See past highlights of MHRN activity in our Fall Newsletter





New MHRN Findings

Does Patient Adherence to Antidepressant Medication Actually Vary Between Physicians?
There is an assumption that whether a patient adheres to antidepressant medication depends, at least partly, on the quality of care by their physician. To test this, Greg Simon, MD from the Kaiser Permanente Washington Health Research Institute, led an effort to determine whether a  patient’s antidepressant medication adherence actually varies between prescribing physicians.

Using electronic health records and insurance claims data from 5 integrated health systems over three years, the authors identified 150,318 adults starting new episodes of antidepressant treatment for depression, as well as patient-level demographic and clinical characteristics potentially associated with adherence.

After accounting for sampling variation and case mix differences among prescribing physicians, the researchers found that early adherence to antidepressant medication did vary, but only slightly. This indicates that early discontinuation of antidepressant treatment is not an appropriate measure of individual physician performance, and efforts to improve adherence should emphasize system-level interventions instead.


What are the odds of racial and ethnic minority patients returning for a second psychotherapy visit within 45 days of the initial session?
Research indicates there are potential racial/ethnic inequities in healthcare systems. One large study of veterans with serious mental illness demonstrated that African-Americans and Hispanics were diagnosed with schizophrenia over 3-4 times more often than white patients. Another study found that racial and ethnic minorities were less likely to receive a diagnosis for depression and initiate pharmacotherapy even though they were more likely to initiate psychotherapy. Another study found that a patients’ race and ethnicity were the strongest predictors of adherence to medication treatment for depression, even after adjusting for patient factors such as age, education, income, insurance type, disease burden, mental healthcare use, and type of prescribing provider. Finally, other studies’ results have been mixed and contained significant limitations.

John E. Zeber, PhD of Baylor Scott and White, along with Karen Coleman, PhD at Kaiser Permanente Southern California, led a study designed to address previous research limitations by including a large, diverse ethnic sample, focusing on depression treatment, and having a uniform definition of psychotherapy retention to address the question of how much a patient’s racial and ethnic background contributes to the likelihood that they would return for a second psychotherapy visit within 45 days after their first visit.

The study sample consisted of 242,765 patients ≥ 18 years old, from six healthcare systems in the Mental Health Research Network (MHRN), who had a new episode of psychotherapy treatment for depression between 1/1/2010 and 12/31/2013. Data were from electronic medical records and organized in a Virtual Data Warehouse.

Return rates within 45 days of the first psychotherapy visit were 47.6%. Compared to non-Hispanic whites, racial and ethnic minority patients were somewhat less likely to return to psychotherapy for a second visit. However, results also suggest that individual healthcare system and provider factors likely represent stronger predictors of return rates for psychotherapy.


MHRN study examines what general risk factors are associated with suicide by firearm, compared with other methods
A recent MHRN study examined what general risk factors (e.g., general medical, mental health, and demographic risk factors) were associated with suicide using firearms, compared with suicide by other methods. The study was published in the February 2018 issue of Psychiatry Services. See a write-up of the findings here and the full manuscript here.


People diagnosed with psychotic disorders have a higher risk of unnatural death, but is the risk even higher shortly after they’re diagnosed?
People diagnosed with psychotic disorders have a higher risk of dying than the general population, and a new study, published in JAMA Psychiatry, suggests that there is a marked increase in death shortly after their diagnosis.

Led by Greg Simon, MD, researchers looked at the first recorded diagnosis of a psychiatric disorder in younger patients and then examined deaths within 3 years after the initial diagnosis. The study team found that, in the year after a first diagnosis, mortality from all causes was .55% in the psychotic disorder group, compared with .21% in the unipolar depression group and .07% in the general outpatient group.

After adjusting for race, ethnicity, and preexisting chronic medical conditions, the relative hazard of death in the psychotic disorder group compared with the general outpatient group was 34.93 for self-inflicted injury or poisoning versus 4.67 for other types of injury or poisoning. However, the risk of death from heart disease or diabetes did not differ significantly between the psychotic disorder and the general outpatient groups.

In the three years after diagnosis, mortality (all causes) in the psychotic disorder group decreased from 54.6 to 27.1 per 10 000 persons and injury and poisoning mortality decreased from 30.6 to 15.1 per 10 000 persons. Both rates, however, remained 3 times as high as in the general outpatient group (9.0 per 10 000 for all causes; 4.8 per 10 000) for injury or poisoning .

These findings in early mortality underscore the importance of systematic intervention for young people experiencing the first onset of psychosis. The authors suggest that clinicians should attend to the elevated suicide risk after the first diagnosis a psychotic disorder.


What types of care pathways do patients take before first being diagnosed with psychotic symptoms?
Greg Simon, MD, at the Kaiser Permanente Washington Health Research Institute, led a study to describe patterns of health care use prior to a first diagnosis of a psychotic disorder in a population-based sample of patients aged 15-29 years old. Results indicate that young patients who use inpatient or emergency department mental health care may indicate a higher risk of a first psychotic disorder diagnosis.

While the study team found that most patients who received a first diagnosis of a psychotic disorder had some indication of mental health care needs during the previous year, general use of primary care or mental health services did not clearly distinguish people who later received a diagnosis of a psychotic disorder from those who later received a diagnosis of unipolar depression. However, use of inpatient or emergency department mental health care did appear to be a more precise marker of risk.

See this news article for more information.


Project News

Lessons Learned from the Safer Use of Antipsychotics for Youth (SUAY) Pilot Study
MHRN researchers completed a feasibility pilot study, Safer Use of Antipsychotics for Youth (SUAY), at Kaiser Permanente Washington and Nationwide Children’s Hospital in 2017. The pilot informed the design of a large trial set to begin in April 2018. The intervention involves triggering a best practice alert when clinicians order an antipsychotic medication for youth with non-psychotic disorders (excluding youth with autism or intellectual disability). The intervention also involves: universal review of eligible antipsychotic orders by a child and adolescent psychiatrist, behavioral health navigation by a social worker, and televideo psychotherapy visits when barriers to face-to-face care are identified.

The pilot enrolled 26 youth who were prescribed an antipsychotic medication. Participants were predominantly adolescents. Most youth had multiple diagnoses and a long history of treatment reflecting a high acuity population. During the pilot, 17 providers were exposed to a control (8) or intervention (9) best practice alert when they ordered the antipsychotic medication. Nearly all (24/26) prescriptions were written by a psychiatrist.

While there is insufficient statistical power to assess true change, the intervention appears to have reduced the frequency of ordering antipsychotic medications. Behavioral health navigation was accepted by 65% of intervention arm patients (n=13). Both providers and these patients/families felt the navigation support was a valuable service. The pilot experience resulted in numerous protocol refinements, including extensive programming to fire the best practice alert correctly for idiosyncratic medication order pathways (e.g., patient reported medications, ‘doc of the day’ and pharmacist orders, etc.); improvements to provider messaging; enhancements to technical tools to support navigation and study processes; streamlining and better standardizing communication mechanisms between providers, study psychiatrists and navigators; and moving away from protocolized therapy modules for bridging to better meet patient needs.


MHRN-Related Job Opportunities

Department of Research & Evaluation at Kaiser Permanente Southern California seeks Mental Health Research Scientist
The Department of Research & Evaluation (R&E) at Kaiser Permanente Southern California (KPSC) seeks a mental health research scientist to expand its mental health research program.

The ideal applicant is an established investigator with relevant experience and expertise in mental health research. Qualifications include a PhD or equivalent in psychology, epidemiology, health services research, or related field, or MD or equivalent with a master’s degree in a related field. Research topics of particular interest include mental health conditions across the lifespan, especially in children, adolescents and older adults, mental health implementation research and pragmatic trials in real-world mental health care settings, and pregnancy and post-partum mental health. An established track record of extramural funding in related topics is required.

The objectives of the research program are to:

  • Build sustainable partnerships with regional stakeholders and national mental health researchers to identify, prioritize, execute, evaluate, and disseminate research that enhances mental health and well-being in the diverse communities of Southern California;
  • Identify disparities in mental health care treatment and outcomes and create research programs and methods to remove disparities,
  • Promote the uptake of large-scale evidence-based mental health services.

The Department of Research & Evaluation is in Pasadena, California and is home to 38 research scientists and clinician investigators and over 300 support staff. Interested candidates should submit their letter of interest and CV to Dr. Deborah Rohm Young and Jennifer.X.Wong@kp.org.

KPSC is an Equal Opportunity/Affirmative Action Employer and offers competitive salary and comprehensive benefit packages.


People News

MHRN welcomes new NIMH Science Officer, Agnes Rupp, PhD
MHRN welcomes Agnes Rupp, PhD as the MHRN NIMH science officer. Dr. Rupp will be taking over for Susan Azrin, PhD, since Dr. Azrin has begun leading the Early Psychosis Prediction and Prevention Unit (EP3) at the NIMH.  Dr. Rupp is an experienced project officer and scientist and brings a strong background in research methods and financing.  MHRN staff appreciate Dr. Azrin’s years of guidance and look forward to working with Dr. Rupp.


New MHRN Investigator at Baylor Scott and White site

Katherine Sanchez, PhD, LCSW, joined the Center for Applied Health Research (CAHR) at Baylor Scott and White site as a new investigator. Dr. Sanchez practiced as a bilingual clinical social worker for 15 years, primarily in medical settings with monolingual Spanish-speaking populations. Her principal area of research is in integrated health care and the provision of socio-culturally, linguistically adapted models for the treatment of co-morbid mental and physical illness. Her current studies aim to advance the scientific knowledge around eliminating mental health disparities by testing a culturally and linguistically centered integrated care approach, and promoting sustainability of the model through peer services to expand the capacity of primary care.

In her new position with CAHR, Dr. Sanchez will examine system level interventions and research opportunities to understand the social determinants of health and result in high impact, innovative strategies to address mental health disparities.


New MHRN Researcher, Vanessa Simiola, PhD, joins Center for Health Research, at Kaiser Permanente Hawaii
New Research Associate, Vanessa Simiola, Psy.D., has joined the Center for Health Research, at Kaiser Permanente Hawaii. Dr. Simiola is a licensed clinical psychologist whose expertise and primary interests are in traumatic stress studies, with an emphasis on dissemination and implementation of evidence-based treatments, patient preferences, and education and training. Dr. Simiola will begin working on the MHRN projects, beginning with the SRS-III, where she will serve as Project Manager for the KP-Hawaii site.