Documenting AOT Implementation: Misinformed ...

2 downloads 0 Views 424KB Size Report
Misinformed Informants? TO THE EDITOR: Those of us who want to see assisted out- patient treatment (AOT) used effectively have long lamented the dearth of ...
LETTERS

Dieneke Hubbeling, M.Res., M.R.C.Psych. Dr. Hubbeling is with the Wandsworth Crisis and Home Treatment Team, South West London and St. George’s Mental Health NHS Trust, London. Psychiatric Services 2016; 67:814–815; doi: 10.1176/appi.ps.670711

Documenting AOT Implementation: Misinformed Informants? TO THE EDITOR: Those of us who want to see assisted out-

patient treatment (AOT) used effectively have long lamented the dearth of data on how widely and fully AOT has been implemented across the United States. Unfortunately, the unreliable method by which Meldrum and colleagues (1) collected such information—relying solely on an interview with an “informed contact” in each state—has yielded a data set that falls far short of valid. We must acknowledge having conducted a similar survey ourselves, as one component of a 2014 Treatment Advocacy Center report on state civil commitment laws. Therefore, we know from experience that it is much easier to find state mental health officials who think that they know the extent of AOT implementation in their state than it is to find anyone who actually does. The reason is that with a few notable exceptions, AOT programs are neither implemented on the state level nor monitored by state mental health agencies. AOT programs are typically established by city, county, and regional mental health systems in collaboration with local courts. They function under authority granted by state law, but there is no administrative role for state government. Which is to say that in seeking to discover “the ways in which individual states have utilized” AOT [emphasis added], we believe that Meldrum and colleagues started off by asking the wrong question. Predictably, the result is an inaccurate and misleading set of findings, based on verbal, unverified claims of the interviewees. Meldrum and colleagues report that 20 states have “active, operational, and documented” AOT programs. Of these, 14 were found to be full statewide programs, and six were “limited to one or more counties.” Meanwhile, 17 states were found to have “relatively inactive” programs. From our own deep engagement in AOT nationally, we know that much of what Meldrum and colleagues were told by their informants is not accurate. New Jersey, listed as an “inactive” state, has, in fact, been one of the most active; it recently achieved implementation of AOT in all 21 counties. Illinois, listed as a statewide success, has frustratingly little AOT. New York, with AOT implementation supposedly “limited to one or more counties,” has actually been the national leader, with active programs in all regions. Nevada makes the list of “limited active” states, presumably on the strength of its sole, fledgling, and still-modest program in Clark County, whereas many states with long-standing robust programs in certain counties—such as Texas (Bexar), Florida (Seminole), Ohio (Butler, Summit) and Michigan (Oakland)—are inexplicably relegated to the “inactive” list. To properly survey the implementation of AOT would require a county-by-county effort across the states with AOT Psychiatric Services 67:7, July 2016

laws, with independent verification of interviewees’ claims. The state-level approach taken by Meldrum and colleagues provides little basis for their various claims regarding the prevalence and nature of AOT programs nationally. REFERENCE 1. Meldrum ML, Kelly EL, Calderon R, et al: Implementation status of assisted outpatient treatment programs: a national survey. Psychiatric Services 67:630–635, 2016 Jeffrey Geller, M.D., M.P.H. Brian Stettin, J.D. Dr. Geller is with the Department of Psychiatry, University of Massachusetts Medical School, Worcester. Mr. Stettin is with the Treatment Advocacy Center, Arlington, Virginia. Psychiatric Services 2016; 67:815; doi: 10.1176/appi.ps.670706

Documenting AOT Implementation: Misinformed Informants? In Reply TO THE EDITOR: We certainly agree with Dr. Geller and Mr. Stettin’s concern for reliable data on AOT implementation, which, as they state, can be challenging to obtain. However, their specific criticisms are a miscategorization of our data. We acknowledge that Tables 2 and 3 in our article could be wrongly interpreted if not read carefully. On page 2, we stated that “In 14 of the 37 states we were able to contact, implementation of the statutory program appeared to be limited or was not well documented.” In addition, our original title for Table 3 was “States with new or relatively inactive AOT programs or limited documentation”; the original title noted the limited documentation as well as the inactivity. However, this detail was omitted in the editing process, and we are pleased to be able to correct this omission now. The 17 states listed in Table 3 were not all inactive: they had either relatively inactive AOT programs or possibly active programs for which informants were not able to provide data or, in three cases, were implementing new statutes and had not yet had the opportunity to gather data. These specific differences in AOT status are shown in the table itself. In the specific instances cited, New Jersey reported having an active program but was in the process of implementing a new statute when we made our contacts. The same is true of Florida. Illinois is not identified as “a statewide success” but as an active program, although with a low number of participants for such a populous state (170). New York has been a national leader in AOT implementation; nevertheless, our informants indicated that upstate counties were much less active than the metropolitan areas. Nevada is shown in the table as having implementation limited to one county, as Dr. Geller and Mr. Stettin note. We think that readers will not err in assuming that the New York and Nevada programs are similar in scope, when readers note the relative number of participants listed in the table (3,147 versus 70). Finally, we are aware that there are active single-county programs in Michigan, Ohio, and Texas, but, as shown in Table 3, we were unable to obtain good data on numbers enrolled or other specific information about implementation. ps.psychiatryonline.org 815

LETTERS

We believe that we were honest about the methods and limitations of the project and presented our findings without overstating their significance or thoroughness. We presented our data not as the final word on AOT implementation but as an informed statement about the commonalities and variances of the active programs we identified across the country—and, in particular, about differences in enrollment mechanisms. In addition, our work highlighted the lack of reliable, accurate data that are needed fully to assess the effectiveness of programs such as AOT in many states. Finally, as Dr. Geller and Mr. Stettin noted in their own report (1), we found implementation in many states and counties to be “occasional, half-hearted or nonexistent.” We would welcome additional information from state and county programs that would enable us to develop a more complete report. REFERENCE 1. Stettin B, Geller J, Ragosta K, et al: Mental Health Commitment Laws: A Survey of the States. Arlington, Va, Treatment Advocacy Center, Feb 2014. Available at TACReports.org/state-survey. Accessed April 14, 2016 Marcia Meldrum, Ph.D. Erin Kelly, Ph.D. Joel Braslow, M.D., Ph.D. Psychiatric Services 2016; 67:815–816; doi: 10.1176/appi.ps.670708

Consultant Psychiatrists’ Role in Ensuring High-Quality Care From Nonspecialists TO THE EDITOR: The column by Wagenaar and colleagues (1) in the June issue provides a strong warning about efforts that focus only on expanding access to mental health services without being equally attentive to the quality of care. Given the large shortage of mental health providers in lowand middle-income countries (2), service delivery systems have embraced “task shifting,” whereby nonspecialists provide care that is often available only from specialists, such as psychiatrists (3). In our work in Nepal, we have found that task shifting may be limited to conducting training for health care workers and sending them off to provide services with minimal or no clinical supervision. There are similarities between conditions in Nepal and those described by Wagenaar and colleagues in Mozambique, where any patient with disruptive behavior is prescribed antipsychotics. In addition, we have seen unnecessarily high medication doses (for example, haloperidol routinely started at 10 mg daily) and other inappropriate regimens (for example, benzodiazepine monotherapy for various mental illnesses). As in Mozambique, rates of diagnosis of bipolar disorder in several clinical settings in Nepal are low, and we wonder whether patients with depression are not being screened for a history of mania—a common oversight even in high-income countries. When such patients switch to mania as a result of taking the antidepressant, the family may take them to a different health

816

ps.psychiatryonline.org

care center because they do not trust the first clinician. Such patients may then be misdiagnosed as having schizophrenia. Both situations can lead to lower rates of bipolar disorder diagnosis and may help explain the findings in Mozambique. In some settings where task shifting is used, on-demand consultations may be provided, whereby prescribers in rural clinics call the off-site psychiatrist with questions. However, this does not address errors resulting from the unknown unknowns—for example, the prescribers may not know that they lack the training to differentiate behavioral problems of dementia from those of schizophrenia. They may prescribe antipsychotics, believing that they are providing appropriate care, and never seek a consultation. In our setting, we are implementing collaborative care, in which an off-site psychiatrist regularly conducts a panel review of all patients with mental illness (4). Fortunately, the data available in the paper registry are very useful to guide such reviews and to correct the inappropriate practices highlighted by Wagenaar and colleagues. Although some targets will certainly require data analysis (for example, determining the rate of bipolar disorder diagnosis), much of the harm from inappropriate medications, such as prescribing antipsychotics for substance use disorders, can be avoided by routinely reviewing the simple paper registry that is used in many similar settings. Wagenaar and colleagues found that 76% of the visits to their hospital were follow-ups, which provides an opportunity to improve the quality of care. This kind of proactive consultation from psychiatrists should be an essential feature of task shifting. We thank Wagenaar and colleagues, note the applicability of their findings in our setting, and hope that their column and this letter will bring attention to the importance of increased access to quality care rather than simply to expansion of care. REFERENCES 1. Wagenaar BH, Cumbe V, Raunig-Berhó M, et al: Outpatient mental health services in Mozambique: use and treatments. Psychiatric Services 67:588–590, 2016 2. Kakuma R, Minas H, van Ginneken N, et al: Human resources for mental health care: current situation and strategies for action. Lancet 378:1654–1663, 2011 3. Patel V: The future of psychiatry in low- and middle-income countries. Psychological Medicine 39:1759–1762, 2009 4. Raney LE: integrating primary care and behavioral health: the role of the psychiatrist in the collaborative care model. American Journal of Psychiatry 172:721–728, 2015 Bibhav Acharya, M.D. Sikhar B. Swar, M.D. Dr. Acharya is with the Department of Psychiatry, University of California, San Francisco. He is cofounder and mental health advisor for Possible, a nonprofit organization that provides health care services in rural Nepal in partnership with the Nepali government. Dr. Swar is with the Department of Psychiatry, Kathmandu Medical College, Duwakot, Nepal. He is the consultant psychiatrist for Possible’s collaborative mental health care program in rural Nepal. Psychiatric Services 2016; 67:816; doi: 10.1176/appi.ps.670701

Psychiatric Services 67:7, July 2016