Preventive health care for mentally ill women

Utilization of preventive medical care was compared for two low-income groups--47 women with serious mental illness in an urban mental health center and 17 women patients at a primary care center. Appropriate preventive care was defined as at least one physical examination, a Pap test, and a breast examination in the past five years and a mammogram if the patient was over age 40. Receipt of preventive care by women in both settings was similar. Histories of physical and sexual abuse were prevalent in both groups, and a history of abuse was associated with less frequent receipt of preventive care. Results indicate that procedures to identify and provide services to women with abuse histories should be further developed.

Intersite variation in the impact of intensive psychiatric community care on hospital use

Differences among treatment facilities in effectiveness of intensive psychiatric community care (IPCC) for reducing hospital dependence are examined. Experimental data from nine VA hospitals showed IPCC to be most effective where former orientation to inpatient care was changing to improved accessibility of outpatient services. These hospitals appeared to have the greatest need for community care programs and to be most committed to shifting their system of service delivery.

Effects of compensation-seeking on treatment outcomes among veterans with posttraumatic stress disorder

The desire to acquire or increase financial compensation for a psychiatric disability is widely believed to introduce a response bias into patients' reports of their symptoms and their work performance. The hypothesized effects of compensation-seeking in inhibiting improvement from treatment are examined. Data from outpatient (N = 455) and inpatient (N = 553) programs for the treatment of posttraumatic stress disorder and associated disorders in the Department of Veterans Affairs were used to compare outcomes for veterans who were and were not seeking compensation. Outcome was measured as pre/post improvement in symptoms and work performance over the course of 1 year after the initiation of treatment. No compensation-seeking effect was observed among outpatients, but a significant effect was found for some inpatients. The effect for inpatients was manifested essentially by patients in a program type which was designed to have an extremely long length of stay, thus triggering a virtually automatic increase in payments. Like outpatients, inpatients in programs with a moderate length of stay did not manifest a compensation-seeking effect on improvement. Although not permitting a definitive explanation, the preponderance of the evidence favors the overstatement of symptoms rather than either the severity or the chronicity of the disorder as the most likely explanation for the compensation-seeking effect that was observed. For patients treated in standard outpatient and short-stay inpatient programs, compensation does not seem to affect clinical outcomes adversely.

Access to public mental health services: determinants of population coverage

OBJECTIVES

This study examined factors that affect access to Veterans Administration mental health services.

METHODS

Data from national Veterans Affairs databases and the 1990 Decennial Census were used to estimate rates of Veterans Affairs mental health service use in each US county (n = 3,156) among all US veterans and in three subpopulations defined by eligibility and clinical status. Independent variables examined in standard multivariate analyses and using hierarchical linear modeling techniques included county-level sociodemographic characteristics (age, race, and income); "unmanaged" service system characteristics (those not directly controlled by Veterans Affairs program managers, eg, distance from residence to Veterans Affairs and to non-Veterans Affairs services, local supply of non-Veterans Affairs services); and "managed" service system factors (those directly controlled by Veterans Affairs program managers, eg, per capita Veterans Affairs funding level and the efficiency of Veterans Affairs service delivery).

RESULTS

Altogether, 2.0% of US veterans used Veterans Affairs mental health services. More than one third (36%) of the variance in utilization was explained by sociodemographic factors; 8% was explained by unmanaged service system factors and 7% was explained by managed service system factors, with variations among subgroups. Substitution effects were demonstrated between Veterans Affairs and non-Veterans Affairs systems and appeared to be diagnosis-specific.

CONCLUSIONS

Both per capita funding levels and efficient service delivery were significantly associated with increased access to mental health services. Implications for health system performance assessment and management are discussed.

Treatment involvement and outcomes for four subtypes of homeless veterans

A longitudinal study examined treatment services and outcomes in a nationwide sample of 565 homeless veterans who were classified as alcoholic, psychiatrically impaired, multiproblem, or best-functioning. All four groups experienced some improvement in their primary problem area, in employment status, and in residential quality at eight-month follow-up, but there were significant differences in degree of improvement across groups. Implications for the design of homeless programs and policies are discussed.

Substance use and psychiatric problems of homeless Native American veterans

OBJECTIVE

This study estimated the proportion and representation of Native Americans among homeless veterans and compared their psychiatric and substance abuse problems with those of other ethnic groups of homeless veterans.

METHODS

The study was based on data from the Department of Veterans Affairs' Health Care for Homeless Veterans program, a national outreach program operating at 71 sites across the country. Alcohol, drug, and psychiatric problems of Native American veterans (N=950) reported during intake assessment were compared with problems reported by white, black, and Hispanic veterans (N=36,938).

RESULTS

Native Americans constituted 1.6 percent of veterans in the program. Age-adjusted analyses suggested that relative to the general veteran population (of which 1.3 percent are Native Americans), Native Americans are overrepresented in the homeless population by approximately 19 percent. Regression analyses controlling for demographic characteristics found that Native American veterans reported more current alcohol abuse, more previous hospitalizations for alcohol dependence, and more days of recent alcohol intoxication than members of other ethnic groups. In contrast, Native American veterans reported fewer drug dependence problems than other minority groups and fewer current psychiatric problems and previous psychiatric hospitalizations than the reference group of white homeless veterans.

CONCLUSIONS

Native Americans are overrepresented in the homeless veteran population. They have more severe alcohol problems than other minority groups but somewhat fewer psychiatric problems.

A mental health program report card: a multidimensional approach to performance monitoring in public sector programs

This report presents a comprehensive, multi-dimensional mental health program performance monitoring system that has recently been implemented in the Department of Veterans Affairs. Principles underlying the development of the system are reviewed and 68 specific monitors are described addressing four major performance domains: access, inpatient care, outpatient care, and economic performance. Simple methods are presented for identifying outliers, for generating summary performance scores across series' of related monitors, and for adjusting results for differences in patient characteristics across locales. Although still technically imperfect, and therefore requiring continuous improvement, monitoring systems such as the one presented can be useful tools guiding and improving service delivery and mental health system performance, and providing a medium of accountability to consumers and other stakeholders.

Compliance with medication regimens for mental and physical disorders

OBJECTIVE

The authors reviewed research on medication compliance in psychiatric treatment and compared compliance rates with compliance rates in treatment of physical disorders.

METHODS

MEDLINE was used to locate reports in the literature on medication compliance in psychiatric treatment for the years 1975 through 1996. These reports and studies cited in the reports were reviewed to determine the methods used to assess compliance and the compliance rates reported. Ten reports describing assessment methods and including medication compliance rates for antidepressant medication and 24 reports for antipsychotic medication were selected. They were compared with 12 reports that used microelectronic monitoring to assess medication compliance of patients with a range of nonpsychiatric disorders.

RESULTS

Studies of psychiatric patients used various methods of estimating medication compliance, including interviews with patients, clinicians' judgment, and pill counts, but overall showed low rates of compliance. Patients receiving antipsychotics took an average of 58 percent of the recommended amount of the medications, with a range from 24 to 90 percent. Patients receiving antidepressants took 65 percent of the recommended amount, with a range from 40 to 90 percent. The mean compliance rate for patients with physical disorders was 76 percent, with a range from 60 to 92 percent, although the microelectronic monitoring showed frequent omission of doses and discontinuation of medication.

CONCLUSIONS

Compliance with medication regimens among patients with psychiatric disorders may be lower than among patients with physical disorders. However, the difference may be largely attributable to the methods used for estimating compliance. The findings suggest the need for new and improved methods for monitoring compliance and increasing patients' compliance with pharmacotherapy.

Influence of patient and hospital factors on consumer satisfaction with inpatient mental health treatment

OBJECTIVE

This study examines patient- and facility-related determinants of satisfaction with inpatient mental health services.

METHODS

A random sample of veterans discharged from Department of Veterans Affairs inpatient units with primary diagnoses of a psychiatric or substance use disorder (N = 13,574) were mailed a 73-item questionnaire that addressed aspects of their recent hospital experience. Multiple regression analysis was used to evaluate the relationship between patient and hospital characteristics and both the likelihood of responding to the survey and aspects of satisfaction measured by 14 subscales.

RESULTS

A total of 4,968 veterans, or 37 percent, mailed back responses to the questionnaire. Respondents were older than nonrespondents and were more likely to be white and married and to have nonpsychotic disorders other than substance use disorders. The strongest and most consistent predictors of satisfaction were older age and better self-reported health. Longer length of stay was also associated with greater satisfaction on a majority of subscales. Findings among female and minority veterans were mixed across measures. Large facilities and facilities that specialize in mental health treatment had lower levels of satisfaction than others. Patient characteristics accounted for more of the variance in satisfaction than did facility characteristics.

CONCLUSIONS

Older and healthier patients reported greater satisfaction with mental health care services. Accurate comparison of patient satisfaction between facilities requires that adjustments be made for differences in patient characteristics. Large facilities may need to make special efforts to personalize their services.

Social support and psychopathology in the war zone

Unit cohesion and homecoming support are examined for their protective effects on the development of posttraumatic stress disorder (PTSD) and other psychopathology. Data on 1198 male theater veterans were taken from the National Vietnam Veterans Readjustment Study. Unit cohesion had no significant relationship, as a direct effect, to either PTSD or other psychopathology. In a pattern that was opposite to predictions from the buffering hypothesis of support, however, a high level of unit cohesion in combination with high war zone stress was associated with the highest levels of PTSD and psychopathology. This is consistent with Israeli experiences, suggesting that unit cohesion may have detrimental long-term effects on psychological well-being. In contrast, homecoming support was related negatively as a direct effect to both PTSD and other psychopathology. In addition, interaction results, consistent with the buffering hypothesis, suggest that the protective effects of homecoming support are magnified for veterans with high compared with low levels of exposure.

Homeless mentally ill veterans: race, service use, and treatment outcomes

Comparisons of service use and treatment outcomes for 145 black and 236 white homeless veterans with mental disorders showed few differences. A greater improvement in psychiatric symptoms and alcohol problems among white than black veterans did not hold true when black veterans had participated in the residential treatment component of the program. The implications of the findings for the successful treatment of homeless black veterans are discussed.

Individual and community-level variation in intensity and diversity of service utilization by homeless persons with serious mental illness

This study examines individual client- and community-level sources of variation in service use among clients entering 18 community treatment programs for homeless mentally ill persons as part of a national demonstration project. Assessment data on 1,828 clients were used to evaluate the relationship of a) individual client characteristics and b) site of entry, to both the intensity and diversity of service use. Hierarchical multiple regression was used to identify the relative importance of client characteristics and site of entry. Client characteristics explained only 2% to 3% of the variance in service use. Inter-site variation accounted for 2 to 3 times as much of the variance. Inter-site differences account for substantially more of the variance in service use among homeless persons with mental illness than individual client characteristics. Further studies are needed to identify specific community-level factors that account for these variations.

A comparison of clozapine and haloperidol in hospitalized patients with refractory schizophrenia. Department of Veterans Affairs Cooperative Study Group on Clozapine in Refractory Schizophrenia

BACKGROUND

Clozapine, a relatively expensive antipsychotic drug, is widely used to treat patients with refractory schizophrenia. It has a low incidence of extrapyramidal side effects but may cause agranulocytosis. There have been no long-term assessments of its effect on symptoms, social functioning, and the use and cost of health care.

METHODS

We conducted a randomized, one-year, double-blind comparative study of clozapine (in 205 patients) and haloperidol (in 218 patients) at 15 Veterans Affairs medical centers. All participants had refractory schizophrenia and had been hospitalized for the disease for 30 to 364 days in the previous year. All patients received case-management and social-rehabilitation services, as clinically indicated.

RESULTS

In the clozapine group, 117 patients (57 percent) continued their assigned treatment for the entire year, as compared with 61 (28 percent) of the patients in the haloperidol group (P<0.001). As judged according to the Positive and Negative Syndrome Scale of Schizophrenia, patients in the clozapine group had 5.4 percent lower symptom levels than those in the haloperidol group at all follow-up evaluations (mean score, 79.1 vs. 83.6; P=0.02). The differences on a quality-of-life scale were not significant in the intention-to-treat analysis, but they were significant among patients who did not cross over to the other treatment (P=0.003). Over a one-year period, patients assigned to clozapine had fewer mean days of hospitalization for psychiatric reasons than patients assigned to haloperidol (143.8 vs. 168.1 days, P=0.03) and used more outpatient services (133.6 vs. 97.9 units of service, P=0.03). The total per capita costs to society were high -- $58,151 in the clozapine group and $60,885 in the haloperidol group (P=0.41). The per capita costs of antipsychotic drugs were $3,199 in the clozapine group and $367 in the haloperidol group (P<0.001). Patients assigned to clozapine had less tardive dyskinesia and fewer extrapyramidal side effects. Agranulocytosis developed in three patients in the clozapine group; all recovered fully.

CONCLUSIONS

For patients with refractory schizophrenia and high levels of hospital use, clozapine was somewhat more effective than haloperidol and had fewer side effects and similar overall costs.

A new method for assessing interexaminer agreement when multiple ratings are made on a single subject: applications to the assessment of neuropsychiatric symtomatology

A new method is introduced for assessing levels of interexaminer agreement when multiple ratings are made on a single subject, with an application in psychiatric research. It is designed to provide an overall level of interexaminer agreement and separate indices of agreement for each examiner. These indices are based on biostatistical and clinical criteria to determine whether the ratings of any given examiner are appreciably higher or lower than the group average, or a consensus diagnosis. A number of examples, from ongoing psychiatric research, are provided to illustrate conditions favoring the application of the new methodology. Finally, the necessary software for performing the analyses is available to clinical investigators with interest in this area of assessment.

Inpatient treatment of war-related posttraumatic stress disorder: a 20-year perspective

These papers show that long-stay inpatient PTSD programs provide treatment that is quite different from other programs but that they are neither as effective, from a psychometric perspective, nor as helpful, from the veterans' subjective perspective, as has been expected. VA treatment of PTSD is changing its focus and is being influenced by three distinct societal forces, in addition to data from studies like these: (1) the continuing effort of American society to come to terms with its Vietnam War experience; (2) the crisis of U.S. health care costs; and (3) the emergence of a movement to "re-invent" government and to increase public accountability through performance data.

Effectiveness of treatment elements in a residential-work therapy program for veterans with severe substance abuse

OBJECTIVE

This study evaluated outcomes of a residential-work therapy program for veterans with chronic, severe substance use disorders.

METHODS

Admission and three-month outcome data were gathered for 496 veterans treated in the Department of Veterans Affairs' Compensated Work Therapy-Transitional Residence program. Multivariate techniques were used to assess the relationship between admission risk factors, treatment elements, and outcome measures.

RESULTS

Substantial improvement was observed in substance abuse and most other outcome domains, with 65 percent of the sample reporting no substance use during the three months after discharge. The most powerful baseline prognostic factors were functional status and frequency of social contact. Of 14 significant relationships observed between the intensity of treatment elements and outcomes, 12 were in the expected direction, associating more intensive treatment with improvement. The largest number of significant relationships with outcome were observed for weekly toxicology screens, earnings, and length of stay.

CONCLUSIONS

The study results support the effectiveness of a rehabilitative approach to the treatment of severe substance abuse that combines residential support with demands for responsible behavior.

Assessing the structure, content, and perceived social climate of residential posttraumatic stress disorder treatment programs

This study utilized a comprehensive assessment of program structure, content, and social climate to determine whether specialized residential posttraumatic stress disorder (PTSD) programs (SIPUs, n = 19) can be differentiated from general psychiatric units (GPUs, n = 18) within the Department of Veterans Affairs. Significant differences between program types were found: SIPUs were more clearly differentiated from the larger hospital system, had more strict patient selection criteria and program regulations, longer length of stays and lower admission rates, and spent more program time on PTSD symptoms and war zone experiences than GPUs. Veterans in the SIPUs (n = 453) rated the programs significantly higher on most social climate measures than veterans with PTSD in the GPUs (n = 153), indicating that veterans perceived these programs as more active, supportive, and better structured.

Effectiveness and cost of the inpatient treatment of posttraumatic stress disorder: comparison of three models of treatment

OBJECTIVE

This study compared the outcomes and costs of three models of Department of Veterans Affairs (VA) inpatient treatment for posttraumatic stress disorder (PTSD): 1) long-stay specialized inpatient PTSD units, 2) short-stay specialized evaluation and brief-treatment PTSD units, and 3) nonspecialized general psychiatric units.

METHOD

Data were drawn from 785 Vietnam veterans undergoing treatment at 10 programs across the country. The veterans were followed up at 4-month intervals for 1 year after discharge. Successful data collection averaged 66.1% across the three follow-up intervals.

RESULTS

All models demonstrated improvement at the time of discharge, but during follow-up symptoms and social functioning rebounded toward admission levels, especially among participants who had been treated in long-stay PTSD units. Veterans in the short-stay PTSD units and in the general psychiatric units showed significantly more improvement during follow-up than veterans in the long-stay PTSD units. Greatest satisfaction with their programs was reported by veterans in the short-stay PTSD units. Finally, the long-stay PTSD units proved to be 82.4% and 53.5% more expensive over 1 year than the short-stay PTSD units and general psychiatric units, respectively.

CONCLUSIONS

The paucity of evidence of sustained improvement from costly long-stay specialized inpatient PTSD programs and the indication of high satisfaction and sustained improvement in the far less costly short-stay specialized evaluation and brief-treatment PTSD programs suggest that systematic restructuring of VA inpatient PTSD treatment could result in delivery of effective services to larger numbers of veterans.

Influence of retroactive disability payments on recipients' compliance with substance abuse treatment

OBJECTIVE

This study examined whether substance abusers who received large retroactive payments from Social Security disability programs were more likely to terminate residential treatment precipitously than those who did not receive payments.

METHODS

The records of 43 patients of a long-term residential treatment facility who received disability payments at some point during their treatment stay were blindly examined. Twenty-six of these patients received a large one-time retroactive payment representing money that accumulated during processing of the claims. To test the hypothesis that receipt of such a payment would lead to precipitous discharge, a survival regression model was used. A control group of nonrecipient patients was sampled at a comparable point in treatment.

RESULTS

Subjects in the recipient group were significantly more likely to have unplanned discharges than those in the comparison group.

CONCLUSIONS

These preliminary data suggest that large cash infusions can be disruptive to the course of treatment for substance abusers.

Disability payments and chemical dependence: conflicting values and uncertain effects

Receipt of public support payments by people with substance abuse disorders has been a subject of intense controversy in recent years. Observing that such funds are often used to purchase addictive substances, many critics have questioned whether people with chemical dependencies are entitled to such payments and whether they should be allowed to spend these funds unsupervised. This discussion introduces a special section of five data-based papers on the relation of disability payments to chemical dependence. The papers address five questions: Do public support payments worsen substance abuse in vulnerable populations? Does assignment of a representative payee reduce substance abuse among such beneficiaries? What money management procedures are most likely to yield positive outcomes for clients? How can clients who need payees be fairly identified? And how should skilled, responsible payees or guardians be recruited, trained, and retained? In the absence of scientific data, both clinical practice and social policy are vulnerable to the whims of public opinion. These papers shed new light on a heated area of policy debate.

The relationship of public support payments to substance abuse among homeless veterans with mental illness

OBJECTIVE

A suspicion that disability payments may exacerbate substance use among persons with chemical addictions recently led Congress to limit federal disability entitlements of applicants whose disability status is related to substance abuse, even if they have another serious mental disorder. This study empirically explored the relationship between receipt of disability payments and substance use among homeless mentally ill veterans.

METHODS

The study sample included 2,474 homeless veterans with a current diagnosis of schizophrenia and a substance abuse or dependence disorder who were assessed in a community outreach program sponsored by the Department of Veterans Affairs.

RESULTS

After adjustment for other relevant factors, receipt of disability payments showed no significant relationship to the number of days of substance use a month, even among frequent users of alcohol and drugs.

CONCLUSIONS

Findings about substance use among the homeless veterans with serious mental disorders in this study provide no support for the assertion that disability payments exacerbate substance use.

Impact of representative payees on substance use by homeless persons with serious mental illness

OBJECTIVE

Assignment of representative payees, third parties responsible for managing clients' funds, has been proposed to counter potential use of public support payments for abused substances by people with severe mental illness and substance use disorders. This study examines substance use outcomes in a sample of homeless persons with serious mental illness and substance use disorders, some of whom were assigned representative payees.

METHODS

The subjects were participating in the Access to Community Care and Effective Services and Supports (ACCESS) program, a federally funded demonstration program on integrating service systems. Clients were assessed at baseline and three months after case management services were initiated. Factorial repeated-measures analysis of covariance was used to examine substance use among four client subgroups, two of which had payees and two of which did not.

RESULTS

Clients in this sample (N = 1,348) showed significant improvement on all measures of substance use over the first three months in the program. Those with payees showed no greater improvement in substance abuse than those without payees, although they did have fewer days of homelessness.

CONCLUSIONS

This study failed to find evidence that merely adding external money management services to existing services improves substance abuse outcomes among clients who had dual diagnoses and were homeless. Besides assigning a payee, structured behavioral interventions may be needed to produce additional clinical benefits.

The impact of the homecoming reception on the development of posttraumatic stress disorder. The West Haven Homecoming Stress Scale (WHHSS)

This study reports on the development of a self-report measure of the homecoming experience among Vietnam veterans with posttraumatic stress disorder (PTSD). The West Haven Homecoming Stress Scale (WHHSS), measuring Frequency of Events, Intensity of Feelings, and Level of Support during the first 6 months after return from overseas, and within the past 6 months, was collected from 247 veterans who were receiving inpatient treatment for PTSD. Homecoming Stress was the most significant predictor of current PTSD symptomatology superseding combat exposure, childhood and civilian traumas, and stressful life events. A factor analysis resulted in four orthogonal factors: Shame, Negative Interpersonal Interaction, Social Withdrawal, and Resentment. Homecoming Stress was unchanged over the course of a 4 month inpatient program.

Client and site characteristics as barriers to service use by homeless persons with serious mental illness

Clients entering the Access to Community Care and Effective Services and Supports (ACCESS) program for homeless mentally ill persons in 18 U.S. communities identified barriers to service use. The most frequent barrier was not knowing where to go for a service (encountered by 32.4 percent of the 1,828 clients). It was followed by not being able to afford it (29.5 percent); experiencing too much confusion, hassle, or waiting to obtain it (27.1 percent); and having been previously denied the service (16.5 percent). Differences in the program site (that is, the 18 communities) explained two to three times more of the variance in encountering barriers use than did individual client characteristics.