Needle syringe programmes and opioid substitution therapy for preventing HCV transmission among people who inject drugs: findings from a Cochrane Review and meta-analysis.

AIMS: To estimate the effects of needle syringe programmes (NSP) and opioid substitution therapy (OST), alone or in combination, for preventing acquisition of Hepatitis C virus (HCV) in people who inject drugs (PWID). METHODS: Systematic review and meta-analysis. Bibliographic databases were searched for studies measuring concurrent exposure to current OST (within last 6 months) and/or NSP and HCV incidence among PWID. High NSP coverage was defined as regular NSP attendance or ≥100% coverage (receiving sufficient or greater number of needles/syringes per reported injecting frequency). Studies were assessed using the Cochrane risk of bias in non-randomised studies tool. Random effects models were used in meta-analysis. RESULTS: We identified 28 studies (n=6279) in North America (13), UK (5), Europe (4), Australia (5), and China (1). Studies were at moderate (2), serious (17) critical (7) and non-assessable risk of bias (2). Current OST is associated with 50% (risk ratio (RR) 0.50 95% CI 0.40-0.63) reduction in HCV acquisition risk, consistent across region and with low heterogeneity (I(2) =0, p=0.889). Weaker evidence was found for high NSP coverage (RR=0.79 95% CI 0.39-1.61) with high heterogeneity (I(2) =77%, p=0.002). After stratifying by region, high NSP coverage in Europe was associated with a 56% reduction in HCV acquisition risk (RR=0.44, 95% CI 0.24-0.80) with low heterogeneity (I(2) =12.3%, p=0.337) but not in North America (RR=1.58, I(2) =89.5%, p=<0.001). Combined OST/NSP is associated with a 76% reduction in HCV acquisition risk (RR=0.24 95% CI=0.07-0.89, I(2) =80% p=0.007). According to GRADE criteria, the evidence on OST and combined OST/NSP is low quality while NSP is very low. CONCLUSIONS: Opioid substitution therapy reduces risk of hepatitis C acquisition and is strengthened in combination with needle syringe programmes. There is weaker evidence for the impact of needle syringe programmes alone, although stronger evidence that high coverage is associated with reduced risk in Europe

Sustainability of collaborative care management for depression in primary care settings with academic affiliations across New York State

Background In a large statewide initiative, New York State implemented collaborative care (CC) from 2012 to 2014 in 32 primary care settings where residents were trained and supported its sustainability through payment reforms implemented in 2015. Twenty-six clinics entered the sustainability phase and six opted out, providing an opportunity to examine factors predicting continued CC participation and fidelity. Methods We used descriptive statistics to assess implementation metrics in sustaining vs. opt-out clinics and trends in implementation fidelity 1 and 2 years into the sustainability phase among sustaining clinics. To characterize barriers and facilitators, we conducted 31 semi-structured interviews with psychiatrists, clinic administrators, primary care physicians, and depression care managers (24 at sustaining, 7 at opt-out clinics). Results At the end of the implementation phase, clinics opting to continue the program had significantly higher care manager full-time equivalents (FTEs) and achieved greater clinical improvement rates (46% vs. 7.5%, p = 0.004) than opt-out clinics. At 1 and 2 years into sustainability, the 26 sustaining clinics had steady rates of depression screening, staffing FTEs and treatment titration rates, significantly higher contacts/patient and improvement rates and fewer enrolled patients/FTE. During the sustainability phase, opt-out sites reported lower patient caseloads/FTE, psychiatry and care manager FTEs, and physician/psychiatrist CC involvement compared to sustaining clinics. Key barriers to sustainability noted by respondents included time/resources/personnel (71% of respondents from sustaining clinics vs. 86% from opt-out), patient engagement (67% vs. 43%), and staff/provider engagement (50% vs. 43%). Fewer respondents mentioned early implementation barriers such as leadership support, training, finance, and screening/referral logistics. Facilitators included engaging patients (e.g., warm handoffs) (79% vs. 86%) and staff/providers (71% vs. 100%), and hiring personnel (75% vs. 57%), particularly paraprofessionals for administrative tasks (67% vs. 0%). Conclusions Clinics that saw early clinical improvement and who invested in staffing FTEs were more likely to elect to enter the sustainability phase. Structural rules (e.g., payment reform) both encouraged participation in the sustainability phase and boosted long-term outcomes. While limited to settings with academic affiliations, these results demonstrate that patient and provider engagement and care manager resources are critical factors to ensuring sustainability

Global Assessment of Functioning (GAF): properties and frontier of current knowledge

ABSTRACT: BACKGROUND: Global Assessment of Functioning (GAF) is well known internationally and widely used for scoring the severity of illness in psychiatry. Problems with GAF show a need for its further development (for example validity and reliability problems). The aim of the present study was to identify gaps in current knowledge about properties of GAF that are of interest for further development. Properties of GAF are defined as characteristic traits or attributes that serve to define GAF (or may have a role to define a future updated GAF). METHODS: A thorough literature search was conducted. RESULTS: A number of gaps in knowledge about the properties of GAF were identified: for example, the current GAF has a continuous scale, but is a continuous or categorical scale better? Scoring is not performed by setting a mark directly on a visual scale, but could this improve scoring? Would new anchor points, including key words and examples, improve GAF (anchor points for symptoms, functioning, positive mental health, prognosis, improvement of generic properties, exclusion criteria for scoring in 10-point intervals, and anchor points at the endpoints of the scale)? Is a change in the number of anchor points and their distribution over the total scale important? Could better instructions for scoring within 10-point intervals improve scoring? Internationally, both single and dual scales for GAF are used, but what is the advantage of having separate symptom and functioning scales? Symptom (GAF-S) and functioning (GAF-F) scales should score different dimensions and still be correlated, but what is the best combination of definitions for GAF-S and GAF-F? For GAF with more than two scales there is limited empirical testing, but what is gained or lost by using more than two scales? CONCLUSIONS: In the history of GAF, its basic properties have undergone limited changes. Problems with GAF may, in part, be due to lack of a research programme testing the effects of different changes in basic properties. Given the widespread use, research-based development of GAF has not been especially strong. Further research could improve GAF

The Epidemiology of Nonspecific Psychological Distress in New York City, 2002 and 2003

The 30-day prevalence of nonspecific psychological distress (NPD) is 3%, nationwide. Little is known about the prevalence and correlates of NPD in urban areas. This study documents the prevalence of NPD among adults in New York City (NYC) using population-based data from the 2002 and 2003 NYC Community Health Surveys (CHS) and identifies correlates of NPD in this population. We examined two cross-sectional random-digit-dialed telephone surveys of NYC adults (2002: N = 9,764; 2003: N = 9,802). Kessler’s K6 scale was used to measure NPD. Age-adjusted 30-day prevalence of NPD declined from 6.4% [95% Confidence Interval (CI): 5.8–7.0] in 2002 to 5.1% [95% CI: 4.5–5.6] in 2003. New Yorkers who were poor, in poor health, chronically unemployed, uninsured, and formerly married had the highest prevalence of NPD. Declines occurred among those who were married, white, recently unemployed, and female. NPD prevalence in NYC is higher than national estimates. A stronger economy and recovery from September 11th attacks may have contributed to the 2003 decline observed among selected subgroups. The excess prevalence of NPD may be associated with substantial economic and societal burden. Research to understand the etiology of this high prevalence and interventions to promote mental health in NYC are indicated.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/40312/2/McVeigh_The Epidemiology of Nonspecific Psychological Distress_2006.pd

Managed care and technical efficiency in outpatient substance abuse treatment units

This article examines (1) the extent to which managed care participation is associated with technical efficiency in outpatient substance abuse treatment (OSAT) organizations and (2) the contributions of specific managed care practices as well as other organizational, financial, and environmental attributes to technical efficiency in these organizations. Data are from a nationally representative sample survey of OSAT organizations conducted in 1995. Technical efficiency is modeled using data envelopment analysis. Overall, there were few significant associations between managed care dimensions and technical efficiency in outpatient treatment organizations. Only one managed care oversight procedure, the imposition of sanctions by managed care firms, was significantly associated with relative efficiency of these provider organizations. However, several organizational factors were associated with the relative level of efficiency including hospital affiliation, mental health center affiliation, JCAHO accreditation, receipt of lump sum revenues, methadone treatment modality, percentage clients unemployed, and percentage clients who abuse multiple drugs.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/45766/1/11414_2005_Article_BF02287509.pd

Science to Practice: Making What We Know What We Actually Do

The perspective of the medical director of a large public mental health agency is provided regarding how to close the gap between what we know and what we do in mental health care. Tools for change, actions required, and key actors are identified. The author believes the moment is propitious for improving care systemically