Date of Award

January 2011

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Vinod H. Srihari

Subject Area(s)

Mental health, Psychology

Abstract

Beyond searching for new treatments, the field of psychiatry also faces the challenge of ensuring that patients actually receive existing treatments. So far, mental health systems have had difficulty meeting that need, especially in psychotic disorders, but advances in the science of health care delivery offer hope. This thesis focuses on two ways in which services can be better delivered to patients with early psychosis: (1) by better disseminating empirically-validated early intervention programs, and (2) by ensuring that patients have continuous insurance coverage.

In the first chapter, a narrative review of the implementation literature is conducted to determine how closely, and in what ways, new early intervention programs should follow an existing program model. The decision of whether to adopt multi-component programs depends on the perceived levels of risk in doing so. Such risk is related to complexity of the model, and the risk may be managed by incorporating flexibility into the model. While high fidelity to a treatment model is associated with better outcomes in some types of interventions, an approach to fidelity that focuses on underlying principles, rather than specific features of programs, may combine the benefits of both flexibility and model specification.

The second chapter reports on the frequency and continuity of insurance coverage among a cohort of early-psychosis patients in Connecticut. Participants' (N=48) insurance status at baseline, six months and 12 months were collected from a combination of self-report, clinical charts, clinician report, and a state Department of Social Services database. Two-thirds of participants lacked continuous insurance coverage during their first year of follow up. Thirteen of 18 participants with private insurance at baseline and 5 of 13 with public insurance at baseline lost their coverage by 6 or 12 months. This study shows that continuous insurance coverage over the course of a year was uncommon among this group of participants in a phase of illness when continuity of care is even more important than usual. These findings have implications for the design of early psychosis specialty services.

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