatment decisions would you make with this information? and 3) What characteristics would a decision support tool need to have to make it meaningful and useful? Client participants were asked the same questions with rewording to reflect what they believed providers should know to provide the best care and what they should do with the information. All focus groups were audiotaped and transcribed. The constant comparative method was used to analyze the data. Two coders independently coded participant responses and identified focal themes based on the key questions. An investigator and assistant independently reviewed the transcripts and met until the final coding structure was determined.

Results: Forty-seven individuals participated (14 persons with SCD, 16 physicians, and 17 nurses) in a total of seven different groups. Two major themes emerged: acute management and health care utilization. Major subthemes included the following: physiologic findings, diagnostics, assessment and treatment of acute painful episodes, and disposition. The most common minor subthemes that emerged included past medical history, presence of a medical home (physician or clinic), individualized analgesic treatment plan for treatment of painful episodes, history of present illness, medical home follow-up available, patient-reported analgesic treatment that works, and availability of analgesic prescription at discharge. Additional important elements in treatment of acute pain episodes included the use of a standard analgesic protocol, need for fluids and nonpharmacologic interventions, and the assessment of typicality of pain presentation. The patients' interpretation of the need for hospital admission also ranked high.

Conclusions: Participants identified several areas that are important in the assessment, management, and disposition decisions that may help guide best practices for SCD patients in the ED setting.
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http://dx.doi.org/10.1111/j.1553-2712.2010.00779.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2914333PMC
August 2010

Evolving systems of care with total clinical outcomes management.

Eval Program Plann 2010 Feb 6;33(1):53-5. Epub 2009 Jun 6.

University of Ottawa, Faculty of Social Sciences, School of Psychology, 145 Jean-Jacques Lussier Street, Ottawa, Ontario, K1N 6N5, Canada.

The current article proposes that further specification of the system of care concept is required. Based on the assertions that the system of care concept (a) refers to an ideal as opposed to an observable phenomenon, and (b) is engaged in offering transformational experiences, the authors propose that the system of care definition must be expanded to include measurement and outcomes monitoring strategies that extend beyond current quality improvement initiatives. The authors propose that communication across multiple levels is essential if the goal of offering transformational experiences to children and families is to be realized.
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http://dx.doi.org/10.1016/j.evalprogplan.2009.05.015DOI Listing
February 2010

Predictors of residential placement following a psychiatric crisis episode among children and youth in state custody.

Am J Orthopsychiatry 2009 Apr;79(2):228-35

School of Social Work, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA.

This study examined the extent and correlates of entry into residential care among 603 children and youth in state custody who were referred to psychiatric crisis services. Overall, 27% of the sample was placed in residential care within 12 months after their 1st psychiatric crisis screening. Among the children and youth placed in residential care, 51% were so placed within 3 months of their 1st crisis screening, with an additional 22% placed between 3 and 6 months after screening. Risk behavior and functioning, psychiatric hospitalization following screening, older age, placement type, and caregiver's capacity for supervision were associated with increased residential placement. The findings highlight the importance of early identification and treatment of behavior and functioning problems following a crisis episode among children and youth in state custody to reduce the need for subsequent residential placement. Having an inpatient psychiatric episode following a crisis episode places children at greater risk for residential placement, suggesting that the hospital is an important point for diversion programs. Children and youth in psychiatric crisis may also benefit from efforts to include their families in the treatment process.
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http://dx.doi.org/10.1037/a0015939DOI Listing
April 2009

Knowledge creation through total clinical outcomes management: a practice-based evidence solution to address some of the challenges of knowledge translation.

Authors:
John S Lyons

J Can Acad Child Adolesc Psychiatry 2009 Feb;18(1):38-45

University of Ottawa, Ottawa, Ontario.

Introduction: The challenges of knowledge translation in behavioural health care are unique to this field for a variety of reasons including the fact that effective treatment is invariably embedded in a strong relationship between practitioners and the people they serve.

Methods: Practitioners' knowledge gained from experience and intuition become an even more important consideration in the knowledge translation process since clinicians are, in fact, a component of most treatments. Communication of findings from science must be conceptualized with sensitivity to this reality.

Results: Considering knowledge translation as a communication process suggests the application of contemporary theories of communication which emphasize the creation of shared meaning over the transmission of knowledge from one person to the next.

Conclusion: In this context outcomes management approaches to create a learning environment within clinical practices that facilitate the goals of knowledge transfer while respecting that the scientific enterprise is neither the sole nor primary repository of knowledge.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2651210PMC
February 2009

Evaluating psychiatric hospital admission decisions for children in foster care: an optimal classification tree analysis.

J Clin Child Adolesc Psychol 2007 Mar;36(1):8-18

Department of Psychology, Loyola University Chicago, 6525 N. Sheridan, Chicago, IL 60626, USA.

This study explored clinical and nonclinical predictors of inpatient hospital admission decisions across a sample of children in foster care over 4 years (N = 13,245). Forty-eight percent of participants were female and the mean age was 13.4 (SD = 3.5 years). Optimal data analysis (Yarnold & Soltysik, 2005) was used to construct a nonlinear classification tree model for predicting admission decisions. As expected, clinical variables such as suicidality, psychoticism, and dangerousness predicted psychiatric admissions; however, several variables that are not direct indications of acute psychiatric distress, such as the presence of family problems and the location of the hospital screening, impacted decision making in a subsample of cases. Further analyses indicated that the model developed in Year 1 reliably and consistently predicted admission decisions (with 64%-68% overall accuracy) across the next 3 years. Policy, research, and clinical implications are discussed.
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http://dx.doi.org/10.1080/15374410709336564DOI Listing
March 2007

Operationalizing integrated care on a clinical level: the INTERMED project.

Med Clin North Am 2006 Jul;90(4):713-58

Service de Psychiatrie de Liaison, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 44, CH-1011 Lausanne, Switzerland.

During the last 10 years the INTERMED method has been developed as a generic method for the assessment of bio-psychosocial health risks and health needs and for planning of integrated treatment. The INTERMED has been conceptualized to counteract divisions and fragmentation of medical care. Designed to enhance the communication between patients and the health providers as well as between different professions and disciplines, the INTERMED is a visualized, action-oriented decision-support tool. This article presents various aspects of the INTERMED, such as its relevance, description, scoring, the related patient interview and treatment planning, scientific evaluation, implementation, and support for the method.
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http://dx.doi.org/10.1016/j.mcna.2006.05.006DOI Listing
July 2006

The complexity of communication in an environment with multiple disciplines and professionals: communimetrics and decision support.

Authors:
John S Lyons

Med Clin North Am 2006 Jul;90(4):693-701

Psychiatry and Community Medicine, Feinberg School of Medicine, Northwestern University, Weibolt 717, Chicago, IL 60611, USA.

Accurate and efficient communication among all the parties is an important component of providing efficient and effective medical care to patients who have complex needs. The evolution of clinimetric measurement approaches designed to be congruent with the clinical process into communimetric tools designed to communicate the clinical process to wider audiences allows the use of technology to support improved care. Computerized medicine offers many opportunities for speeding up the communication of data and thereby improving the efficiency and effectiveness of medical care. The use of communimetric tools within this information environment represents an important opportunity to bridge the quality chasm.
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http://dx.doi.org/10.1016/j.mcna.2006.05.004DOI Listing
July 2006

Expanded mental health benefits and outpatient depression treatment intensity.

Med Care 2006 Apr;44(4):366-72

Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, Illinois 60612, USA.

Background: The justification for higher cost-sharing for behavioral health treatment is its greater price sensitivity relative to general healthcare treatment. Despite this, recent policy efforts have focused on improving access to behavioral health treatment.

Objectives: We measured the effects on outpatient treatment of depression of a change in mental health benefits for employees of a large U.S.-based corporation.

Research Design: The benefit change involved 3 major elements: reduced copayments for mental health treatment, the implementation of a selective contracting network, and an effort to destigmatize mental illness. Claims data and a difference-in-differences methodology were used to examine how the benefit change affected outpatient treatment of depression.

Subjects: Subjects consisted of 214,517 employee-years of data for individuals who were continuously enrolled for at least 1 full year at the intervention company and 96,365 employee-years in the control group.

Measures: We measured initiation into treatment of depression and the number of outpatient therapy visits.

Results: The benefit change was associated with a 26% increase in the probability of initiating depression treatment. Conditional on initiating treatment, patients in the intervention company received 1.2 additional (P < 0.001) outpatient mental health treatment visits relative to the control group.

Conclusions: Our results suggest that the overall effect of the company's benefit change was to significantly increase the number of outpatient visits per episode of treatment conditional on treatment initiation.
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http://dx.doi.org/10.1097/01.mlr.0000204083.55544.f8DOI Listing
April 2006

The hospital as predictor of children's and adolescents' length of stay.

J Am Acad Child Adolesc Psychiatry 2006 Mar;45(3):322-328

Drs. Leon and Bryant and Ms. Snowden are with the Department of Psychology, Loyola University Chicago; and Dr. Lyons is with the Division of Psychology, Department of Psychiatry, Northwestern University Medical School, Chicago.

Objective: To predict psychiatric hospital length of stay (LOS) for a sample of Illinois Department of Children and Family Services wards across 4 fiscal years.

Method: A prospective design was implemented using the Children's Severity of Psychiatric Illness scale, a reliable and valid measure of psychiatric severity, risk factors, youth strengths, and contextual/environmental factors. Data were collected for 1,930 hospital episodes across 44 hospitals from fiscal year 1998 through fiscal year 2001. Youths were screened for admission appropriateness by the Illinois Screening, Assessment, and Supportive Services (SASS) program. The Children's Severity of Psychiatric Illness was completed by SASS workers upon conclusion of their crisis interviews. In addition to completing the Children's Severity of Psychiatric Illness, SASS workers reported on demographic information and LOS.

Results: The sample of 1,930 youths was randomly split to form development (n = 983) and validation (n = 947) samples. LOS was predicted using ordinary least squares regression. Thirty percent of the variance (F(19,666) = 16.6, p < .0001) in LOS was predicted for the development sample and 22% (F(14,657) = 14.6, p < .0001) was predicted for the confirmation sample. Hospital was the largest and most consistent predictor of LOS for both samples after controlling for clinical variables. Two hospitals accounted for approximately 10% of the variance in both samples (development beta = .273, p < .01 and beta = -.169, p < .01). Two SASS agencies also consistently predicted LOS (development beta = -.134, p < .05 and beta = .102, p < .05). No consistent changes in predictors of LOS occurred over time (FY98-FY01).

Conclusions: These findings suggest that nonclinical variables are the primary predictors of LOS in the Illinois system of care. In addition, these variables are consistent predictors over time. Quality assurance efforts might seek to further understand potential practice pattern variations across hospitals and SASS agencies.
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http://dx.doi.org/10.1097/01.chi.0000194565.78536.bbDOI Listing
March 2006

Monitoring and managing outcomes in residential treatment: practice-based evidence in search of evidence-based practice.

J Am Acad Child Adolesc Psychiatry 2006 Feb;45(2):247-51

Mental Health Services and Policy Program, Northwestern University, Feinberg School of Medicine, Abbott Hall, Suite 1205, 710 North Lake Shore Drive, Chicago, IL 60611, USA.

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http://dx.doi.org/10.1097/01.chi.0000190468.78200.4eDOI Listing
February 2006

Adolescent attitudes toward serious mental illness.

J Nerv Ment Dis 2005 Nov;193(11):769-72

Evanston Northwestern Healthcare, Evanston, Illinois, USA.

While there is a growing literature on mental illness stigma and strategies for reducing stigma among adults, less is known about how children and adolescents view persons with mental illness. In this paper, we describe the Attitudes Toward Serious Mental Illness Scale-Adolescent Version (ATSMI-AV) and our initial examinations of its factor structure and variations among subgroups of adolescents. Findings suggest that strategies aimed at reducing stigma in this age group would be wise to specifically target categorical thinking about mental health and mental illness and perceptions of persons with mental illness being violent and out of control.
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http://dx.doi.org/10.1097/01.nmd.0000185885.04349.99DOI Listing
November 2005

Incidence of disability among preretirement adults: the impact of depression.

Am J Public Health 2005 Nov;95(11):2003-8

Institute for Healthcare Studies and the Multidisciplinary Clinical Research Center in Rheumatology, Northwestern University, 339 East Chicago, 7th Floor, Chicago, IL 60611, USA.

Objectives: We evaluated the effect of depression on risk, on the basis of standardized assessment, for developing activities of daily living (ADL) disability.

Methods: Depression-related risk on 2-year ADL disability is estimated from 6871 participants in a population-based national sample aged 54-65 years and free of baseline ADL disability. We evaluated the effects of factors amenable to clinical and public health intervention that may explain the relationship between depression and incident disability.

Results: The odds of ADL disability were 4.3 times greater for depressed adults than their non-depressed peers (95% confidence interval=3.1, 6.0). Among depressed adults, 18.7% of African Americans, 8.0% of Whites, and 7.8% of His-panics developed disability within 2 years. The attributable population fraction because of depression is 17.3% (95% confidence interval=11%, 24%). Concurrent health factors moderated depression-associated risk.

Conclusions: Elevated risk of ADL disability onset because of depression, in a cohort whose medical costs will imminently be covered via Medicare, is attenuated by factors amenable to public health intervention. Prevention and/or public health/policy programs that lead to more accessible and effective mental health and medical care could reduce the development of ADL disability among depressed adults.
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http://dx.doi.org/10.2105/AJPH.2004.050948DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449475PMC
November 2005

Determinants of indicated versus actual level of care in psychiatric emergency services.

Psychiatr Serv 2005 Apr;56(4):452-7

Mental Health Group Europoort, Barendrecht, The Netherlands.

Objective: This study was undertaken to improve understanding of the admission decision process by distinguishing between the clinically indicated level of care and actual level-of-care decisions in emergency psychiatry.

Methods: Clinicians in emergency psychiatric services in Rotterdam, The Netherlands, prospectively rated 720 patients by using the Severity of Psychiatric Illness Scale and collected information on demographic, clinical, and contextual parameters. The clinically indicated level of care and actual level-of-care decisions were studied independently, by using multivariate logistic regression analyses. The decision-making process was divided into three consecutive steps: evaluation of clinically indicated inpatient or outpatient level of care (step 1), voluntary or involuntary admission (step 2), and actual admission of patients for whom voluntary admission was indicated (step 3).

Results: Each step was determined by separate factors. Specifically, clinically indicated admission (step 1) was associated with family or friends' desire for admission (odds ratio [OR]=3.7), previous admissions (OR=2.9), symptom severity (OR=2.7), and personality disorder (OR=.4). Involuntary admission (step 2) was associated with lack of motivation (OR=5.7), symptom severity (OR=3.7), time of referral (OR=3.5) and danger to self or others (OR=2.7). Actual voluntary admission (step 3) was associated mainly with bed availability (OR=8.7). The overall percentage of correctly predicted cases was 82 percent for all steps in the decision process.

Conclusions: This study showed that each step in the admission decision process is determined by a unique set of variables and provided evidence that contextual factors influence decision making. Guidelines for voluntary admission and civil commitment need to be based on the results of studies that distinguish between the clinical needs of patients and contextual factors.
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http://dx.doi.org/10.1176/appi.ps.56.4.452DOI Listing
April 2005

Modeling crisis decision-making for children in state custody.

Gen Hosp Psychiatry 2004 Sep-Oct;26(5):378-83

Institute for Health Services Research and Policy Studies, Northwestern University, 710 N. Lake Shore Drive, Abbott 1206, Chicago, IL 60611, USA.

We studied 1492 children in state custody over a 6-month period to investigate the relationship between children's hospital admissions and the crisis workers' clinical assessment. A 27-item standardized decision-support tool [the Childhood Severity of Psychiatric Illness (CSPI)] was used to evaluate the symptoms, risk factors, functioning, comorbidity, and system characteristics. The CSPI has been shown to have a reliability range from 0.70 to 0.80 using intraclass correlations. Logistic regression was used to calculate age-adjusted odds ratios (AOR) of hospitalization, their 95% confidence intervals, and corresponding P values. The results showed that risk factors, symptoms, functioning, comorbidities, and system characteristics were all associated with hospital admissions. Children with a recent suicide attempt, severe danger to others, or history of running away from home/treatment settings were more likely to be hospitalized (respective AOR=12.7, P<.0001; AOR=32.3, P<.0001; AOR=3.0, P=.001). In addition, hospitalization was inversely associated with caregiver knowledge of children (AOR=0.2, P=.01) and multisystem needs (AOR=0.3, P=.04). The decision to hospitalize children psychiatrically appears to be complex. As predicted, risk behaviors and severe symptoms were independent predictors of children's hospital admissions. Interestingly, the capacity of the caregiver and the children's involvement in multiple systems also predict children's hospital admissions.
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http://dx.doi.org/10.1016/j.genhosppsych.2004.01.006DOI Listing
February 2005

The U.S. child welfare system: a de facto public behavioral health care system.

J Am Acad Child Adolesc Psychiatry 2004 Aug;43(8):971-3

Mental Health Services and Policy Program, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.

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http://dx.doi.org/10.1097/01.chi.0000127575.23736.90DOI Listing
August 2004

Racial differences in the mental health needs and service utilization of youth in the juvenile justice system.

J Behav Health Serv Res 2004 Jul-Sep;31(3):242-54

Division of Psychology, Northwestern University Feinberg Medical School, 339 E Chicago Ave, Suite 717, Chicago, IL 60614, USA.

Mental health placement rates by the juvenile justice system differ by race. However, it is unknown whether mental health needs differ by race. This study attempted to investigate potential differences in mental health needs and service utilization among Caucasian, African American, and Hispanic juvenile justice involved youth. A stratified random sample of 473 youth petitioned, adjudicated, and incarcerated from 1995-1996 was examined using a standard chart review protocol and the Childhood Severity of Psychiatric Illness measure for mental health needs. Significant and unique mental health needs were demonstrated for all racial groups. African American youth demonstrated the greatest level of needs. Minority status indicated significantly lower rates of mental health service utilization. Minority youth in the juvenile justice system are most at risk for underserved mental health needs. Based on the current data, it can be inferred that the first contact with the state's child and adolescent serving system, which includes the juvenile justice and mental health sectors, appears to be through the juvenile justice sector for many minority youth with delinquency problems.
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http://dx.doi.org/10.1007/BF02287288DOI Listing
August 2004

Regional variation and clinical indicators of antipsychotic use in residential treatment: a four-state comparison.

J Behav Health Serv Res 2004 Apr-Jun;31(2):178-88

Institute for Health Services Research and Policy Studies, Northwestern University Feinberg Medical School, 339 E Chicago Ave, Suite 717, Chicago, IL 60614, USA.

The last decade saw an increase in psychotropic use with pediatric populations. Antipsychotic prescriptions are used frequently in residential treatment settings, with many youth receiving antipsychotics for off-label indications. Residential treatment data from 4 states were examined to determine if regional variation exists in off-label prescription and what clinicalfactors predict use. The study used clinical and pharmacological data collected via retrospective chart reviews (N = 732). The Child and Adolescent Needs and Strengths Assessment-Mental Health Version was used to measure symptom and risk severity. Of youth receiving antipsychotics, 42.9% had no history of or current psychosis. Statistical analyses resulted in significant regional variation in use across states and yielded attention deficit/impulsivity, physical aggression, elopement, sexually abusive behavior, and criminal behavior as factors associated with antipsychotic prescription in nonpsychotic youth. Antipsychotic prescription is inconsistent across states. Off-label prescription is frequent and likelihood of use increases with behavior problems.
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http://dx.doi.org/10.1007/BF02287380DOI Listing
August 2004

Psychotropic medications prescribing patterns for children and adolescents in New York's public mental health system.

Community Ment Health J 2004 Apr;40(2):101-18

Mental Health Services and Policy Program, Northwestern University, USA.

Context: Breakthroughs in the development of effective medications for a number of psychiatric disorders have led to increased use of these compounds in the treatment of children.

Objectives: To understand the use of psychotropic medications in the treatment of children, a state-wide study was undertaken based on the data collected in a large planning study. DATA AND SETTING: A stratified random sample of 10 different program types in New York State produced data on children served in different specialty mental health services.

Participants: Randomly selected cases were reviewed at a randomly selected sites to generate a sample of 1592 cases on which data were collected on clinical presentation and service use, including psychotropic medication prescriptions.

Main Outcome Measures: The Child and Adolescent Needs and Strengths (CANS-MH) tool was used to provide a reliable review of clinical indicators.

Results: Psychotropic medication use is common in the children's public mental health service system in New York. Most children served in high intensity settings receive medication as a part of their treatment. It appears that most prescriptions for stimulants and antidepressants are consistent with either diagnostic or symptom indications. Many children with these indications are not on medications. On the other hand, a large number of children without evidence of psychosis receive antipsychotic medications.

Conclusion: The evidence suggests that stimulant and antidepressant are not over-prescribed. However, the use of antipsychotic medications for other indications is a priority for further research.
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http://dx.doi.org/10.1023/b:comh.0000022731.65054.3eDOI Listing
April 2004

Arthritis and heart disease as risk factors for major depression: the role of functional limitation.

Med Care 2004 Jun;42(6):502-11

Institute for Health Services Research and Policy Studies, The Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA.

Background: Major depression in later life is highest among people with chronic illness. Identifying amenable factors that mediate the relationship between known risk factors such as arthritis and heart disease with major depression is important to the design of clinical and public health strategies to reduce depression and its consequences.

Objective: This study investigates factors amenable to clinical and public health intervention that could mediate the relationship between chronic illness and major depression.

Design: Population-based national sample.

Setting: United States preretirement age (54-65) adults.

Participants: A total of 7825 participants from the 1996 Health and Retirement Survey.

Measurement: The outcome is major depression based on standardized assessment. Independent variables include sociodemographics chronic illness profile, functional limitation, health and medical access.

Results: A substantial burden of major depression is related to chronic illness, particularly arthritis (attributable risk [AR], 18.1%; 95% confidence interval [CI], 9.9-25.6) and heart disease (AR, 17.6%; 95% CI, 13.4-21.7). Functional limitation is the strongest investigated factor associated with depression (AR, 34.4%; 95% CI, 24.8-42.7) and attenuates the associations of arthritis and heart disease with depression.

Conclusion: Functional limitation mediates the association of arthritis and heart disease with major depression. This relationship offers potential clinical and public health strategies to reduce major depression in older adults through intervention and management of functional limitation. Alternatively, it might be possible to reduce functional loss through screening for depression, particularly among people with functional limitation, and effective mental health treatment. The importance for clinical management of depression, comorbidity, and functional limitation spectrum supports the value of systems-based medicine.
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http://dx.doi.org/10.1097/01.mlr.0000127997.51128.81DOI Listing
June 2004

The sensitivity of substance abuse treatment intensity to co-payment levels.

J Behav Health Serv Res 2004 Jan-Mar;31(1):50-65

Institute for Policy Research, Northwestern University, 2040 Sheridan Rd, Evanston, IL 60208, USA.

This study exploits variation in co-payment levels among different contractual arrangements within a regional managed behavioral health care organization to estimate the relationship between co-payment levels for substance use treatment services and the intensity of substance use treatment. The substance use treatment benefits involved a range of co-payment levels across nearly 400 employers during the years 1993 through 1998. Multiple regression techniques were used to estimate the effect of co-payment levels on treatment intensity. The results indicate that co-payment levels had a significant negative effect on outpatient and inpatient substance use treatment. For outpatient treatment the effect on intensity implied a co-payment elasticity of -0.18, implying that moving from a $10 co-payment to a $20 co-payment would result in, for example, a reduction from 5 to 4 outpatient visits per episode. However, the effect was larger for persons with combined alcohol and drug use disorders, as they exhibited a co-payment elasticity of -0.27. For inpatient days, the co-payment elasticity was considerably smaller at -0.017. Given the benefits of maintaining persons with substance use disorders in treatment, employers may have an incentive to take steps to minimize the barriers to treatment.
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http://dx.doi.org/10.1007/BF02287338DOI Listing
March 2004

Clinical and forensic outcomes from the Illinois mental health juvenile justice initiative.

Psychiatr Serv 2003 Dec;54(12):1629-34

Mental Health Services and Policy Program, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.

Objective: To address the mental health needs of youths who are arrested and detained in Illinois, an initiative was designed and implemented that identified youths with psychotic or affective disorders, linked them to community services, and monitored their cases. This study assessed whether such linkage is possible and whether it improves clinical and forensic outcomes.

Method: S: Under the initiative, court staff refer youths who may have a mental illness to a clinical liaison. If the youth is eligible for the program, the liaison works with the family to develop a community-based action plan. For the analysis presented here, the Child and Adolescent Needs and Strengths-Mental Health Scale (CANS-MH) and the Child and Adolescent Functional Assessment Scale (CAFAS) were used to assess outcomes among 314 youths who had completed the program at the time of the study. School and forensic outcomes were also monitored.

Results: Seventy-five percent of the youths were successfully linked to at least one mental health or community service. A comparison of average CANS-MH dimension scores at enrollment and program completion indicated that youths' emotional problems decreased considerably within three months of referral. CAFAS scores six months after enrollment improved across nearly all dimensions. Home, community, and school functioning were significantly improved from baseline. Only 42 percent of the youths were rearrested, compared with a statewide rate of 72 percent of detained youths.

Conclusion: S: By linking youths with significant mental health needs to existing community-based services, it appears possible both to ameliorate psychopathology and to reduce delinquency.
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http://dx.doi.org/10.1176/appi.ps.54.12.1629DOI Listing
December 2003

Racial/ethnic differences in rates of depression among preretirement adults.

Am J Public Health 2003 Nov;93(11):1945-52

Institute for Health Services Research and Policy Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA.

Objectives: We estimated racial/ethnic differences in rates of major depression and investigated possible mediators.

Methods: Depression prevalence rates among African American, Hispanic, and White adults were estimated from a population-based national sample and adjusted for potential confounders.

Results: African Americans (odds ratio [OR] = 1.16, 95% confidence interval [CI] = 0.93, 1.44) and Hispanics (OR = 1.44, 95% CI = 1.02, 2.04) exhibited elevated rates of major depression relative to Whites. After control for confounders, Hispanics and Whites exhibited similar rates, and African Americans exhibited significantly lower rates than Whites.

Conclusions: Major depression and factors associated with depression were more frequent among members of minority groups than among Whites. Elevated depression rates among minority individuals are largely associated with greater health burdens and lack of health insurance, factors amenable to public policy intervention.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1199525PMC
http://dx.doi.org/10.2105/ajph.93.11.1945DOI Listing
November 2003

Competency to stand trial in preadjudicated and petitioned juvenile defendants.

J Am Acad Psychiatry Law 2003 ;31(3):314-20

Mental Health Services and Policy Program, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA.

As state legislatures across the United States continue to permit younger juvenile defendants to be tried in adult court, juvenile competence to stand trial has become an issue of increasing legal and forensic significance. This study examined competency to stand trial in a sample of preadjudicated and petitioned juvenile defendants. Results revealed that juveniles deemed unfit to stand trial were younger than their competent counterparts, had more severe special education needs, and had more extensive mental health treatment histories. These results are consistent with those of prior research in this area. Implications for treatment planning and system reform are discussed.
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March 2004