Psychotropic medication management for youth in state care: consent, oversight, and policy considerations

The use of psychotropic medications in youth with emotional disturbances in state custody is increasing and presents unique challenges concerning consent and oversight. We examine various means that state child welfare agencies use to provide consent for and oversight of psychotropic medications for children in state custody and describe benefits of a consent process that provides for expert consultation to the child welfare agency and prescribing clinicians, case-specific and systemic oversight of psychotropic medication use, and education for stakeholders.     

Psychotropic medications in child welfare: From federal mandate to direct care

Background and objectiveChildren in the welfare system are prone to uncoordinated and unmonitored mental health care, including psychotropic medications. To address these issues, federal legislation mandated that state child welfare agencies improve the coordination and oversight of psychotropic medications. However, there is no clear guidance on how to improve these practices, particularly at the level of direct care. We aimed to identify specific areas for improvement through state-wide surveys of four groups.MethodsWe surveyed all known members of four groups working directly with children in foster care in one small northeastern state. Respondents included 209 foster and adoptive parents, 169 child welfare staff, 84 mental health therapists, and 33 clinical prescribers. Survey items addressed practices and perceptions related to sharing of information and cross-system communication and monitoring of medication effects and side effects.ResultsNearly two in five foster and adoptive parents reported not regularly receiving information about the purpose or side effects of psychotropic medications, and they disagreed among themselves on who was primarily responsible for monitoring safety and effectiveness. One-third of child welfare staff and two-thirds of mental health therapists reported that information about psychotropic medications is not regularly shared with the child's provider team. Half of clinical prescribers reported not regularly communicating with child welfare staff.ConclusionsWe identified specific areas for improvement related to communication, sharing of information, monitoring, and role clarification. Strategies to improving these activities are key to ensuring the safe and effective use of psychotropic medications in this population.     

Overcoming medication refusal using a patient-centered approach

The refusal of psychotropic medication is a challenge faced by many healthcare providers when treating patients with mental illness. Controversy surrounds medication refusal because some mental health professionals believe that psychiatric patients should be forced to take medications for the safety of the general public, while patients are often acutely aware of potential lifelong adverse side effects and are sometimes reluctant to comply. The proposed alternative to this problem begins with developing the patient-provider relationship through a patient-centered approach. This approach emphasizes the individual needs of patients and creates opportunities for input from patients about their care, which helps form relationships of mutual trust and respect between patients and providers. This article explores the literature to: (1) understand some of the challenges and controversies involved in patient medication refusal from a clinical and societal level; (2) identify some issues in a patient-centered approach; and (3) make some brief clinical and policy recommendations that might help to bring about an increase in the use of patient-centered care. Hopefully, as efforts are made toward a patient-centered approach, increased psychotropic medication adherence and decreased medication coercion will result as providers listen and act upon the needs of their patients.     

Evaluation in the community mental health centers program: A bold new reproach?

The Federal Community Mental Health Centers Program (CMHC)-from 1963 to 1981-was heralded as a revolution in mental health care. Championed by many, and severely criticized by others, the actual impact of the program on the nation's mental health remains unclear. The authorization to evaluate the CMHC Program came originally from congressional legislation (PL 90-174), and later from the policies and regulations of NIMH under a series of Federal laws, notably PL 94-63. From 1976-1980, two dominant evaluation strategies were prevalent: funds expended by NIMH each year for studies of CMHC services or program-wide evaluations, and a much larger expenditure by CMHCs to conduct their own, independent evaluations following federal guidelines. As the Center's Program was turned over to the states in the form of block grants (PL 97-35), a group of professionals involved with setting and carrying out federal CMHC evaluation policy of both varieties met in public forum to debate the impact of these two evaluation approaches. While some participants cited gains in evaluation technology and impact upon local management of CMHCs, others found the lack of a coordinated and systematic approach to evaluating the CMHC Program to have been an opportunity missed. The impact of CMHC evaluation efforts are also discussed in terms of their major contribution to the field of evaluation research as a whole.     

Evaluation in a down-loaded mental health system.

Speculation that policy and funding shifts in the nation's mental health system would negatively impact program evaluation services in community mental health centers (CMHC) is substantiated. Performance of program evaluation activities was investigated in 71 CMHCs in 15 states over a two-year period. Twenty-five percent of the centers reported cutbacks, including staff attrition and diminished funding devoted to evaluation functions. The majority of centers reported no changes, but many directors representing these centers also indicated that they had never fully developed a capacity for performing evaluations and would cease to devote attention to these activities without available funding. In some centers evaluation functions are being transferred to clinical administrators; integrated into quality assurance activities; performed "as needed' by external consultants; or ignored altogether. Many centers are developing or enhancing a computerized information system to improve internal efficiency and to meet state accountability requirements. The professional issues raised to these trends as well as their implications for federal and state policy are discussed.     

Migrant Health Policies. Actors and Levels in a Multi‐Level Perspective

Until recently, migrant health policies have been overlooked as a topic of policy analysis. Although interest in the issue has developed in parallel with the progressive acknowledgement of the presence of unhealthy migrants and the transformation of welfare states and policy dynamics in Europe, studies on migrant health policies have often focused on the state as a unique unit of observation while hindering the role played by other institutional and non‐institutional actors taking part in the migrant health multi‐level governance. This contribution will bridge this gap, deconstructing the various actors and levels involved in migrant health policymaking from a multi‐level perspective. By critically reviewing migrant health policy research and discussing it with the new MIPEX Health Strand, this contribution suggests a more encompassing perspective in the analysis of migrant health policies and processes, looking at the different players at stake in this multifaceted policy field.     

Revising a medication education program on an inpatient child and adolescent psychiatric unit

Adherence to a medication regimen can be challenging for children and adolescents with mental health disorders. Medication education can be a beneficial tool for nurses to help promote adherence to psychotropic medications. This article describes an initiative to improve medication education offered to children and adolescents and their families on an acute child and adolescent inpatient unit in a mental health facility. Strategies included adding a game to medication education groups, creating and distributing medication education handouts, and developing and implementing medication education sessions for parents. When used by the patients and families, the interventions were appreciated. Having successful interventions in place may help meet the diverse educational needs of this population as nurses seek to improve medication adherence.     

Student Knowledge of and Attitudes toward Psychotropic Drugs

Abstract

Expanding social work roles in medication management and psychoeducation, especially in mental health, clearly require that students possess an enlarged knowledge base and a set of enlightened attitudes regarding psychotropic medications and their use. This article reports the results of a survey that investigated the knowledge of and attitudes toward psychotropic medications among a population of social work students. If the survey results were scored like a school exam, then the average student surveyed scored a “C !.” The article also suggests that both personal and professional experiences in the mental health field apparently influence knowledge of and attitudes toward psychotropic drugs. It is recommended that social work course content be expanded to include relevant information on psychotropic drugs.     

The Social and Policy Predictors of Driving Mobility Among Older Adults

This research was designed to identify the impact of state driver's license renewal requirements on the driving mobility (i.e., the reduction or cessation of driving) of older (70 years or older) drivers in the United States. Nationally representative data from four waves (1993–2000) of the Asset and Health Dynamics of the Oldest Old study were linked to state policies on relicensing and used in a longitudinal logistic regression analysis. The author assessed the driving behaviors of a sample of 9,638 men and women. The findings demonstrate that the driving mobility of older people is influenced by state relicensing policies. The analysis indicates that five policies—accelerated renewal, mental testing, peripheral vision testing, renewal in person at age 70+ (as opposed to renewal by mail or online), and restricted licensing—have a significant effect on an older driver's decision to reduce or cease driving. The driving patterns of older adults are influenced not only by their health and socioeconomic backgrounds, but also by state relicensing policies. In terms of public policy, this result shows that there is a mechanism for extending the years of independent mobility for older people: restricted licensing.     

Labeling theory and community care of the mentally ill in California: the relationship of social theory and ideology to public policy

The practical merit of a labeling theory approach to mental illness is examined and assessed through an exploration of its application in terms of public policy, i.e., community mental health policy in the state of California since 1968. Primary focus is placed on the impact of the deinstitutionalization of mental health services in that state, and the release of former mental patients into the community. Similarities in the fundamental ideological underpinnings of labeling theory, an associated conspiratorial model of mental illness, and contemporary California mental health policy, are presented and examples of policy input by labeling theorists and researchers are detailed. The impact of the California policy on the mentally ill is generally negatively assessed in terms of three major criteria: (1) rehabilitation; (2) reintegration; and (3) quality and continuity of care. The "translation" of several theoretical misconceptions regarding mental illness, caused by putting labeling theory into official policy, is suggested to lie at the root of many of the policy's implementation problems. The uses of social science theory and research are discussed, and caution is advised in the translation and application of social scientific theory and research to public policy proposals and programs.     

Emerging adult identity following adolescent experiences with psychotropic medications: A retrospective study

This study examines the perceptions of mental illness identity among a group of emerging adults based on their retrospective experiences with diagnoses and psychotropic medication use during their earlier formative adolescent years. A short questionnaire was administered via online social media platforms to volunteers between the ages of 19 and 30 and who self-identified as having taken psychotropic medication between the ages of 12 and 18 (N = 46). Correlation analysis revealed that several variables were associated with a stronger illness identity, including participant’s happiness with their medication experiences, the belief that medication made them more like their “true” selves, and the belief that their diagnosis was accurate. Content analysis of participant narratives suggested themes related to discontinuation and barriers to adherence. These results contribute to the growing knowledge base around lived experiences of psychiatric medication use and suggest further study on how to advance more informed and compassionate mental health care.     

Does state spending on mental health lower suicide rates?

Using recently released data on public mental health expenditures by U.S. states from 1997 to 2005, this study is the first to examine the effect of state mental health spending on suicide rates. We find the effect of per capita public mental health expenditures on the suicide rate to be qualitatively small and lacking statistical significance. This finding holds across different estimation techniques, gender, and age groups. The estimates suggest that policies aimed at income growth, divorce prevention or support, and assistance to low income individuals could be more effective at suicide prevention than state mental health expenditures.     

The social and policy predictors of driving mobility among older adults

This research was designed to identify the impact of state driver's license renewal requirements on the driving mobility (i.e., the reduction or cessation of driving) of older (70 years or older) drivers in the United States. Nationally representative data from four waves (1993-2000) of the Asset and Health Dynamics of the Oldest Old study were linked to state policies on relicensing and used in a longitudinal logistic regression analysis. The author assessed the driving behaviors of a sample of 9,638 men and women. The findings demonstrate that the driving mobility of older people is influenced by state relicensing policies. The analysis indicates that five policies--accelerated renewal, mental testing, peripheral vision testing, renewal in person at age 70+ (as opposed to renewal by mail or online), and restricted licensing--have a significant effect on an older driver's decision to reduce or cease driving. The driving patterns of older adults are influenced not only by their health and socioeconomic backgrounds, but also by state relicensing policies. In terms of public policy, this result shows that there is a mechanism for extending the years of independent mobility for older people: restricted licensing.     

Can Health Care Reform End Stigma Toward Mental Illness?

This article addresses the destigmatization of mental health through health care reform by incorporating antistigma efforts—a destaining of mental illness—through prevention and early intervention in community-based programs that would be mandated and funded through the auspices of Patient Protection and the Affordable Care Act (ACA). Mental health care policies under the ACA and the Mental Health Parity Act are briefly described, following a definition of mental health stigma and its impacts. Recommendations for statutory mandates in stigma reduction at the community and federal levels and guidelines for mental health/behavioral health providers form the article’s conclusion.     

Determinants of the Rigor of State Protection Policies for Persons With Dementia in Assisted Living

Continued growth in the number of individuals with dementia residing in assisted living (AL) facilities raises concerns about their safety and protection. However, unlike federally regulated nursing facilities, AL facilities are state-regulated and there is a high degree of variation among policies designed to protect persons with dementia. Despite the important role these protection policies have in shaping the quality of life of persons with dementia residing in AL facilities, little is known about their formation. In this research, we examined the adoption of AL protection policies pertaining to staffing, the physical environment, and the use of chemical restraints. For each protection policy type, we modeled policy rigor using an innovative point-in-time approach, incorporating variables associated with state contextual, institutional, political, and external factors. We found that the rate of state AL protection policy adoptions remained steady over the study period, with staffing policies becoming less rigorous over time. Variables reflecting institutional policy making, including legislative professionalism and bureaucratic oversight, were associated with the rigor of state AL dementia protection policies. As we continue to evaluate the mechanisms contributing to the rigor of AL protection policies, it seems that organized advocacy efforts might expand their role in educating state policy makers about the importance of protecting persons with dementia residing in AL facilities and moving to advance appropriate policies.     

Adapting a Family-Based HIV Prevention Program for HIV-Infected Preadolescents and Their Families

Summary

This article describes a family-based HIV prevention and mental health promotion program specifically designed to meet the needs of perinatally-infected preadolescents and their families. This project represents one of the first attempts to involve perinatally HIV-infected youth in HIV prevention efforts while simultaneously addressing their mental health and health care needs. The program, entitled CHAMP+ (Collaborative HIV Prevention and Adolescent Mental Health Project-Plus), focuses on: (1) the impact of HIV on the family; (2) loss and stigma associated with HIV disease; (3) HIV knowledge and understanding of health and medication protocols; (4) family communication about puberty, sexuality and HIV; (5) social support and decision making related to disclosure; and (6) parental supervision and monitoring related to sexual possibility situations, sexual risk taking behavior and management of youth health and medication. Findings from a preliminary evaluation of CHAMP+ with six families are presented along with a discussion of challenges related to feasibility and implementation within a primary health care setting for perinatally infected youth.     

Resource Scarcity in Mental Health: Crisis or Opportunity for Social Work Education?

This paper suggests that the funding crisis faced by mental health provides an opportunity for structural and policy changes that can benefit the entire system. The effect of increasing state control, trends in mental health treatment, new technologies, and changing higher education constituencies on social work education are examined. Stress is placed on the need for social worker educators to become more involved in the determination of state priorities and policies in order to shift the emphasis of mental health from institution to community, from medical model to psychosocial treatment, and from physician dominance to multidisciplinary control.     

Foster child health care supervision policy

Foster children represent a high-risk group for physical, emotional, and social health problems, yet few federal or state policies explicitly address foster child health. This article reviews foster child health and the legal background for policy, then discusses components of a comprehensive health care supervision program.