Strategies to Improve Mental Health Care for Children and Adolescents: Research Review

The Agency for Healthcare Research and Quality review assesses the effectiveness of quality improvement, implementation, and dissemination strategies that seek to improve the mental health care of children and adolescents.

Approximately one in five children and adolescents living in the United States has one or more mental, emotional, or behavioral health disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria in any given year. These disorders contribute to problems with family, peers, and academic functioning; comorbidity (including other mental and substance use disorders and chronic health conditions); and reduced quality of life; they also increase the risk of involvement with the criminal justice system and other risk-taking behaviors and suicide. The evidence base for pediatric mental health interventions that target mood disorders, anxiety disorders, disruptive behavior disorders, psychotic disorders, eating disorders, and substance use disorders continues to grow. Despite advances in the evidence base, outcomes for children with mental health problems remain suboptimal because of issues with access to care, failure of systems and providers to adopt interventions with proven efficacy (e.g., evidence-based practices [EBPs]), and variability in the quality of mental health care received. Studies using nationally representative data on U.S. adolescents show that only approximately one in five children with mental health problems receives services, and only one-third of treatment episodes are considered minimally adequate (at least four visits with psychotropic medication or at least eight visits without psychotropic medication). The current health care system continues to provide fragmented care to children in numerous uncoordinated systems, rendering inefficient delivery of needed services. Other issues include providers not having the time available or knowledge/training to identify mental health problems and treat or refer accordingly.

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HHS selects eight states for new demonstration program to improve access to high quality behavioral health services

HHS announced the selection of eight states for participation in a two-year Certified Community Behavioral Health Clinic (CCBHC) demonstration program designed to improve behavioral health services in their communities. This demonstration is part of a comprehensive effort to integrate behavioral health with physical health care, increase consistent use of evidence-based practices, and improve access to high-quality care for people with mental and substance use disorders. The eight states HHS selected for this demonstration program include Minnesota, Missouri, New York, New Jersey, Nevada, Oklahoma, Oregon, and Pennsylvania.

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Chantix and Zyban: Drug Safety Communication – Mental Health Side Effects Revised, FDA

Based on a Food and Drug Administration (FDA) review of a large clinical trial that FDA required the drug companies to conduct, FDA determined the risk of serious side effects on mood, behavior, or thinking with the stop-smoking medicines Chantix (varenicline) and Zyban (bupropion) is lower than previously suspected. The risk of these mental health side effects is still present, especially in those currently being treated for mental illnesses such as depression, anxiety disorders, or schizophrenia, or who have been treated for mental illnesses in the past; however, most people who had these side effects did not have serious consequences such as hospitalization. The results of the trial confirm that the benefits of stopping smoking outweigh the risks of these medicines. FDA review of the clinical trial results also confirmed that Chantix, Zyban, and nicotine replacement patches were all more effective for helping people quit smoking than was an inactive treatment called a placebo. These medicines were found to better help people quit smoking regardless of whether or not they had a history of mental illness.

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Adding Better Mental Health Care to Primary Care

Many people visit a primary health care provider to treat physical diseases and injuries; however, it is also common for patients to see a primary care provider because of brain health issues, including such as depression, anxiety, alcohol use and might be the first contact for schizophrenia prodrome. The primary care provider can treat some brain disorders, particularly through medication, but that may not be enough. Integrating a “Collaborative Care” approach is one proven way primary care providers can enhance the quality and effectiveness of their brain health treatment. This Science Update describes new Centers for Medicare and Medicaid Services (CMS) Medicare coverage policy in which CMS will begin paying primary care clinicians separately for Collaborative Care services that they provide to patients who are being treated for a mental, or behavioral health condition. It also summarizes an analysis of the new CMS behavioral health integration policy by National Institute of Mental Health (NIMH) and CMS staff.

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SERIOUS MENTAL ILLNESS AMONG ADULTS BELOW THE POVERTY LINE

The challenges that adults with mental illness face are made more difficult if they are living in poverty. For example, adults with mental illness who are living in poverty may face higher health care costs, decreased productivity, and poor general health. According to the National Survey of Drug Use and Health (NSDUH), an estimated 9.8 million adults aged 18 or older in the U.S. had a serious mental illness (SMI), including 2.5 million adults living below the poverty line. SMI is defined in NSDUH as adults who in the past year have had a diagnosable mental, behavioral, or emotional disorder (excluding developmental and substance use disorders) of sufficient duration to meet diagnostic criteria and has resulted in serious functional impairment substantially interferes with major life activities. Adults aged 26 or older living below the poverty line were more likely to experience SMI than those living at and above the poverty line (7.5 percent vs. 4.1 and 3.1 percent, respectively). In contrast, the percentage of young adults with SMI was similar in each of the  levels of poverty.

The relationship between mental illness and poverty is complicated. Poverty may intensify the experience of mental illness. Poverty may also increase the likelihood of the onset of mental illness. At the same time, experiencing mental illness may also increase the chances of living below the poverty line. The Substance Abuse and Mental Health Services Administration provides resources for those  with mental illness. For information on accessing treatment, please visit http://findtreatment.samhsa.gov

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As Some States Implement New Marijuana Laws, Science Should Guide Public Health Policy

After the election on November 8, marijuana is now or will soon be legal for adult recreational use in eight states plus the District of Columbia. These states, and those that may join them in the future, will have choices to make in how they enact and implement their policies. Careful thought should be given to creating regulatory frameworks that prioritize public health. Science needs to be the guide.

A 2015 report prepared by the RAND Corporation for the state of Vermont pointed out that marijuana policy need not be seen as a binary choice between maintaining the status quo (prohibition) or putting in place a for-profit commercial model, such as those that now exist in Colorado and Washington. The latter could create an industry that stands to profit from encouraging heavy drug use by aggressively marketing its product and lobbying for less regulation. Heavy users account for the majority of sales currently in both the alcohol and tobacco industry. But a broad spectrum of models exists, varying in terms of who can provide marijuana (the state versus private or not-for-profit entities), what regulations govern how they operate, what kinds of products can be produced and distributed, including potency of the products, and how they are priced.

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Metabolic Changes in Schizophrenia May Predate Antipsychotic Use

By the time a person with schizophrenia presents at the onset of the illness, he or she may already be experiencing glucose dysregulation—increasing the risk of type 2 diabetes, a meta-analysis published today in JAMA Psychiatry reports. The findings highlight the importance of prescribing antipsychotics at a dose that limits the metabolic impact and educating patients about diet, exercise, and diabetic screening as early as possible after diagnosis.

While rates of type 2 diabetes are known to be two to three times higher in patients with schizophrenia than the general population, it was previously unknown whether schizophrenia confers an inherent risk for glucose dysregulation in the absence of the effects of chronic illness and long-term antipsychotic treatment.

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NIMH Director’s Message, Neural Circuits Research: How and Why

Yes, schizophrenia spectrum disorders are neuro-circuitry disorder and NIMH is focused on discovering which neuro-circuits and how to manage them to alleviate symptoms. It would be amazing if this could lead to eradicating schizophrenia spectrum illnesses. Read NIMH Director, Dr. Joshua Gordon’s message.

By Joshua Gordon

I wrote in my welcome message about my priorities. First, we need to fund excellent science. Second, we should support studies that will yield benefits on short, medium, and long-term timescales. I also have three particular areas of interest: neural circuits, computational and theoretical psychiatry, and suicide prevention. Here I will discuss an approach to translating neural circuit technology into novel treatment methods. These studies are an example of a research program with the potential to yield benefits in the medium-term.

“No way this will work.”

That is what I told my grad student, Nancy Padilla-Coreano, when she came to me with an idea. She had just spent the last three years on an experiment aimed at reducing activity in a specific component of a neural circuit we thought was critical for anxiety in mice. This circuit carries information from the hippocampus—a brain area involved in memory—to the prefrontal cortex—an area involved in interpreting information and making decisions. Using a carefully engineered virus, she was able to direct an inhibitory opsin—a protein that responds to light by decreasing neural activity—to the connections between these brain regions. She then used light to activate the opsin and inhibit circuit activity, which reduced anxiety in the mice. Nancy’s next idea was to try stimulating those inputs in a specific pattern, to see if she could increase anxiety instead of decreasing it. “Go ahead,” I said. “But that pattern won’t perfectly mimic brain activity. I’ll bet you it won’t work.” I promised a set of premium audio speakers for the lab if she proved me wrong.

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Can Mental Illness Be Prevented In The Womb?

Every day in the United States, millions of expectant mothers take a prenatal vitamin on the advice of their doctor.

The counsel typically comes with physical health in mind: folic acid to help avoid fetal spinal cord problems; iodine to spur healthy brain development; calcium to be bound like molecular Legos into diminutive baby bones.

But what about a child’s future mental health? Questions about whether ADHD might arise a few years down the road or whether schizophrenia could crop up in young adulthood tend to be overshadowed by more immediate parental anxieties. As a friend with a newborn daughter recently fretted over lunch, “I’m just trying not to drop her!”

Yet much as pediatricians administer childhood vaccines to guard against future infections, some psychiatrists now are thinking about how to shift their treatment-centric discipline toward one that also deals in early prevention.

In 2013, University of Colorado psychiatrist Robert Freedman and colleagues recruited 100 healthy, pregnant women from greater Denver to study whether giving the B vitamin choline during pregnancy would enhance brain growth in the developing fetus.

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New Way of Studying DNA as it’s Bundled in Cells Reveals New Schizophrenia Risk Genes, Daniel Geschwind, Ph.D.

A new study implicates two cellular pathways in schizophrenia risk that haven’t been well supported by genetic evidence before. They involve processes related to the birth of new nerve cells, called neurogenesis, and cell-to-cell signaling by a neurotransmitter called acetylcholine.

The study, published October 19 in Nature, characterized interactions between genome segments that regulate genes, called regulatory elements, and the genes they regulate – which are often located at distant sites on chromosomes.  This occurs because our genetic material is almost unimaginably compressed inside the nucleus of each of our cells, and twists and turns in the “packaged” form of DNA often brings genes and genome sites that regulate them into close proximity even though they are not adjacent to one another.

The study, whose first author was Hyejung Won of the University of California, Los Angeles, and was led by 1999 NARSAD Young Investigator grantee, 2015 NARSAD Distinguished Investigator grantee, and 2012 Ruane Prizewinner, Daniel Geschwind, Ph.D., of UCLA, revealed that 65% percent of regulatory elements called gene enhancers did not, in fact, interact with adjacent genes as is often assumed. When integrating new data on interactions of genes and regulatory sequences, the team found approximately 500 new candidate risk genes that were previously obscured because of their physical distance on the genome from sites where risk genes themselves are located.  Much more work will need to be done to know which of these 500 genes do in fact impact schizophrenia risk. But prior to the new research, these 500 had not been suspected of having such impact.

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