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Susan V Eisen,
Mark R Schultz,
Lisa N Mueller,
Curt Degenhart,
Jack A Clark,
Sandra G Resnick,
Cindy L Christiansen,
Moe Armstrong,
Kathryn A Bottonari,
Robert A Rosenheck,
Dolly Sadow
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ABSTRACT: Study objectives were to compare mental health outcomes of a peer-led recovery group, a clinician-led recovery group, and usual treatment and to examine the effect of group attendance on outcomes.
The study used a randomized design with three groups: a recovery-oriented peer-led group (Vet-to-Vet), a clinician-led recovery group, and usual treatment. The sample included 240 veterans. Recovery and mental health assessments were obtained at enrollment and three months later. Intention-to-treat analysis using mixed-model regression was performed to examine the effect of the intervention. "As treated" analysis was performed to examine the effect of group attendance.
There were no statistically significant differences in improvement among the groups. Across groups, depression and functioning, psychotic symptoms, and overall mental health improved significantly. Better group attendance was associated with more improvement.
This study adds to the evidence suggesting no short-term incremental benefit (or harm) from peer services beyond usual care.
Psychiatric services (Washington, D.C.) 12/2012; 63(12):1243-6. · 2.81 Impact Factor
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ABSTRACT: The diagnostic criteria for posttraumatic stress disorder (PTSD) have received significant scrutiny. Several studies have investigated the utility of Criterion A2, the subjective emotional response to a traumatic event. The American Psychiatric Association (APA) has proposed elimination of A2 from the PTSD diagnostic criteria for DSM-5; however, there is mixed support for this recommendation and few studies have examined A2 in samples at high risk for PTSD such as veterans. In the current study of 908 veterans who screened positive for a traumatic event, A2 was not significantly associated with having been told by a doctor that the veteran had PTSD. Those who endorsed A2, however, reported greater PTSD symptom severity in the 3 DSM-IV symptom clusters of reexperiencing (d = 0.45), avoidance (d = 0.61), and hyperarousal (d = 0.44), and A2 was significantly associated with PTSD symptom severity for all 3 clusters (R(2) = .25, .25, and .27, respectively) even with trauma exposure in the model. Thus, although A2 may not be a necessary criterion for PTSD diagnosis, its association with PTSD symptom severity warrants further exploration of its utility.
Journal of Traumatic Stress 07/2012; 25(4):368-75. · 2.72 Impact Factor
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ABSTRACT: Differential item functioning (DIF) in tests and multi-item surveys occurs when a lack of conditional independence exists
between the response to one or more items and membership to a particular group, given equal levels of proficiency. We develop
an approach to detecting DIF in the context of item response theory (IRT) models based on computing a diagnostic which is
the posterior mean of a p-value. IRT models are fit in a Bayesian framework, and simulated proficiency parameters from the posterior distribution are
retained. Monte Carlo estimates of the p-value diagnostic are then computed by comparing the fit of nonparametric regressions of item responses on simulated proficiency
parameters and group membership. Some properties of our approach are examined through a simulation experiment. We apply our
method to the analysis of responses from two separate studies to the BASIS-24, a widely used self-report mental health assessment
instrument, to examine DIF between the English and Spanish-translated version of the survey.
Health Services and Outcomes Research Methodology 04/2012; 9(3):145-161.
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ABSTRACT: We examined (1) mental and physical health symptoms and functioning in US veterans within 1 year of returning from deployment, and (2) differences by gender, service component (Active, National Guard, other Reserve), service branch (Army, Navy, Air Force, Marines), and deployment operation (Operation Enduring Freedom/Operation Iraqi Freedom [OEF/OIF]).
We surveyed a national sample of 596 OEF/OIF veterans, oversampling women to make up 50% of the total, and National Guard and Reserve components to each make up 25%. Weights were applied to account for stratification and nonresponse bias.
Mental health functioning was significantly worse compared with the general population; 13.9% screened positive for probable posttraumatic stress disorder, 39% for probable alcohol abuse, and 3% for probable drug abuse. Men reported more alcohol and drug use than did women, but there were no gender differences in posttraumatic stress disorder or other mental health domains. OIF veterans reported more depression or functioning problems and alcohol and drug use than did OEF veterans. Army and Marine veterans reported worse mental and physical health than did Air Force or Navy veterans.
Continuing identification of veterans at risk for mental health and substance use problems is important for evidence-based interventions intended to increase resilience and enhance treatment.
American Journal of Public Health 03/2012; 102 Suppl 1:S66-73. · 3.93 Impact Factor
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ABSTRACT: Many people with depression recognize their symptoms as depression, but fail to seek treatment for a number of years. We aimed to explore the reasons for this. Thirty primary care patients who screened positive for depression participated in semistructured, face-to-face interviews. Transcripts were analyzed using grounded thematic analysis. Patients who sought depression treatment emphasized their understanding of depression, their belief that treatment would work, and the negative consequences that would ensue if they did not seek treatment. Patients who did not seek treatment emphasized that treatment would not be effective, thought that depression would not last very long, and believed that depression did not affect their everyday lives. Patients' illness perceptions of depression were represented by and organized using the framework of the Self-Regulation Model of Illness Behavior. This model might be useful for planning patient activation intervention studies to increase the uptake of depression treatment in primary care.
Qualitative Health Research 06/2011; 21(11):1495-507. · 2.19 Impact Factor
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ABSTRACT: The authors report results of work to enhance self-report posttraumatic stress disorder (PTSD) assessment by developing an item bank for use in a computer-adapted test. Computer-adapted tests have great potential to decrease the burden of PTSD assessment and outcomes monitoring. The authors conducted a systematic literature review of PTSD instruments, created a database of items, performed qualitative review and readability analysis, and conducted cognitive interviews with veterans diagnosed with PTSD. The systematic review yielded 480 studies in which 41 PTSD instruments comprising 993 items met inclusion criteria. The final PTSD item bank includes 104 items representing each of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association [APA], 1994), PTSD symptom clusters (reexperiencing, avoidance, and hyperarousal), and 3 additional subdomains (depersonalization, guilt, and sexual problems) that expanded the assessment item pool.
Journal of Traumatic Stress 02/2011; 24(2):191-9. · 2.72 Impact Factor
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ABSTRACT: Research on patient-centered care supports use of patient/consumer self-report measures in monitoring health outcomes. This study examined the incremental value of self-report mental health measures relative to a clinician-rated measure in predicting functional outcomes among mental health service recipients. Participants (n = 446) completed the Behavior and Symptom Identification Scale, the Brief Symptom Inventory, and the Veterans/Rand Short Form-36 at enrollment in the study (T1) and 3 months later (T2). Global Assessment of Functioning (GAF) ratings, mental health service utilization, and psychiatric diagnoses were obtained from administrative data files. Controlling for demographic and clinical variables, results indicated that improvement based on the self-report measures significantly predicted one or more functional outcomes (i.e., decreased likelihood of post-enrollment psychiatric hospitalization and increased likelihood of paid employment), above and beyond the predictive value of the GAF. Inclusion of self-report measures may be a useful addition to performance measurement efforts.
The Journal of Behavioral Health Services & Research 12/2010; 38(2):170-90. · 1.32 Impact Factor
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ABSTRACT: Though demand for mental health services (MHS) among US veterans is increasing, MHS utilization per veteran is decreasing. With health and social service needs competing for limited resources, it is important to understand the association between patient factors, MHS utilization, and clinical outcomes.
We use a framework based on Andersen's behavioral model of health service utilization to examine predisposing characteristics, enabling resources, and clinical need as predictors of MHS utilization and clinical outcomes.
This was a prospective observational study of veterans receiving inpatient or outpatient MHS through Veterans Administration programs. Clinician ratings (Global Assessment of Functioning [GAF]) and self-report assessments (Behavior and Symptom Identification Scale-24) were completed for 421 veterans at enrollment and 3 months later. Linear and logistic regression analyses were conducted to examine: (1) predisposing characteristics, enabling resources, and need as predictors of MHS inpatient, residential, and outpatient utilization and (2) the association between individual characteristics, utilization, and clinical outcomes.
Being older, female, having greater clinical need, lack of enabling resources (employment, stable housing, and social support), and easy access to treatment significantly predicted greater MHS utilization at 3-month follow-up. Less clinical need and no inpatient psychiatric hospitalization predicted better GAF and Behavior and Symptom Identification Scale-24 scores. White race and residential treatment also predicted better GAF scores. Neither enabling resources, nor number of outpatient mental health visits predicted clinical outcomes.
This application of Andersen's behavioral model of health service utilization confirmed associations between some predisposing characteristics, need, and enabling resources on MHS utilization but only predisposing characteristics, need, and utilization were associated with clinical outcomes.
Medical care 04/2010; 48(4):288-95. · 3.24 Impact Factor
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ABSTRACT: This study examined the relationship between race-ethnicity, psychiatric and substance abuse symptoms and diagnoses, and number of outpatient visits for mental health or substance abuse problems in the two months after intake. Data were examined from clients who had an initial intake visit at one of 12 outpatient mental health or substance abuse treatment sites in each of the four U.S. census regions.
The sample included 1,899 patients with a new intake to outpatient mental health or substance abuse programs between May 2001 and June 2002. Demographic characteristics and symptom and problem difficulty, including alcohol or drug use, were assessed at intake with the revised 24-item Behavior and Symptom Identification Scale (BASIS-24) as part of a continuous quality improvement program. DSM-IV diagnoses and number of outpatient visits in the two-month period after intake were extracted from medical records or administrative databases.
Diagnoses were available for 1,807 patients. Non-Latino black clients and Latino clients reported worse symptoms of psychiatric disorders and substance use disorders at intake than non-Latino white clients, but race-ethnicity was not associated with the number of outpatient visits. Having a diagnosis of a substance use disorder, alone or with another mental disorder, and baseline symptom severity were associated with a greater number of outpatient treatment visits in the two months after intake.
This study did not find racial or ethnic disparities in service use among clients who had already initiated outpatient mental health or substance abuse treatment. These findings suggest that racial and ethnic disparities in mental health care may be due to treatment-seeking rates, that more emphasis should be placed on ensuring that treatment is available and accessible, and that those who need treatment are activated to initiate it.
Psychiatric services (Washington, D.C.) 12/2008; 59(11):1285-91. · 2.81 Impact Factor
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ABSTRACT: Assessment of clinically meaningful change is useful for treatment planning, monitoring progress, and evaluating treatment response. Outcome studies often assess statistically significant change, which may not be clinically meaningful. Study objectives are to: (1) evaluate responsiveness of the BASIS-24 using three methods for determining clinically meaningful change: reliable change index (RCI), effect size (ES), and standard error of measurement (SEM); and (2) determine which method provides an estimate of clinically meaningful change most concordant with other change measures. BASIS-24 assessments were obtained at two time points for 1,397 inpatients and 850 outpatients. The proportion showing clinically meaningful change using each method was compared to the proportion showing change in global mental health, retrospectively reported change, and clinician-assessed change. BASIS-24 demonstrated responsiveness at both aggregate and individual levels. Regarding clinically meaningful improvement and decline, SEM was most concordant with all three outcome measures; regarding no change, RCI was most concordant with all three measures.
The Journal of Behavioral Health Services & Research 08/2007; 34(3):272-89. · 1.32 Impact Factor
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ABSTRACT: Culturally and linguistically appropriate outcome measures are needed to address the needs of Latino consumers of mental health services. The revised Behavior and Symptom Identification Scale (BASIS-R(c)) is an English-language consumer self-report measure designed to assess outcome of behavioral health or substance abuse treatment. This study sought to develop a culturally and linguistically appropriate version of the BASIS-R(c) for Spanish-speaking Latinos. To achieve this goal, the English instrument was translated and adapted into Spanish by an international bilingual committee and tested in four focus groups and 45 cognitive interviews with Puerto Ricans, Dominicans, and Mexicans living in the United States and Puerto Rico. Focus groups and cognitive interviews provided qualitative and quantitative information about the instrument's content and format, and respondents' understanding of the instructions, questionnaire items, time frame, and response options. Respondents' ratings of the clarity and importance of each item were also obtained. Analyses of focus group and cognitive interview data identified items that were confusing or difficult for participants. Findings suggest that the Spanish version of the BASIS-R(c) incorporated the cultural diversity of the three groups of Latinos in this study without compromising the validity of the English version of the BASIS.
Culture Medicine and Psychiatry 04/2007; 31(1):25-49. · 1.29 Impact Factor
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ABSTRACT: This study compared the self-report Behavior and Symptom Identification Scale (BASIS-32) and clinician-rated Global Assessment of Functioning (GAF) in their ability to predict a measure of psychiatric outcome, 1-year psychiatric hospital readmission. BASIS-32 and GAF were completed at admission for 1034 patients in an inpatient psychiatric facility. Multiple informants analysis was used to determine the difference between the two in predicting readmission within 1 year. We also examined sensitivity, specificity, and predictive value positive of the two measures, and whether self-report added information above clinician rating in predicting outcome. While the odds of 1-year readmission decreased with increasing BASIS-32 score, there was no association between change in GAF score and 1-year readmission. Although neither measure used alone demonstrated high predictive value, using both scores improved predictive ability over using clinician rating alone. In this setting, self-report was better than clinician rating in predicting psychiatric outcome. Differences between the two in relation to other outcomes need to be examined.
Administration and Policy in Mental Health 10/2006; 33(5):568-77. · 2.09 Impact Factor
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ABSTRACT: Increasing racial and ethnic diversity calls for mental health assessment instruments that are appropriate, reliable, and valid for the wide range of cultures that comprise the current US population. However, most assessment instruments have not been tested on diverse samples. This study assessed psychometric properties and sensitivity to change of the revised Behavior and Symptom Identification Scale (BASIS-24) among the three largest race/ethnicity groups in the USA: Whites, African-Americans, and Latinos. BASIS-24 assessments were obtained for 2436 inpatients and 2975 outpatients treated at one of 27 mental health and/or substance abuse programs. Confirmatory factor analysis and several psychometric tests supported the factor structure, reliability, concurrent validity, and sensitivity of the instrument within each race/ethnicity group, although discriminant validity may be weaker for African-Americans and Latinos than for Whites. Further research is needed to test and validate assessment instruments with other race/ethnicity groups.
The Journal of Behavioral Health Services & Research 08/2006; 33(3):304-23. · 1.32 Impact Factor
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ABSTRACT: In measuring outcomes of health care, information is obtained from subjects employing instruments that often use Likert scales. These instruments are typically designed using classical testing theory which assumes the errors around the true scores are normally distributed and constant. Advances in psychometric practices through the use of item response theory (IRT) models have led to more flexibility in scale development and in data analyses. In this paper, we introduce statisticians and health services researchers to IRT models through a case-study of data collected to measure subjective distress. The data consist of self-reports of symptom and problem difficulty obtained from a sample of 2,656 patients discharged with a psychiatric disorder from 13 hospitals in the United States between May 2001 and April 2002. Dimensionality of the trait is assessed using principal factor analysis. Model assessment is made using χ2 statistics and residual analyses. We select items for the scale using the Fisher Information available at selected levels of the underlying trait.
Health Services and Outcomes Research Methodology 05/2006; 6(1):1-19.
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ABSTRACT: To assess outcomes of health services, providers need brief, responsive, reliable, and valid measures that can be implemented in clinical settings with minimal cost and burden. The Behavior and Symptom Identification Scale (BASIS-32) is a self-report measure developed in 1984 to assess mental health treatment outcomes. During the past 3 years, multiple methods were used to revise the instrument to improve reliability, validity, and applicability to diverse groups of mental health service recipients.
The objective of this study was to field test the revised instrument, make further changes based on analysis of the field test data, and assess reliability and validity of the final version (BASIS-24).
A field test was implemented at 27 treatment sites across the United States. A total of 2656 inpatients and 3222 outpatients participated. Factor analytic methods, classic test theory, and item response theory modeling were used to select the most discriminating, nonredundant items for inclusion in the final version of the instrument and to assess its reliability and validity. Item response theory modeling was used to score the instrument.
The final instrument includes 24 items assessing 6 domains: depression/ functioning, interpersonal relationships, self-harm, emotional lability, psychosis, and substance abuse. Test-retest and internal consistency reliability were acceptable. Tests of construct and discriminant validity supported the instrument's ability to discriminate groups expected to differ in mental health status, and its correlation with other measures of mental health.
Analyses of the BASIS-24 supported its reliability and validity for assessing mental health status from the patient's perspective.
Medical Care 01/2005; 42(12):1230-41. · 3.41 Impact Factor
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ABSTRACT: Medicaid-managed care has been shown to reduce the number and length of psychiatric hospitalizations, but little is known about the clinical and social consequences of such managed care programs. The purpose of this study was to compare the treatment of schizophrenia for disabled Medicaid beneficiaries who were and were not enrolled in managed care.
This was a prospective observational study of patients who sought care for a psychiatric crisis from June 7, 1997, to May 13, 1999. Patients were followed up for 6 months. Inpatient and outpatient mental health facilities in Massachusetts were studied. The participants included 420 adult Medicaid beneficiaries, aged 24 to 64 years, who were treated for schizophrenia; 784 eligible beneficiaries were originally contacted and invited to participate (53.6% response). A private managed behavioral health care organization administered the Medicaid mental health benefit for about half the patients in the study. The other half were enrolled in the dually insured fee-for-service Medicare/Medicaid plan. The main outcome measures were adherence to the Schizophrenia Patient Outcomes Research Team treatment recommendations from inpatient and outpatient medical records, self-reported quality of interpersonal interactions between patient and clinician, self-reported care experiences and outcomes, and clinician-reported outcomes.
There were no differences between the managed care plan and the unmanaged fee-for-service plan in adherence to the schizophrenia treatment guidelines. However, much outpatient care in both programs was inconsistent with treatment guidelines. Inpatient treatment was far more likely to conform to guidelines than outpatient treatment. Patient ratings of their care were positive and not different between plans. Clinical outcome and health-related quality of life were not different between plans.
A major change in Massachusetts in the way mental health care is organized and financed had neither a negative nor a positive effect on care quality. However, adherence to nationally accepted guidelines for care was only modest, suggesting a need to improve the delivery of treatment to the most disabled highest-risk adults with schizophrenia.
Archives of General Psychiatry 05/2003; 60(4):340-8. · 12.02 Impact Factor
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Journal of Psychiatric Practice 02/2003; 9(1):5-6. · 2.16 Impact Factor
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ABSTRACT: Despite current emphasis on consumer-based performance measures, little is known about factors that influence consumer ratings of behavioral health care. This study examines the influence of patient characteristics, health care use, and insurance coverage on patients' ratings of their managed behavioral health care in both commercial and public plans. Older and healthier patients rated their behavioral health care and health plan more highly than did other patients. Patients with less education and those whose insurance paid all costs of care gave consistently higher plan ratings. Women and frequent users enrolled in commercial plans gave more positive care ratings. After adjusting for enrollee characteristics and coverage, there were no differences between ratings of patients in commercial and public plans. These results are consistent with other research that illustrates the importance of adjusting health care ratings for patient characteristics when comparing plans.
The Journal of Behavioral Health Services & Research 12/2002; 29(4):481-9. · 1.32 Impact Factor
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ABSTRACT: Consumer perceptions of behavioral health care are widely recognized as important quality indicators. This article reports the development and use of the Perceptions of Care (PoC) survey, a standardized public domain measure of consumer perceptions of the quality of inpatient mental health or substance abuse care. The goals were to develop a low-cost, low-burden survey that would address important quality domains, allow for interprogram comparisons and national benchmarks, be useful for quality improvement purposes, and meet accreditation and payer requirements.
The sample was composed of 6,972 patients treated in 14 inpatient behavioral health or substance abuse treatment programs. The PoC survey was given to patients by program staff in the 24-hour period before discharge.
Aggregate reports and ratings of care identified areas that are highly evaluated by consumers, as well as areas that provide opportunities for quality improvement. Factor analysis identified four domains of care, and a 100-point score was developed for each domain. Regression analyses identified significant predictors of perceptions of care for use in computing risk-adjusted scores. Unadjusted and adjusted scores were presented to demonstrate the impact of risk adjustment on quality of care scores and relative ranking of programs. Examples were given of how programs used survey results to improve the quality of care.
Results demonstrated that the PoC survey is sensitive to detecting differences among inpatient behavioral health programs and can be useful in guiding quality improvement efforts. However, risk adjustment is important for appropriate interpretation of results.
The Joint Commission journal on quality improvement 10/2002; 28(9):510-26.
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ABSTRACT: The authors report on the development and use of a standardized measure of consumer perceptions of the quality of inpatient psychiatric and substance abuse treatment programs.
Joint Commission journal on quality and patient safety / Joint Commission Resources 08/2002; 28(9):510-526.
