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Biomedical subjects

H A Pincus

Publications and source records attributed to H A Pincus.

At least 37 records · Page 2Linked to original sources
PubMed1999

Therapeutic drug monitoring of mood stabilizers in Medicaid patients with bipolar disorder.

OBJECTIVE: The authors' goal was to determine the extent and pattern of blood serum monitoring of mood stabilizers in Medicaid patients with bipolar disorder. METHOD: Data were drawn from a Medicaid medical claims data set from Pittsburgh and the surrounding region. The authors identified bipolar patients using lithium, valproate, and carbamazepine (N = 718) and then examined the patient demographic, diagnostic, and service use variables associated with therapeutic drug monitoring. RESULTS: A substantial proportion of lithium users (36.5%), valproate users (42.4%), and carbamazepine users (42.2%) with bipolar disorder diagnoses did not receive therapeutic drug level testing during the 12-month study period. Carbamazepine users who were male or in the 30-49-year age range were significantly less likely to be tested for serum drug level. Lithium users who did not receive partial-hospitalization psychiatric services and valproate users who received mental health case management were also less likely to be tested for serum drug level. Over one-half of the lithium users (54.1%) did not receive thyroid function tests, and few (4.2%) received renal function tests. Patients who did receive tests for serum drug level were likely to receive the other recommended tests. CONCLUSIONS: Many Medicaid patients with bipolar disorder received no therapeutic drug monitoring. Patient sociodemographic characteristics contributed little to explaining this omission, although some types of service utilization were related to rates of serum drug level testing.

Adolescent↗
PubMed1999

'Subthreshold' mental disorders. A review and synthesis of studies on minor depression and other 'brand names'.

BACKGROUND: Subthreshold conditions (i.e. not meeting full diagnostic criteria for mental disorders in DSM-IV or ICD-10) are prevalent and associated with significant costs and disability. Observed more in primary care and community populations than in speciality settings, varying conceptualisations have been applied to define these conditions. AIMS: To examine definitional issues for subthreshold forms of depression (e.g. minor depression) and to suggest future directions for research and nosology in psychiatry and primary care. METHOD: A Medline search was conducted. The relevant articles were reviewed with regard to specific categories of information. RESULTS: Studies applied a myriad of names and definitions for subthreshold depression with varying duration, symptom thresholds and exclusions. Prevalence rates also vary depending upon the definitions, settings and populations researched. CONCLUSIONS: Future research needs to apply methodological and intellectual rigour and systematically consider a broader clinical and nosological context. In addition, collaboration between psychiatry and primary care on research and clinical issues is needed.

Depression↗
PubMed1998

Prescribing trends in psychotropic medications: primary care, psychiatry, and other medical specialties.

CONTEXT: Psychotropic medications are widely prescribed, but how new classes of psychotropic medications have affected prescribing patterns has not been well documented. OBJECTIVE: To examine changes between 1985 and 1994 (data from 1993 and 1994 were combined) in the prescribing patterns of psychotropic medications by office-based primary care physicians, psychiatrists, and other medical specialists. DESIGN: National estimates for the number of visits during which a physician prescribed a psychotropic medication based on the National Ambulatory Medical Care Surveys conducted in 1985, 1993, and 1994. SETTING: Office-based physician practices in the United States. PARTICIPANTS: A systematically sampled group of office-based physicians. MAIN OUTCOME MEASURES: National estimates of visits that included a psychotropic medication. RESULTS: The number of visits during which a psychotropic medication was prescribed increased from 32.73 million to 45.64 million; the proportion of such visits, as a proportion of all visits, increased from 5.1% to 6.5% (P< or =.01). Antianxiety or hypnotic drug visits, previously the largest category, decreased as a proportion of psychotropic drug visits (P< or =.01) and are now surpassed by antidepressant visits. Visits for depression increased from 10.99 million in 1988 to 20.43 million in 1993 and 1994 (P< or =.01). Stimulant drug visits increased from 0.57 million to 2.86 million (P< or =.01). Although visits for depression doubled for both primary care physicians and psychiatrists, the proportion of visits for depression during which an antidepressant was prescribed increased for psychiatrists but not for primary care physicians. CONCLUSIONS: The patterns of psychotropic medication use in outpatient medical practice changed dramatically during the study period, especially in psychiatric practice.

Data Collection↗
PubMed1998

Antidepressant prescribing practices of outpatient psychiatrists.

BACKGROUND: The authors examined recent changes in the number and proportion of patients prescribed antidepressants by psychiatrists in outpatient private practice and characterized antidepressant prescription patterns by patient age, sex, race, payment source, and clinical diagnosis. METHODS: The authors analyzed physician-reported data from the 1985 and 1993-1994 National Ambulatory Medical Care Survey, focusing on visits to physicians specializing in psychiatry. Logistic regressions were used to examine associations between survey year and antidepressant prescription, adjusting for the presence of other variables. RESULTS: The proportion of outpatient psychiatric visits in which an antidepressant was prescribed increased from 23.1% (95% confidence interval [CI], 19.7%-26.5%) in 1985 to 48.6% (95% CI, 47.5%-49.7%) in 1993-1994. After controlling for several patient variables, psychiatric patients were approximately 2.3 (95% CI, 1.8-2.9) times more likely to receive an antidepressant in 1993-1994 than in 1985. In 1993-1994, selective serotonin reuptake inhibitors accounted for approximately half of the psychiatric visits with an antidepressant prescription. Increases in the rate of antidepressant prescription were particularly evident for children and young adults; whites; new patients; and patients with adjustment disorders, personality disorders, depression not otherwise specified or dysthymia, and some anxiety disorders. CONCLUSIONS: During the late 1980s and early 1990s, there was a significant increase in the prescription of antidepressants by office-based psychiatrists. This increase was greatest for patients with less severe psychiatric disorders.

Adjustment Disorders↗
PubMed1998

Assessing the feasibility of recruiting a randomly selected sample of psychiatrists to participate in a national practice-based research network.

This study tested the feasibility of recruiting and retaining a randomly selected sample of psychiatrists compared to a volunteer sample to participate in the American Psychiatric Association's Practice Research Network (PRN). One hundred-forty psychiatrists were randomly selected and contacted by phone by peer psychiatrists for recruitment into the PRN. As a comparison group, a sample of 146 self-selected volunteer psychiatrists were also included in the study. Recruited and volunteer psychiatrists were asked to participate in three studies to assess study compliance and retention. The representativeness of each sample was evaluated by comparing the psychiatrists' sociodemographic and practice characteristics to existing national data on psychiatrists. Study response rates and long-term retention rates were compared for the two groups. Sixty-one percent of the recruited sample who were eligible to participate in the network were willing to participate. Both the recruited and volunteer samples were broadly representative of the American Psychiatric Association's membership (with some differences in race, ethnicity and board certification). Of the recruited sample, 74.5% (38/51) successfully completed the network's first three pilot studies compared to 72.5% (98/135) of the volunteer sample. No psychiatrists in the recruited sample withdrew from the network compared to 2.1% (3/138) of the volunteer sample. These findings indicate a randomly selected sample of psychiatrists can be recruited and retained to participate in practice-based research. These methods can be used to enhance the generalizability of observational health services research studies, which require the participation of practicing clinicians. More effective methods should be tested to enhance participation rates.

Feasibility Studies↗
PubMed1998

The impact of managed care on psychiatry.

It is estimated that 50% of all practicing psychiatrists have at least one contract with a managed care organization (AMA, 1994). As the field of psychiatry increasingly adopts the tools of managed care, it is important for researchers to clarify the extent to which managed care affects the practice of psychiatry, and how the changing practice climate in turn affects patients seeking mental health care. A diverse array of managed care techniques have been introduced into the profession of psychiatry in an effort to alter treatment patterns. One commonly used tool, utilization review, can alter treatment patterns by restricting access to treatment alternatives and providing incentives to practitioners to meet managed care goals. Other managed care tools are the determination of "medical necessity" and the use of triage and treatment guidelines among insured enrollees requesting services. These guidelines serve as selection criteria to help determine not only which members of the insured population receive treatment for mental health care, but also to determine the allocation of enrollees to staff members and to prescribe the starting point for the types of services received. Managed care psychiatrists may find changes not only in their client populations and treatment alternatives, but in many other aspects of their practice. Some psychiatrists working in managed care have become increasingly involved in treatment teams. Other psychiatrists contracting with MCOs are reserved for medication management, consultation, or administration in carved-out mental health departments or agencies. Little is known about the extent to which managed care restrictions affect psychiatrists' patient care roles, collaborative relationships with other mental health professionals, and the degree to which psychiatrists are involved in administration of managed mental health care benefits. The era of managed care has constrained the clinical decision making of psychiatrists whose magnitude and impact on job satisfaction and labor market responses are unknown. Surveys of general physicians in MCOs have provided a framework for understanding some of the difficulties and opportunities faced by managed care psychiatrists, but have failed to shed much light on many aspects of medical practice specific to the provision of mental health care within the boundaries of managed care. Future research in this area would help fill this gap, and assist in shaping the roles of psychiatrists in managed mental health care organizations.

Attitude of Health Personnel↗
PubMed1998

Clinical and treatment characteristics of children with attention-deficit/hyperactivity disorder in psychiatric practice.

OBJECTIVE: To capture information about the clinical characteristics of, and treatments for, children with attention-deficit/hyperactivity disorder (ADHD) in psychiatric practice. METHOD: A mailed, self-administered questionnaire was sent to 81 practicing psychiatrists for them to complete on the next three consecutive patients aged 14 years and younger with ADHD seen during the 12-day study period. Information collected included the sociodemographic, clinical, and treatment characteristics of sampled patients. RESULTS: Patients in the study were predominantly white (85%), male (78%), and between 10 and 14 years old (58%). The most common ADHD subtype was combined/predominantly hyperactive (86%); 31% had no other comorbidity. Ninety-seven percent were receiving medications, with 49% receiving two or more. The single most common medication reported was methylphenidate (51% of patients) followed by clonidine (20%). Psychotropics other than psychostimulants were used in a majority of patients (55%). CONCLUSIONS: Psychiatrists, and child and adolescent psychiatrists in particular, see a more severely impaired and complex group of patients than would be expected of primary care providers. The treatment patterns of psychiatrists for these patients do not reflect the simpler treatments usually studied in clinical trials.

Adolescent↗
PubMed1998

Use of ECT for the inpatient treatment of recurrent major depression.

OBJECTIVE: The authors' goals were to determine the frequency and distribution of ECT for general hospital inpatients with recurrent major depression and to estimate the effects of prompt ECT on the length and cost of inpatient care. METHOD: Data from the 1993 Healthcare Cost and Utilization Project were analyzed to determine the rate of ECT use for adult inpatients with a principal discharge diagnosis of major depression, recurrent. Associations between prompt initial use of ECT (in the first 5 hospital days) and length and cost of inpatient care were examined before and after control for sociodemographic, diagnostic, and hospital organizational characteristics. RESULTS: An estimated 9.4% of general hospital adult inpatients with a principal diagnosis of recurrent major depression received ECT in the survey year. A majority (59.2%) of these received their initial ECT session within the first 5 days after hospital admission. In univariate analyses, the likelihood of receiving ECT was greater for older patients, whites, privately insured individuals, and patients who lived in more affluent areas. Patients who received ECT tended to have relatively long and costly admissions. After control for several demographic, diagnostic, and hospital organizational characteristics, prompt ECT (as compared with delayed ECT or none) was associated with significantly shorter and less costly inpatient care. CONCLUSIONS: The longer stays and higher treatment costs associated with ECT may be a consequence of patient selection. When patient selection is taken into account, prompt administration of ECT is associated with shorter and less costly hospital stays. Nonetheless, economically disadvantaged patients are relatively unlikely to receive this treatment.

Adolescent↗
PubMed1998

Characterizing psychiatry with findings from the 1996 National Survey of Psychiatric Practice.

OBJECTIVE: The authors' goal was to characterize psychiatric practice by reporting findings from the 1996 National Survey of Psychiatric Practice. METHODS: A random sample of 1,481 APA members was selected to participate in the study; 1,375 APA members were determined to be eligible for study participation. The authors report data from 970 respondents (70.5% response rate) and compare them with data from previous surveys of psychiatrists. RESULTS: Twenty-five percent of the participating psychiatrists were women, compared with 19% in a 1988-1989 survey. Since 1988-1989, the proportion of psychiatrists 39 years old or younger has decreased and the proportion of those 55 years old or older has increased. In 1996, psychiatrists saw, on average, 35.4 unduplicated patients and worked an average of 46.4 hours in a typical week. Patients with mood disorders as their primary diagnoses accounted for the greatest proportion of psychiatrists' caseloads, followed by patients with anxiety disorders, then those with schizophrenia and other psychotic disorders. Public sources of payment and uncompensated care were the main sources of payment for psychiatrists services for 41.7% of patients. The primary payment mechanism for psychiatrists' patient care services was fee-for-service, accounting for 52.5% of psychiatrists' income from direct patient care. Twenty-nine percent of psychiatric patients received care through some form of managed care system, and 41.6% received treatment through a nonmanaged public or private health plan. CONCLUSIONS: As psychiatry moves into the next century, findings from the National Survey of Psychiatric Practice will form a baseline for monitoring changes and trends in the delivery and financing of mental health services.

Adolescent↗