Acculturation and the lifetime risk of psychiatric and substance use disorders among Hispanics

Between 1981 and 1995, approximately 5 million people from either Mexico, Cuba, Central America, or South America immigrated to the United States. Some regional studies have suggested that as Hispanic immigrants become acculturated to American society, their risk of mental illness increases sharply. This study examined the lifetime risk of psychiatric and substance use disorders among U.S. Hispanic subgroups and the specific role of nativity, parental nativity, language preferences, and other sociodemographic characteristics as risk factors for these disorders. The study used the National Comorbidity Survey (NCS), a national probability sample of 8098 U.S. adults aged 15 to 54. Selected DSM-III-R psychiatric diagnoses were collapsed into eight categories. When compared with non-Hispanic whites, Mexican-Americans were less likely to have any psychiatric disorder. After multivariate adjustment, acculturation items predicted greater risk of having any DSM-III-R disorders for Mexican-Americans and "other" Hispanics and greater risk of having a substance abuse disorder for Puerto Ricans, among other significant relationships. The results suggest that there is likely to be an increasing prevalence of psychiatric and substance use disorders among Hispanics that may be attributable to increasing levels of acculturation among the more than 5 million recent immigrants from Latin America.

Military discharge status of homeless veterans with mental illness

The high proportion of veterans among homeless men is perplexing given the opportunities associated with military service and the benefits long available to veterans. One little-examined risk factor for homelessness is that many homeless men may have received punitive discharges that result in ineligibility for Department of Veterans Affairs benefits. Data from a sample of homeless male veterans with mental illness enrolled in the Access to Community Care and Effective Services and Supports Program are used to examine punitive discharges as a risk factor for homelessness and to compare veterans with punitive and non-punitive discharges on premilitary, military, and postmilitary experiences. Only 7% of homeless veterans received punitive discharges. Pre-military experiences are associated with such discharges, but military experiences are not. Although a punitive discharge is a strong risk factor for subsequent homelessness, such discharges primarily reflect premilitary vulnerabilities and are a relatively minor reason for homelessness because they affect a small proportion of the general veteran population.

Cost-effectiveness of services for mentally ill homeless people: the application of research to policy and practice

OBJECTIVE

About one-quarter of homeless Americans have serious mental illnesses. This review synthesizes research findings on the cost-effectiveness of services for this population and their relevance for policy and practice.

METHOD

Service interventions for seriously mentally ill homeless people were grouped into three overlapping categories: 1) outreach, 2) case management, and 3) housing placement and transition to mainstream services. Data were reviewed both from experimental studies with high internal validity and from observational studies, which better reflect typical community practice.

RESULTS

In most studies, specialized interventions are associated with significantly improved outcomes, most consistently in the housing domain, but also in mental health status and quality of life. These programs are also associated with increased use of many types of health service and housing assistance, resulting in increased costs in most cases. The value of these programs to the public thus depends on whether their greater effectiveness is deemed to be worth their additional cost.

CONCLUSIONS

Innovative programs for seriously mentally ill homeless people are effective and are also likely to increase costs in many cases. Their value ultimately depends on the moral and political value society places on caring for its least-well-off members.

Relationship between climate and psychiatric inpatient length of stay in Veterans Health Administration hospitals

OBJECTIVE

The study examined whether climate has an impact on inpatient psychiatric length of stay in Veterans Health Administration hospitals (VHA).

METHOD

Data from the National Weather Service for eight climate variables for the locations of 134 VHA hospitals nationwide were factor analyzed, resulting in two climate factors representing temperature and precipitation. Factor scores were correlated with psychiatric mean lengths of stay from 1994 to 1998 for 99 VHA hospitals with inpatient psychiatric services and for the 22 VHA regional divisions (Veterans Integrated Service Networks).

RESULTS

Climate factors correlated modestly but significantly with length of stay, with correlations ranging from -0. 25 to -0.37 at the hospital level and from -0.38 to -0.45 at the VHA regional level; hospitals in warmer and drier climates had shorter lengths of stay. Medical centers in colder climates had the longest lengths of stay in winter and fall. The significant correlation between climate and length of stay was not affected by recent reductions in length of stay in VHA hospitals.

CONCLUSIONS

Higher clinical costs associated with longer lengths of stay in colder climates have implications for budget planning. Climate factors must also be recognized for their potential effect on performance monitoring systems focused on hospital utilization. Researchers must continue to consider broader contextual variables such as climate if they are to fully understand the determinants of health care utilization and psychiatric hospitalization costs.

Primary care satellite clinics and improved access to general and mental health services

OBJECTIVES

To evaluate the relationship between the implementation of community-based primary care clinics and improved access to general health care and/or mental health care, in both the general population and among people with disabling mental illness.

STUDY SETTING

The 69 new community-based primary care clinics in underserved areas, established by the Department of Veterans Affairs (VA) between the last quarter of FY 1995 and the second quarter of FY 1998, including the 21 new clinics with a specialty mental health care component.

DATA SOURCES

VA inpatient and outpatient workload files, 1990 U.S. Census data, and VA Compensation and Pension files were used to determine the proportion of all veterans, and the proportion of disabled veterans, living in each U.S. county who used VA general health care services and VA mental health services before and after these clinics began operation.

DESIGN

Analysis of covariance was used to compare changes, from late FY 1995 through early FY 1998, in access to VA services in counties in which new primary care clinics were located, in counties in which clinics that included specialized mental health components were located, and for comparison, in other U.S. counties, adjusting for potentially confounding factors.

KEY FINDINGS

Counties in which new clinics were located showed a significant increase from the FY 1995-FY 1998 study dates in the proportion of veterans who used general VA health care services. This increase was almost twice as large as that observed in comparison counties (4.2% vs. 2.5%: F = 12.6, df = 1,3118, p = .0004). However, the introduction of these clinics was not associated with a greater use of specialty VA mental health services in the general veteran population, or of either general health care services or mental health services among veterans who received VA compensation for psychiatric disorders. In contrast, in counties with new clinics that included a mental health component the proportion of veterans who used VA mental health services increased to almost three times the proportion in comparison counties (0.87% vs. 0.31%: F = 8.3, df = 1,3091, p = .004).

CONCLUSIONS

Community-based primary care clinics can improve access to general health care services, but a specialty mental health care component appears to be needed to improve access to mental health services.

The case management relationship and outcomes of homeless persons with serious mental illness

OBJECTIVE

The effect of the case management relationship on clinical outcomes was examined among homeless persons with serious mental illness.

METHODS

The sample consisted of the first two cohorts that entered the Access to Community Care and Effective Services and Supports (ACCESS) program, a five-year demonstration program for mentally ill homeless persons funded by the Center for Mental Health Services in 1994. At baseline, three months, and 12 months, clients were characterized as not having a relationship with their case manager or as having a low or high therapeutic alliance with their case manager. Analyses were conducted to test the association between the case manager relationship at baseline, three months, and 12 months and clinical outcomes at 12 months.

RESULTS

Multivariate analyses of covariance were conducted for 2,798 clients who had outcome data at 12 months. No significant associations were found between the relationship with the case manager at baseline and outcomes at 12 months. At three months, clients who had formed an alliance with their case manager had significantly fewer days of homelessness at 12 months. Clients who reported a high alliance with their case manager at 12 months had significantly fewer days of homelessness at 12 months than those with a low alliance, and those with a low alliance at 12 months had fewer days of homelessness than clients who reported no relationship with their case manager. Clients with a higher alliance at both three and 12 months reported greater general life satisfaction at 12 months.

CONCLUSIONS

The study found that clients' relationship with their case manager was significantly associated with homelessness and modestly associated with general life satisfaction.

Clinical and psychopharmacologic factors influencing family burden in refractory schizophrenia. The Department of Veterans Affairs Cooperative Study Group on Clozapine in Refractory Schizophrenia

BACKGROUND

This study compares the effect of clozapine and haloperidol and identifies other factors related to family burden as experienced by relatives of patients with refractory schizophrenia (DSM-III-R).

METHOD

Of 423 patients participating in a multisite randomized clinical trial, 221 identified a family member who was actively involved in their care and who agreed to complete a standardized measure of family burden at 6 weeks and 3, 6, 9, and 12 months after randomization, simultaneous with comprehensive patient assessments.

RESULTS

Patient factors most consistently correlated with greater family burden were symptom severity, days living in the community (i.e., not in the hospital), and frequency of family contact. Among family members, clozapine was associated with significantly (p = .048) greater reduction in feelings of dissatisfaction related to providing support to the patient, but not in objective measures of support, amount of worry the patient engendered, or days of missed employment or household activity. Although clozapine reduces symptoms, thus lowering family burden, it also increases days living in the community, which tends to increase family burden, perhaps canceling out the benefit to families of reduced symptoms.

CONCLUSION

Clozapine has a small but significant effect on the experience of families of patients. This is the first study to demonstrate that effective pharmacotherapy may be of some benefit to families as well as to patients.

Benzodiazepine use in posttraumatic stress disorder among veterans with substance abuse

Veterans with posttraumatic stress disorder (PTSD) and substance abuse may abuse benzodiazepines and develop violent dyscontrol when using them. A total of 370 veterans were compared by substance abuse diagnosis (50%), benzodiazepine use (36%), and their interaction on 1-year outcomes after inpatient discharge. Substance abusers were less likely to be prescribed benzodiazepines (26% vs. 45%). No outcome showed a differential worsening by substance abuse or benzodiazepines, although some baseline differences were noted. Outpatient health care utilization was lower in benzodiazepine users (47 vs. 33 visits). Among PTSD patients with comorbid substance abuse, benzodiazepine treatment was not associated with adverse effects on outcome, but it may reduce health care utilization.

Comparing consumer and nonconsumer provided case management services for homeless persons with serious mental illness

This study compared the outcomes of services provided by case managers who are mental health system consumers and case managers who were not consumers. The study focused on the first two cohorts that entered the ACCESS program, a 5-year demonstration program funded by the Center for Mental Health Services between 1994 and 1996. We tested the associations between the type of case manager and clinical outcomes at three time points (baseline, 3 months, and 12 months). A series of one-way repeated measures of analyses of variance were conducted on clients from ACCESS sites that hired consumer providers. Although there were significant effects of Time for almost every outcome measure (clients improved over time), there were no significant Time x Case Manager Type interactions. Staff age, race, or gender did not significantly alter the pattern of these results. Given that services provided by consumers and nonconsumers were associated with equivalent client outcomes, the present study shows, using a large sample, the ability of consumers to provide mental health services as members of a case management team.

How long to wait for a response to clozapine: a comparison of time course of response to clozapine and conventional antipsychotic medication in refractory schizophrenia

This study compared the time course to clinical improvement with clozapine and with conventional antipsychotic medications. A double-blind trial compared clozapine and haloperidol in patients with schizophrenia who were refractory to conventional antipsychotic medication and were hospitalized for 30 to 364 days at 15 Veteran Affairs medical centers during the year before study entry. Patients in the original study were randomly assigned to haloperidol or clozapine and followed for 12 months, at maximum tolerable doses. Patients who completed a full year of treatment with clozapine (n = 122), or with either haloperidol or another conventional antipsychotic medication (n = 123) and who also completed the 9- or 12-month assessment were included. Response to treatment was defined as 20 percent improvement on standard scales of symptoms and quality of life at the latter of the 9- or 12-month interviews. More patients assigned to clozapine achieved 20 percent improvement in symptoms at each followup. Among patients who did not improve at 6 weeks, 3 months, or 6 months, there were no significant differences between clozapine and comparison patients in outcomes at 1 year. Among patients who did improve, maintenance of that improvement also did not differ between the groups at 1 year on symptom measures. Maintenance of improvement in quality of life at 1 year was significantly greater for clozapine patients who had improved at 6 months (p < 0.04). Significant differential symptom response to clozapine occurred exclusively during the first 6 weeks of treatment.

Outcomes monitoring and the testing of new psychiatric treatments: work therapy in the treatment of chronic post-traumatic stress disorder

OBJECTIVE

To evaluate the effectiveness of a work therapy intervention, the Department of Veterans Affairs (VA) Compensated Work Therapy program (CWT), in the treatment of patients suffering from chronic war-related post-traumatic stress disorder (PTSD); and to demonstrate methods for using outcomes monitoring data to screen previously untested treatments.

DATA SOURCES/STUDY SETTING

Baseline and four-month follow-up questionnaires administered to 3,076 veterans treated in 52 specialized VA inpatient programs for treatment of PTSD at facilities that also had CWT programs. Altogether 78 (2.5 percent) of these patients participated in CWT during the four months after discharge.

STUDY DESIGN

The study used a pre-post nonequivalent control group design.

DATA COLLECTION/EXTRACTION METHODS

Questionnaires documented PTSD symptoms, violent behavior, alcohol and drug use, employment status, and medical status at the time of program entry and four months after discharge from the hospital to the community. Administrative databases were used to identify participants in the CWT program. Propensity scores were used to match CWT participants and other patients, and hierarchical linear modeling was used to evaluate differences in outcomes between treatment groups on seven outcomes.

PRINCIPAL FINDINGS

The propensity scaling method created groups that were not significantly different on any measure. No greater improvement was observed among CWT participants than among other patients on any of seven outcome measures.

CONCLUSIONS

Substantively this study suggests that work therapy, as currently practiced in VA, is not an effective intervention, at least in the short term, for chronic, war-related PTSD. Methodologically it illustrates the use of outcomes monitoring data to screen previously untested treatments and the use of propensity scoring and hierarchical linear modeling to adjust for selection biases in observational studies.

Posttraumatic stress disorder among Hispanic Vietnam veterans

OBJECTIVE

The purpose of this study was to examine posttraumatic stress disorder (PTSD) among Hispanics who served in the Vietnam War.

METHOD

The authors conducted secondary data analyses of the National Vietnam Veterans Readjustment Study, a national epidemiologic study completed in 1988 of a representative sample of veterans who served during the Vietnam era (N=1,195).

RESULTS

After adjustment for premilitary and military experiences, the authors found that Hispanic, particularly Puerto Rican, Vietnam veterans had significantly more severe PTSD symptoms and a higher probability of experiencing PTSD than nonminority veterans. However, they had no greater risk for other mental disorders, and their greater risk for PTSD was not explained by acculturation. Despite their more severe symptoms, Hispanic veterans, especially Puerto Rican veterans, showed no greater functional impairment than non-Hispanic white veterans.

CONCLUSIONS

Hispanic Vietnam veterans, especially Puerto Rican Vietnam veterans, have a higher risk for PTSD and experience more severe PTSD symptoms than non-Hispanic white Vietnam veterans, and these differences are not explained by exposure to stressors or acculturation. This high level of symptoms was not accompanied by substantial reduction in functioning, suggesting that the observed differences in symptom reporting may reflect features of expressive style rather than different levels of illness.

Impact of combat and sexual harassment on the severity of posttraumatic stress disorder among men and women peacekeepers in Somalia

The impact of combat and sexual harassment on the severity of posttraumatic stress disorder (PTSD) is compared for 1,307 men and 197 women peacekeepers who served in the same military units. A theoretical model was proposed to express the nature of the impact. Structural equation modeling was used to evaluate the model separately for men and women. Good-fitting, parsimonious models were developed that showed substantial similarity for men and women. For men, severity of PTSD symptoms was impacted by exposure to combat directly and indirectly through fear and sexual harassment. For women, severity of PTSD symptoms was impacted by combat indirectly through the same two influences, although the mechanisms involving fear and sexual harassment were somewhat different. For both genders, moreover, PTSD severity was impacted directly by exposure to the dying of the Somali people. These similarities suggest that in modern stressful overseas military missions, both genders may be susceptible to the same types of risk for the development of PTSD. The incidence and impact of sexual harassment is particularly noteworthy in the case of men and calls for more detailed investigation in future studies.

Mortality among homeless and nonhomeless mentally ill veterans

This study directly compared mortality risk in homeless and nonhomeless mentally ill veterans and compared mortality rates in these groups with the general U.S. population. The study used a retrospective cohort design to assess mortality over a 9-year period in homeless (N = 6,714) and nonhomeless (N = 1,715) male veterans who were treated by Department of Veterans Affairs specialized mental health programs. The study showed that mortality rates in all homeless members of the cohort were significantly higher than the general U.S. population. Relative to nonhomeless cohort members, significant increases in mortality risk were observed in cohort members who at baseline were age 45 to 54 and had been homeless 1 year or less (RR = 1.55, 95% CI = 1.02, 2.36) and those age 55 and older who had been homeless 1 year or less (RR = 1.83, 95% CI = 1.33, 2.52). Similar, but nonsignificant trends were observed in cohort members who had been homeless more than 1 year at baseline. Additionally, medical problems at baseline and history of prior hospitalization for alcohol problems elevated mortality risk. Employment at baseline and minority group membership reduced mortality risk. The study suggests that mentally ill veterans served by specialized VA mental health programs are at elevated risk of mortality, relative to the general population. Homelessness increases this risk, particularly in older veterans, and this difference does not abate after entry into a health care system.

The delivery of mental health services in the 21st century: bringing the community back in

The community mental health movement of the 1960s enjoyed widespread public support but poorly served its intended target population of seriously mentally ill individuals because: (1) its professional values and technology were, at least initially, not well-oriented toward serving people with severe mental illness; (2) organizational structures linking Community Mental Health Centers with State Mental Health Agencies, State Hospitals, and other relevant service agencies were lacking; (3) ideologically driven aspirations diverted energies and resources into diffuse goals related to the achievement of social justice; and (4) performance objectives were not operationally defined or monitored. Since that time professional technologies and organizational linkages have substantially improved, but there has been a loss of public support for safety net services for the least well off, in part due to a general ascendence of individualist market values, declining civic engagement and reduced support for specialized services for the disadvantaged. A new community mental health movement would be less oriented towards stimulating broad community change, and more narrowly focused on building support among decision makers and the public at large to expand the availability of costly but effective and improved services for people with severe and persistent mental illness.

Changing patterns of care for war-related post-traumatic stress disorder at Department of Veterans Affairs medical centers: the use of performance data to guide program development

This study traces the development of services for war-related post-traumatic stress disorder (PTSD) provided at Department of Veterans Affairs (VA) medical centers. During the 1980s, long-stay inpatient programs were the major source of specialized VA treatment for PTSD, and an initial effort at development of specialized outpatient clinics resulted in incomplete implementation. In 1988, a full continuum of inpatient and outpatient services was designed and a national program of performance monitoring and outcome assessment was implemented to standardize program structure, monitor delivery, and evaluate outcomes. A series of multisite outcome studies showed significant but modest improvement in association with specialized outpatient treatment; they also showed that traditional long-term inpatient programs were no more effective and were far more costly than short-term specialized inpatient programs. Since 1995, the VA has shifted the emphasis of care substantially from inpatient to outpatient settings. National monitoring efforts have documented maintenance of specialized PTSD treatment capacity, increased access, improvement on available administrative measures of quality of care, and improved inpatient outcomes. Although there have been major changes in the treatment of mental illness in most health care systems in recent years, change in the treatment of PTSD at VA medical centers is unique in that it has been guided by the results of multisite outcome studies conducted in a "real-world" setting and has been supported by ongoing nationwide performance monitoring.

Street outreach for homeless persons with serious mental illness: is it effective?

OBJECTIVES

This study examined data on case management clients who are homeless and have a severe mental illness to determine how those contacted through street outreach differ in their socio-demographic characteristics, service needs, and outcomes from those clients contacted in shelters and other health and social service agencies.

METHODS

As part of the Center for Mental Health Services' Access to Community Care and Effective Services and Supports (ACCESS) program, data were obtained from potential clients over the first 3 years of the program at the time of the first outreach contact (n = 11,857), at the time of enrollment in the case management program (n = 5,431), and 3 months after enrollment (n = 4,587).

RESULTS

Clients contacted at outreach on the street, as opposed to being contacted in shelters and service agencies, were generally worse off. They were more likely to be male, to be older, to spend more nights literally homeless before the contact, to have psychotic disorders, and took longer to engage in case management. They expressed less interest in treatment and were less likely to enroll in the case management phase of the project. Subjects contacted on the street who did enroll were more impaired than their street counterparts who did not enroll. Three month outcome data showed that enrolled clients contacted through street outreach showed improvement that was equivalent to those enrolled clients contacted in shelters and other service agencies on nearly all outcome measures.

CONCLUSION

Street outreach to homeless persons with serious mental illness is justified as these clients are more severely impaired, have more basic service needs, are less motivated to seek treatment, and take longer to engage than those contacted in other settings. Street outreach is further justified as it engages the most severely impaired among the street population. Street outreach also appears to be effective as the clients reached in this way showed improvement equal to that of other clients in most outcome domains when baseline differences were taken into account.

Shifting to outpatient care? Mental health care use and cost under private insurance

OBJECTIVE

Concern over rising health care costs has put pressure on providers to reduce costs, purportedly by reducing inpatient care and increasing outpatient care.

METHOD

Inpatient and outpatient claims were analyzed for adult users of mental health services (180,000/year on average) from a national study group of 3.9 million privately insured individuals per year from 1993 to 1995. Costs and treatment days per patient were compared across diagnostic groups and stratified by whether patients were hospitalized.

RESULTS

Inpatient mental health costs fell $2,507 (30.4%) over the period, driven primarily by decreases in hospital days per patient per year (19.9%), with smaller changes in the proportion of enrollees who received inpatient care (increase of 0.8%) and a decrease in per diem costs (9.1%). Outpatient mental health costs also declined over the period, falling 13.6% for patients also using inpatient services and 14.6% for patients receiving only outpatient care. Patients whose primary diagnosis was mild to moderate depression saw the largest decreases in inpatient cost per patient (42.8%); those diagnosed with schizophrenia experienced the smallest decrease (23.5%). For patients using outpatient services only, those diagnosed with substance abuse experienced the largest decrease in costs (23.5%); those diagnosed with schizophrenia experienced the smallest decrease (8.6%).

CONCLUSIONS

Substantial cost reductions for mental health services are primarily a result of reductions in inpatient and outpatient treatment days. Declines in inpatient service use were not accompanied by increases in outpatient service use, even for severely ill patients requiring hospitalization. Managed care has not caused a shift in the pattern of care but an overall reduction of care.

Analysis of violent behavior in Vietnam combat veteran psychiatric inpatients with posttraumatic stress disorder

This study tested the hypothesis that male Vietnam veterans seeking inpatient treatment for PTSD (n = 228) exhibit more violent behavior compared with a mixed diagnostic group of male psychiatric inpatients without PTSD (n = 64) and a community sample of Vietnam veterans with PTSD not undergoing inpatient treatment (n = 273). Violent acts assessed included property destruction, threats without a weapon, physical fighting, and threats with a weapon. PTSD inpatients engaged in more types of violent behavior than both comparison conditions. Correlates of violence among PTSD inpatients included PTSD symptom severity and, to a lesser degree, measures of substance abuse. These findings justify routine assessment of violent behavior among inpatient with PTSD, as well as application of specialized interventions for anger dyscontrol and aggression.

Burden experienced by care-givers of persons with bipolar affective disorder

BACKGROUND

Family members of patients with schizophrenia frequently report burdens associated with caring for their relatives.

AIMS

We evaluate the impact of illness beliefs on the burden reported by family care-givers of people with bipolar illness.

METHOD

The multivariate relationships between patient symptomatology and family illness beliefs and report of burden were examined at baseline among care-givers of 266 patients with Research Diagnostic Criteria-diagnosed bipolar illness who were subsequently followed for 15 months.

RESULTS

At baseline, 93% of care-givers reported moderate or greater distress in at least one burden domain. As a group, care-giver illness beliefs (illness awareness, perception of patient and family control) explained an additional 18-28% of variance in burden experienced beyond the effects of the patient's clinical state and history.

CONCLUSIONS

Care-givers of patients with bipolar illness report widespread burden that is influenced by beliefs about the illness.

Cost-effectiveness of clozapine in patients with high and low levels of hospital use. Department of Veterans Affairs Cooperative Study Group on Clozapine in Refractory Schizophrenia

BACKGROUND

This study examined the relationship between pretreatment hospital use and the cost-effectiveness of clozapine in the treatment of refractory schizophrenia.

METHODS

Data from a 15-site randomized clinical trial were used to compare clozapine with haloperidol in hospitalized Veterans Affairs patients with refractory schizophrenia (n = 423). Outcomes were compared among those with many days in the hospital use (hereafter, high hospital users) (n = 141; mean = 215 psychiatric hospital days in the year prior to study entry) and those with few days in the hospital use (hereafter, low hospital users) (n = 282; mean = 58 hospital days). Analyses were conducted with the full intention-to-treat sample (n = 423) and with crossovers excluded (n = 291).

RESULTS

Clozapine treatment resulted in greater reduction in hospital use among high hospital users (35 days less than controls, P = .02) than among low users (21 days less than controls, P = .05). Patients taking clozapine also had lower health care costs; after including the costs of both medications and other health services, costs were $7134 less than for controls among high hospital users (P = .14) but only $759 less than for controls among low hospital users (P = .82). Clinical improvement in the domains of symptoms, quality of life, extrapyramidal symptoms, and a synthetic measure of multiple outcomes favored clozapine in both high and low hospital user groups.

CONCLUSIONS

Substantial 1-year cost savings with clozapine are observed only among patients with very high hospital use prior to initiation of treatment while clinical benefits are more similar across groups. Cost-effectiveness evaluations, and particularly studies of expensive treatments, cannot be generalized across type of use groups.

Changes in inpatient mental health utilization and costs in a privately insured population, 1993 to 1995

BACKGROUND

Concerns over rising health care costs have led to pressure on health care providers to reduce inpatient costs.

METHODS

Inpatient claims data were analyzed for adult users of mental health services (n = 45,579) from a national sample of over 3.8 million privately insured individuals between 1993 and 1995 from the MarketScan database. Costs and annual hospital days per treated patient were compared across diagnostic groups and plan types.

RESULTS

Inpatient mental health costs fell 30.5% over the period, driven primarily by decreases in the number of hospital days per treated patient per year (-20.0%), with smaller changes in the proportion of enrollees who received care (-0.2%), and per diem costs (-13.1%). Patients whose primary diagnosis was mild/moderate depression saw the largest decrease in costs per treated patient (44.5%), and those diagnosed with schizophrenia experienced the smallest decrease (23.5%). There was no evidence of substitution of medical for psychiatric care.

CONCLUSIONS

Inpatient cost reductions have been substantial and are primarily caused by reductions in the number of inpatient mental health treatment days per treated patient. Further research is needed to evaluate the impact of these changes on outcome, quality of care, and patient satisfaction.

Interrater reliability levels of multiple clinical examiners in the evaluation of a schizophrenic patient: quality of life, level of functioning, and neuropsychological symptomatology

Sir Ronald Fisher used a single-subject design to derive the concepts of appropriate research design, randomization, sensitivity, and tests of statistical significance. The seminal work of Broca demonstrated that valid and generalizable findings can and have emerged from studies of a single patient in neuropsychology. In order to assess the reliability and/or validity of any clinical phenomena that derive from single subject research, it becomes necessary to apply appropriate biostatistical methodology. The authors develop just such an approach and apply it successfully to the evaluation of the functioning, quality of life, and neuropsychological symptomatology of a single schizophrenic patient.

Residential treatment for dually diagnosed homeless veterans: a comparison of program types

This study compared two types of residential programs that treat dually diagnosed homeless veterans. Programs specializing in the treatment of substance abuse disorders (SA) and those programs addressing both psychiatric disorders and substance abuse problems within the same setting (DDX) were compared on (1) program characteristics, (2) clients' perceived environment, and (3) outcomes of treatment. The study was based on surveys and discharge reports from residential treatment facilities that were under contract to the Department of Veterans Affairs Health Care for Homeless Veterans program, a national outreach and case management program operating at 71 sites across the nation. Program characteristics surveys were completed by program administrators, perceived environment surveys were completed by veterans in treatment, and discharge reports were completed by VA case managers. DDX programs were characterized by lower expectations for functioning, more acceptance of problem behavior, and more accommodation for choice and privacy, relative to SA programs after adjusting for baseline differences. Dually diagnosed veterans in DDX programs perceived these programs as less controlling than SA programs, but also as having lower involvement and less practical and personal problem orientations. At discharge, a lower percentage of veterans from DDX than SA programs left without staff consultation. A higher percentage of veterans from DDX than SA programs were discharged to community housing rather than to further institutional treatment. Program effects were not different for psychotic and non-psychotic veterans. Although differences were modest, integration of substance abuse and psychiatric treatment may promote a faster return to community living for dually diagnosed homeless veterans. Such integration did not differentially benefit dually diagnosed veterans whose psychiatric problems included a psychotic disorder.