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Gal G, Levav I, Kodesh A. Impact of the mental health reform in Israel on health care and mortality among people with severe mental illness. Soc Psychiatry Psychiatr Epidemiol 2024; 59:1227-1234. [PMID: 37831080 DOI: 10.1007/s00127-023-02580-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 09/28/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE Reports show disparities in the health care of people with severe mental illness (SMI). Yet, the moderating effect of mental health reforms on the health care disparities remain unexplored. The current study aimed to investigate the outcomes of the mental health reform in Israel on the use of health services among people with SMI. METHOD A case-control epidemiological study comparing the use of health services 3.5 years before and after the mental health reform for service users diagnosed with schizophrenia, schizoaffective disorder, and bipolar disorder. Data on health services included: blood cholesterol test (LDL), hemogalobin-A1C test, and visits to general practitioners (GPs) and specialists. Mortality was recorded. RESULTS Following the reform the number of visits to GPs was decreased among service users of the three SMI groups, as well as visits to specialists among service users with a schizoaffective or bipolar disorder. Following the reform service users of the three SMI groups showed no-change in the performance of LDL test. Complex findings were noted with regard to the performance of Hemoglobin-A1C test. Mortality rates were higher among service users with SMI and the relative risk were similar before and after the reform. CONCLUSIONS Users of the three SMI groups showed no benefits of the mental health reform in terms of use of health services. Improved health care can be attained by a closer collaboration between the primary physicians and community mental health services.
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Affiliation(s)
- Gilad Gal
- School of Psychology, The Academic College of Tel Aviv-Yaffo, Tel Aviv, Israel.
| | - Itzhak Levav
- Department of Community Mental Health, University of Haifa, Haifa, Israel
| | - Arad Kodesh
- Department of Community Mental Health, University of Haifa, Haifa, Israel
- Department of Mental Health, Meuhedet Health Services, Tel Aviv, Israel
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Jaske E, Wheat CL, Rubenstein LV, Leung L, Curtis I, Wahlberg L, Felker B. Understanding How Contingency Staffing Programs Can Support Mental Health Services in the Veterans Health Administration. Telemed J E Health 2024; 30:1857-1865. [PMID: 38563753 DOI: 10.1089/tmj.2023.0573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
Introduction: Beginning in 2019, the Department of Veterans Affairs (VA) prioritized improving access to care nationally to deliver virtual care and implemented 18 regionally based Clinical Resource Hubs (CRHs) to meet this priority. This observational study describes the quantity and types of care delivered by CRH Mental Health teams, and the professions of those hired to deliver it. Methods: A retrospective cohort study, based on national VA CRH mental health care utilization data and CRH staffing data for CRH's first 3 years, was conducted. Results: CRH Mental Health teams primarily used Telemental Health (TMH) to provide care (98.1% of all CRH MH encounters). The most common disorders treated included depression, post-traumatic stress disorder, and anxiety disorders. The amount of care delivered overtime steadily increased as did the racial and ethnic diversity of Veterans served. Psychologists accounted for the largest share of CRH staffing, followed by psychiatrists. Conclusions: CRH TMH delivered from a regional hub appears to be a feasible and acceptable visit modality, based on the continuously increasing CRH TMH visit rates. Our results showed that CRH TMH was predominantly used to address common mental health diagnoses, rather than serious mental illnesses. Traditionally marginalized patient populations increased over the 3-year window, suggesting that CRH TMH resources were accessible to many of these patients. Future research should assess barriers and facilitators for accessing CRH TMH, especially for difficult-to-service patient populations, and should consider whether similar results to ours occur when regional TMH is delivered to non-VA patient populations.
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Affiliation(s)
- Erin Jaske
- VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, Washington, USA
- Primary Care Analytics Team, Department of Veterans Affairs, Seattle, Washington, USA
| | - Chelle L Wheat
- VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, Washington, USA
- Primary Care Analytics Team, Department of Veterans Affairs, Seattle, Washington, USA
| | - Lisa V Rubenstein
- Center for the Study of Health care Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Health Care System, Department of Veterans Affairs, Los Angeles, California, USA
- Division of General Internal Medicine-Health Services Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Evidence-Based Practice Center, RAND Corporation, Santa Monica, CA, USA
| | - Lucinda Leung
- Center for the Study of Health care Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Health Care System, Department of Veterans Affairs, Los Angeles, California, USA
- Division of General Internal Medicine-Health Services Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Idamay Curtis
- VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, Washington, USA
- Primary Care Analytics Team, Department of Veterans Affairs, Seattle, Washington, USA
| | - Lawrence Wahlberg
- Department of Veterans Affairs, National Clinical Resource Hub, VA Central Office, Washington, District of Columbia, USA
- Department of Psychiatry, School of Medicine, University of Colorado Denver, Aurora, Colorado, USA
| | - Bradford Felker
- VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, Washington, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington Medical School, Seattle, Washington, USA
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Rao M, Greene L, Nelson K, Maciejewski ML, Zulman DM. Associations Between Social Risks and Primary Care Utilization Among Medically Complex Veterans. J Gen Intern Med 2023; 38:3339-3347. [PMID: 37369890 PMCID: PMC10682359 DOI: 10.1007/s11606-023-08269-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Social risks contribute to poor health outcomes, especially for patients with complex medical needs. These same risks may impact access to primary care services. OBJECTIVE To study associations between social risks and primary care utilization among patients with medical complexity. DESIGN Prospective cohort study of respondents to a 2018 mailed survey, followed up to 2 years after survey completion. PARTICIPANTS Nationally representative sample of 10,000 primary care patients in the Veterans Affairs (VA) health care system, with high (≥ 75th percentile) 1-year risk of hospitalization or death. MAIN MEASURES Survey-based exposures were low social support, no family member/friend involved in health care, unemployment, transportation problem, food insecurity, medication insecurity, financial strain, low medical literacy, and less than high school graduate. Electronic health record-based outcomes were number of primary care provider (PCP) encounters, number of primary care team encounters (PCP, nurse, clinical pharmacist, and social worker), and having ≥ 1 social work encounter. KEY RESULTS Among 4680 respondents, mean age was 70.3, 93.7% were male, 71.8% White non-Hispanic, and 15.8% Black non-Hispanic. Unemployment was associated with fewer PCP and primary care team encounters (incident rate ratio 0.77, 95% CI 0.65-0.91; p = 0.002 and 0.75, 0.59-0.95; p = 0.02, respectively), and low medical literacy was associated with more primary care team encounters (1.17, 1.05-1.32; p = 0.006). Among those with one or more social risks, 18.4% had ≥ 1 social work encounter. Low medical literacy (OR 1.95, 95% CI 1.45-2.61; p < 0.001), transportation problem (1.42, 1.10-1.83; p = 0.007), and low social support (1.31, 1.06-1.63; p = 0.01) were associated with higher odds of ≥ 1 social work encounter. CONCLUSIONS We found few differences in PCP and primary care team utilization among medically complex VA patients by social risk. However, social work use was low, despite its central role in addressing social risks. More work is needed to understand barriers to social work utilization.
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Affiliation(s)
- Mayuree Rao
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.
- General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA.
| | - Liberty Greene
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Karin Nelson
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - Matthew L Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Donna M Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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Mouchabac S, Adrien V, Falala-Séchet C, Bonnot O, Maatoug R, Millet B, Peretti CS, Bourla A, Ferreri F. Psychiatric Advance Directives and Artificial Intelligence: A Conceptual Framework for Theoretical and Ethical Principles. Front Psychiatry 2021; 11:622506. [PMID: 33551883 PMCID: PMC7862130 DOI: 10.3389/fpsyt.2020.622506] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 12/16/2020] [Indexed: 01/19/2023] Open
Abstract
The patient's decision-making abilities are often altered in psychiatric disorders. The legal framework of psychiatric advance directives (PADs) has been made to provide care to patients in these situations while respecting their free and informed consent. The implementation of artificial intelligence (AI) within Clinical Decision Support Systems (CDSS) may result in improvements for complex decisions that are often made in situations covered by PADs. Still, it raises theoretical and ethical issues this paper aims to address. First, it goes through every level of possible intervention of AI in the PAD drafting process, beginning with what data sources it could access and if its data processing competencies should be limited, then treating of the opportune moments it should be used and its place in the contractual relationship between each party (patient, caregivers, and trusted person). Second, it focuses on ethical principles and how these principles, whether they are medical principles (autonomy, beneficence, non-maleficence, justice) applied to AI or AI principles (loyalty and vigilance) applied to medicine, should be taken into account in the future of the PAD drafting process. Some general guidelines are proposed in conclusion: AI must remain a decision support system as a partner of each party of the PAD contract; patients should be able to choose a personalized type of AI intervention or no AI intervention at all; they should stay informed, i.e., understand the functioning and relevance of AI thanks to educational programs; finally, a committee should be created for ensuring the principle of vigilance by auditing these new tools in terms of successes, failures, security, and relevance.
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Affiliation(s)
- Stéphane Mouchabac
- Sorbonne Université, AP-HP Department of Psychiatry, Hôpital Saint-Antoine, Paris, France
- Sorbonne Université, iCRIN Psychiatry (Infrastructure of Clinical Research In Neurosciences - Psychiatry), Brain and Spine Institute (ICM), INSERM, CNRS, Paris, France
| | - Vladimir Adrien
- Sorbonne Université, AP-HP Department of Psychiatry, Hôpital Saint-Antoine, Paris, France
- Sorbonne Université, iCRIN Psychiatry (Infrastructure of Clinical Research In Neurosciences - Psychiatry), Brain and Spine Institute (ICM), INSERM, CNRS, Paris, France
| | - Clara Falala-Séchet
- Laboratory of Psychopathology and Health Processes, EA 4057, Institute of Psychology, University of Paris, Paris, France
| | - Olivier Bonnot
- CHU de Nantes, Department of Child and Adolescent Psychiatry, Nantes, France
- Pays de la Loire Psychology Laboratory, EA 4638, Nantes, France
| | - Redwan Maatoug
- Sorbonne Université, iCRIN Psychiatry (Infrastructure of Clinical Research In Neurosciences - Psychiatry), Brain and Spine Institute (ICM), INSERM, CNRS, Paris, France
- Sorbonne Université, AP-HP Department of Psychiatry, Hôpital Pitié-Salpêtrière, Paris, France
| | - Bruno Millet
- Sorbonne Université, iCRIN Psychiatry (Infrastructure of Clinical Research In Neurosciences - Psychiatry), Brain and Spine Institute (ICM), INSERM, CNRS, Paris, France
- Sorbonne Université, AP-HP Department of Psychiatry, Hôpital Pitié-Salpêtrière, Paris, France
| | | | - Alexis Bourla
- Sorbonne Université, AP-HP Department of Psychiatry, Hôpital Saint-Antoine, Paris, France
- Jeanne d'Arc Hospital, INICEA Group, Saint-Mandé, France
| | - Florian Ferreri
- Sorbonne Université, AP-HP Department of Psychiatry, Hôpital Saint-Antoine, Paris, France
- Sorbonne Université, iCRIN Psychiatry (Infrastructure of Clinical Research In Neurosciences - Psychiatry), Brain and Spine Institute (ICM), INSERM, CNRS, Paris, France
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Lemogne C, Blacher J, Airagnes G, Hoertel N, Czernichow S, Danchin N, Meneton P, Limosin F, Fiedorowicz JG. Management of Cardiovascular Health in People with Severe Mental Disorders. Curr Cardiol Rep 2021; 23:7. [PMID: 33409804 DOI: 10.1007/s11886-020-01436-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To review evidence regarding the association between bipolar disorder and schizophrenia, henceforth referred to as severe mental disorders (SMD), and cardiovascular morbidity and mortality, its mechanisms, and the interventions to reduce this burden. RECENT FINDINGS Much of the loss in life expectancy in people with SMD remains driven by cardiovascular mortality. Antipsychotics and mood stabilizers are associated with negative cardio-metabolic outcomes, but large inter-individual differences are observed, and not treating SMD might be associated with even greater cardiovascular mortality. Classical modifiable cardiovascular risk factors remained inadequately screened and, once identified, too seldom treated in people with SMD. After a myocardial infarction, aggressive tertiary prevention may be as effective in people with SMD as in the general population but is less prescribed. Reduced healthcare quality and increased prevalence of cardiovascular risk factors may not fully explain the excess cardiovascular mortality associated with SMDs, which themselves should be considered risk factors in risk calculators. Hazardous health behaviors, the cardio-metabolic adverse effects of medications, and a reduced access to quality healthcare remain priority targets for intervention.
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Affiliation(s)
- Cédric Lemogne
- Université de Paris, AP-HP, Hôpital Hôtel-Dieu, DMU Psychiatrie et Addictologie, Service de Psychiatrie de l'adulte, INSERM, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, Paris, France.
| | - Jacques Blacher
- Université de Paris, AP-HP, Hôpital Hôtel-Dieu, Centre de Diagnostic et de Thérapeutique, Paris, France
| | - Guillaume Airagnes
- Université de Paris, AP-HP, Hôpital européen Georges-Pompidou, DMU Psychiatrie et Addictologie, Centre Ambulatoire d'Addictologie, INSERM, UMS 011 Cohortes Epidémiologiques en Population, Paris, France
| | - Nicolas Hoertel
- Université de Paris, AP-HP, Hôpital Corentin-Celton, DMU Psychiatrie et Addictologie, Service de Psychiatrie de l'adulte et du sujet âgé, INSERM, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, Issy-les-Moulineaux, France
| | - Sébastien Czernichow
- Université de Paris, AP-HP, Hôpital européen Georges-Pompidou, Service de Nutrition, Paris, France
| | - Nicolas Danchin
- Université de Paris, AP-HP, Hôpital européen Georges-Pompidou, Service de Cardiologie, Paris, France
| | - Pierre Meneton
- INSERM U1142 LIMICS, UMRS 1142, Sorbonne Universities, UPMC University of Paris 06, University of Paris 13, Paris, France
| | - Frédéric Limosin
- Université de Paris, AP-HP, Hôpital Corentin-Celton, DMU Psychiatrie et Addictologie, Service de Psychiatrie de l'adulte et du sujet âgé, INSERM, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, Issy-les-Moulineaux, France
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Gentil L, Grenier G, Meng X, Fleury MJ. Impact of Co-occurring Mental Disorders and Chronic Physical Illnesses on Frequency of Emergency Department Use and Hospitalization for Mental Health Reasons. Front Psychiatry 2021; 12:735005. [PMID: 34880788 PMCID: PMC8645581 DOI: 10.3389/fpsyt.2021.735005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 11/01/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Patients with mental disorders (MD) are at high risk for a wide range of chronic physical illnesses (CPI), often resulting in greater use of acute care services. This study estimated risk of emergency department (ED) use and hospitalization for mental health (MH) reasons among 678 patients with MD and CPI compared to 1,999 patients with MD only. Methods: Patients visiting one of six Quebec (Canada) ED for MH reasons and at onset of a MD in 2014-15 (index year) were included. Negative binomial models comparing the two groups estimated risk of ED use and hospitalization at 12-month follow-up to index ED visit, controlling for clinical, sociodemographic, and service use variables. Results: Patients with MD, more severe overall clinical conditions and those who received more intensive specialized MH care had higher risks of frequent ED use and hospitalization. Continuity of medical care protected against both ED use and hospitalization, while general practitioner (GP) consultations protected against hospitalization only. Patients aged 65+ had lower risk of ED use, whereas risk of hospitalization was higher for the 45-64- vs. 12-24-year age groups, and for men vs. women. Conclusion: Strategies including assertive community treatment, intensive case management, integrated co-occurring treatment, home treatment, and shared care may improve adequacy of care for patients with MD-CPI, as well as those with MD only whose clinical profiles were severe. Prevention and outreach strategies may also be promoted, especially among men and older age groups.
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Affiliation(s)
- Lia Gentil
- Douglas Mental Health University Institute Research Centre, Montréal, QC, Canada.,Department of Psychiatry, McGill University, Montréal, QC, Canada
| | - Guy Grenier
- Douglas Mental Health University Institute Research Centre, Montréal, QC, Canada
| | - Xiangfei Meng
- Douglas Mental Health University Institute Research Centre, Montréal, QC, Canada.,Department of Psychiatry, McGill University, Montréal, QC, Canada
| | - Marie-Josée Fleury
- Douglas Mental Health University Institute Research Centre, Montréal, QC, Canada.,Department of Psychiatry, McGill University, Montréal, QC, Canada
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Castillejos Anguiano MC, Martín Pérez C, Bordallo Aragón A, Sepúlveda Muñoz J, Moreno Küstner B. Patterns of primary care among persons with schizophrenia: the role of patients, general practitioners and centre factors. Int J Ment Health Syst 2020; 14:82. [PMID: 33292372 PMCID: PMC7653995 DOI: 10.1186/s13033-020-00409-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/26/2020] [Indexed: 11/10/2022] Open
Abstract
Background Patients with schizophrenia and related disorders have more physical problems than the general population. Primary care professionals play an important role in the care of these patients as they are the main entry point into the healthcare system. We aimed to identify patient, general practitioner, and primary care centre factors associated with the number of visits of patients with schizophrenia and related disorders to general practitioners. Methods A descriptive, cross-sectional study was conducted in 13 primary care centres belonging to the Clinical Management Unit of Mental Health of the Regional Hospital of Málaga, Spain. The eligible population was composed of patients with schizophrenia and related disorders attending the primary care centres in the study area, and the general practitioners who attend these patients. Our dependent variable was the total number of general practitioner visits made by patients with schizophrenia and related disorders during the 3.5-year observation period. The independent variables were grouped into three: (a) patient variables (sociodemographic and clinical), (b) general practitioner variables, and (c) primary care centre characteristics. Descriptive, bivariate, and multivariate analyses using the random forest method were performed. Results A total of 259 patients with schizophrenia and related disorders, 96 general practitioners, and 13 primary care centres were included. The annual mean was 3.9 visits per patient. The results showed that younger general practitioners, patients who were women, patients who were married, some primary care centres to which the patient belonged, taking antipsychotic medication, presenting any cardiovascular risk factor, and more frequency of mental health training sessions at the primary care centre were associated with an increased number of visits to general practitioners. Conclusions The only general practitioner variable that was associated with the number of visits was age, the older the less contact. There were also patient variables involved in the number of visits. Finally, mental health training for general practitioners was important for these professionals to manage patients with schizophrenia and related disorders.
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Affiliation(s)
- Mª Carmen Castillejos Anguiano
- Departament of Personality, Assessment and Psychological Treatment, Faculty of Psychology, Andalusian Group of Psychosocial Research (GAP), Biomedical Research Institute of Malaga (IBIMA), University of Malaga, Campus Teatinos, 29071, Malaga, Spain.
| | - Carlos Martín Pérez
- Clinical Management Unit At Marquesado, Andalusian Health Service, Carretera Los Pozos, North East Granada Sanitary District, 18518, AlquifeGranada, Spain
| | - Antonio Bordallo Aragón
- Clinical Management Unit of Mental Health of the Regional Hospital of Malaga, Andalusian Health Service, Paseo Limonar, Malaga, Spain
| | - Jesus Sepúlveda Muñoz
- Alameda-Perchel Basic Primary Care Team, Health District Malaga-Guadalhorce, Andalusian Health Service, Avenida Manuel Agustín Heredia, Malaga, Spain
| | - Berta Moreno Küstner
- Departament of Personality, Assessment and Psychological Treatment, Faculty of Psychology, Andalusian Group of Psychosocial Research (GAP), Biomedical Research Institute of Malaga (IBIMA), University of Malaga, Campus Teatinos, 29071, Malaga, Spain
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Gandré C, Coldefy M. Disparities in the Use of General Somatic Care among Individuals Treated for Severe Mental Disorders and the General Population in France. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17103367. [PMID: 32408658 PMCID: PMC7277621 DOI: 10.3390/ijerph17103367] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 04/30/2020] [Accepted: 05/10/2020] [Indexed: 01/13/2023]
Abstract
Individuals with severe mental illnesses (SMI) face a striking excess and premature mortality which has been demonstrated in several national contexts. This phenomenon, which constitutes a red-flag indicator of public health inequities, can be hypothesized to result from healthcare access issues which have been insufficiently documented so far. In this context, our objective was to explore patterns of general somatic healthcare use of individuals treated for SMI in comparison to those of the general population in France using national health administrative data and a matched case-control study. Differences in the use of general and specific somatic preventive care services, primary care, routine specialized somatic care and admissions to non-psychiatric hospital departments for somatic causes were described between cases and controls after adjustment on differing clinical needs, socio-economic status, and living environment. Our results show a lower use of general preventive care services and of routine specialized somatic care in the SMI population, despite more frequent comorbidities, and a higher occurrence of avoidable hospitalizations, despite higher contacts with primary care physicians. These findings suggest that the health system fails to address the specific needs of this vulnerable population and support the development of measures aimed at reducing this gap.
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Kouyoumdjian F. Attachment to primary care and team-based primary care: Retrospective cohort study of people who experienced imprisonment in Ontario. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2019; 65:e433-e442. [PMID: 31604754 PMCID: PMC6788664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To examine attachment to primary care and team-based primary care in the community for people who experienced imprisonment in Ontario, and to compare these attachment data with data for the general population. DESIGN Population-based retrospective cohort study. SETTING Ontario. PARTICIPANTS All persons released from provincial prison in Ontario to the community in 2010 who were linked with provincial health administrative data, and an age- and sex-matched general population group. MAIN OUTCOME MEASURES Primary care attachment and team-based primary care attachment in the 2 years before admission to provincial prison (baseline) and in the 2 years after release in 2010 (follow-up) for the prison release group, and for the corresponding periods for the general population group. RESULTS People in the prison release group (n = 48 861) were less likely to be attached to primary care compared with the age- and sex-matched general population group (n = 195 444), at 58.9% versus 84.1% at baseline (P < .001) and 63.0% versus 84.4% during follow-up (P < .001), respectively. The difference in attachment to team-based primary care was small in magnitude but statistically significant, at 14.4% versus 16.1% at baseline (P < .001) and 19.9% versus 21.6% during follow-up (P < .001), respectively. CONCLUSION People who experience imprisonment have lower primary care attachment compared with the general population. Efforts should be made to understand barriers and to facilitate access to high-quality primary care for this population, including through initiatives to link people while in prison with primary care in the community.
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Affiliation(s)
- Fiona Kouyoumdjian
- Assistant Professor in the Department of Family Medicine at McMaster University in Hamilton, Ont, Affiliate Scientist at the Centre for Urban Health Solutions at St Michael’s Hospital in Toronto, Ont, and Adjunct Scientist at ICES
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Browne KC, Hoerster KD, Piegari R, Fortney JC, Nelson KN, Post EP, Fihn SD, Mori AM, Trivedi RB. Clinical Care Quality Among Veterans Health Administration Patients With Mental Illness Following Medical Home Implementation. Psychiatr Serv 2019; 70:816-823. [PMID: 31310189 DOI: 10.1176/appi.ps.201800474] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study sought to compare quality of care following medical home implementation among Veterans Health Administration (VHA) primary care patients with and without mental illness. METHODS VHA primary care patients seen between April 2010 and March 2013 whose medical records were reviewed by the VHA External Peer Review Program were identified. The proportion of patients meeting quality indicators in each mental illness group (depression, posttraumatic stress disorder, anxiety disorder, substance use disorder, serious mental illness, and any mental illness) was compared with the proportion of patients without mental illness. Sample sizes ranged from 210,864 to 236,421. Differences of 5.0% or greater were deemed clinically important, and higher proportions indicated higher quality of care across 33 clinical indicators. RESULTS The proportion of veterans meeting clinical quality indicators ranged from 64.7% to 99.6%. Differences of ≥5.0% between veterans with and without mental illness were detected in six of 33 indicators. A greater proportion of veterans with mental illness received influenza immunizations (age 50-64) and had documented left ventricular functioning (among veterans with chronic heart failure) compared with veterans without mental illness. A lower proportion of veterans with substance use disorders or severe mental illness received colorectal cancer screening or met indicators related to recommended medications if diagnosed as having diabetes or ischemic heart disease. CONCLUSIONS Contrary to earlier reports of lower-quality care, patients with and without mental illness had similar preventive and chronic disease management care quality following medical home implementation.
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Affiliation(s)
- Kendall C Browne
- Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi)
| | - Katherine D Hoerster
- Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi)
| | - Rebecca Piegari
- Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi)
| | - John C Fortney
- Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi)
| | - Karin N Nelson
- Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi)
| | - Edward P Post
- Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi)
| | - Stephan D Fihn
- Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi)
| | - Alaina M Mori
- Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi)
| | - Ranak B Trivedi
- Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi)
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11
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Factors associated with visits to general practitioners in patients with schizophrenia in Malaga. BMC FAMILY PRACTICE 2018; 19:180. [PMID: 30486784 PMCID: PMC6264610 DOI: 10.1186/s12875-018-0866-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 11/13/2018] [Indexed: 02/06/2023]
Abstract
Background Patients with psychiatric disorders have more physical problems than other patients, so their follow-up by the general practitioner is particularly important for them. Methods We aimed to elaborate a multilevel explanatory model of general practitioner (GP) visits made by patients with schizophrenia and related disorders (SRD). An observational, cross-sectional study was conducted from January 1, 2008 to July 1, 2011, in the area of the Clinical Management Unit of Mental Health (CMU-MH) of the Regional Hospital of Malaga (Spain). The eligible population consisted of all patients with SRD in contact with a GP residing in the study area. Our dependent variable was total number GP visits. The independent variables were: 1) patient variables (sociodemographic and clinical variables); 2) primary care centre (PCC) variables. We performed descriptive analysis, bivariate analysis and multilevel regression. Results Four hundred ninety four patients were included. Mean annual number of GP visits was 4.1. Female sex, living in a socioeconomically deprived area, a diagnosis of schizoaffective disorder and contact with a GP who had a more active approach to mental health issues were associated with a higher number of visits whilst being single and good communication between the PCC and mental health teams were associated with a lower number of GP visits. Conclusions Number of GP visits was not just associated with patient factors, but also with organisational and the involvement of health professionals, for example GPs with an active approach to mental health issues. Electronic supplementary material The online version of this article (10.1186/s12875-018-0866-7) contains supplementary material, which is available to authorized users.
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12
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Lemogne C. Troubles mentaux sévères et qualité des soins en oncologie. PSYCHO-ONCOLOGIE 2018. [DOI: 10.3166/pson-2018-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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13
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Mangurian C, Niu GC, Schillinger D, Newcomer JW, Dilley J, Handley MA. Utilization of the Behavior Change Wheel framework to develop a model to improve cardiometabolic screening for people with severe mental illness. Implement Sci 2017; 12:134. [PMID: 29137666 PMCID: PMC5686815 DOI: 10.1186/s13012-017-0663-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 11/01/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Individuals with severe mental illness (e.g., schizophrenia, bipolar disorder) die 10-25 years earlier than the general population, primarily from premature cardiovascular disease (CVD). Contributing factors are complex, but include systemic-related factors of poorly integrated primary care and mental health services. Although evidence-based models exist for integrating mental health care into primary care settings, the evidence base for integrating medical care into specialty mental health settings is limited. Such models are referred to as "reverse" integration. In this paper, we describe the application of an implementation science framework in designing a model to improve CVD outcomes for individuals with severe mental illness (SMI) who receive services in a community mental health setting. METHODS Using principles from the theory of planned behavior, focus groups were conducted to understand stakeholder perspectives of barriers to CVD risk factor screening and treatment identify potential target behaviors. We then applied results to the overarching Behavior Change Wheel framework, a systematic and theory-driven approach that incorporates the COM-B model (capability, opportunity, motivation, and behavior), to build an intervention to improve CVD risk factor screening and treatment for people with SMI. RESULTS Following a stepped approach from the Behavior Change Wheel framework, a model to deliver primary preventive care for people that use community mental health settings as their de facto health home was developed. The CRANIUM (cardiometabolic risk assessment and treatment through a novel integration model for underserved populations with mental illness) model focuses on engaging community psychiatrists to expand their scope of practice to become responsible for CVD risk, with significant clinical decision support. CONCLUSION The CRANIUM model was designed by integrating behavioral change theory and implementation theory. CRANIUM is feasible to implement, is highly acceptable to, and targets provider behavior change, and is replicable and efficient for helping to integrate primary preventive care services in community mental health settings. CRANIUM can be scaled up to increase CVD preventive care delivery and ultimately improve health outcomes among people with SMI served within a public mental health care system.
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Affiliation(s)
- Christina Mangurian
- Department of Psychiatry, Weill Institute for Neurosciences, UCSF at Zuckerberg San Francisco General (ZSFG), 1001 Potrero Avenue, 7M8, San Francisco, CA 94110 USA
- UCSF Center for Vulnerable Populations at ZSFG, San Francisco, CA USA
| | - Grace C. Niu
- Department of Psychiatry, Weill Institute for Neurosciences, UCSF at Zuckerberg San Francisco General (ZSFG), 1001 Potrero Avenue, 7M8, San Francisco, CA 94110 USA
| | - Dean Schillinger
- UCSF Center for Vulnerable Populations at ZSFG, San Francisco, CA USA
- UCSF Department of Medicine, Division of General Internal Medicine at ZSFG, 1001 Potrero Avenue, 1320A, San Francisco, CA 94110 USA
| | - John W. Newcomer
- Department of Clinical Biomedical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, 777 Glades Road, BC-71 Rm 241, Boca Raton, FL 33431 USA
| | - James Dilley
- Department of Psychiatry, Weill Institute for Neurosciences, UCSF at Zuckerberg San Francisco General (ZSFG), 1001 Potrero Avenue, 7M8, San Francisco, CA 94110 USA
| | - Margaret A. Handley
- UCSF Center for Vulnerable Populations at ZSFG, San Francisco, CA USA
- UCSF Department of Medicine, Division of General Internal Medicine at ZSFG, 1001 Potrero Avenue, 1320A, San Francisco, CA 94110 USA
- UCSF Department of Epidemiology and Biostatistics, 550 16th Street, San Francisco, CA 64158 USA
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14
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Grove LR, Olesiuk WJ, Ellis AR, Lichstein JC, DuBard CA, Farley JF, Jackson CT, Beadles CA, Morrissey JP, Domino ME. Evaluating the potential for primary care to serve as a mental health home for people with schizophrenia. Gen Hosp Psychiatry 2017; 47:14-19. [PMID: 28779642 PMCID: PMC5745198 DOI: 10.1016/j.genhosppsych.2017.03.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 02/16/2017] [Accepted: 03/03/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Primary care-based medical homes could improve the coordination of mental health care for individuals with schizophrenia and comorbid chronic conditions. The objective of this paper is to examine whether persons with schizophrenia and comorbid chronic conditions engage in primary care regularly, such that primary care settings have the potential to serve as a mental health home. METHOD We examined the annual primary care and specialty mental health service utilization of adult North Carolina Medicaid enrollees with schizophrenia and at least one comorbid chronic condition who were in a medical home during 2007-2010. Using a fixed-effects regression approach, we also assessed the effect of medical home enrollment on utilization of primary care and specialty mental health care and medication adherence. RESULTS A substantial majority (78.5%) of person-years had at least one primary care visit, and 17.9% had at least one primary care visit but no specialty mental health services use. Medical home enrollment was associated with increased use of primary care and specialty mental health care, as well as increased medication adherence. CONCLUSIONS Medical home enrollees with schizophrenia and comorbid chronic conditions exhibited significant engagement in primary care, suggesting that primary-care-based medical homes could serve a care coordination function for persons with schizophrenia.
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Affiliation(s)
- Lexie R. Grove
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr., Chapel Hill, NC 27599-7411, United States,Corresponding author at: The University of North Carolina at Chapel Hill, Gillings School of Global Public Health, 135 Dauer Dr., Campus Box 7411, Chapel Hill, NC 27599-7411, United States,
| | - William J. Olesiuk
- Truven Health Analytics, an IBM Company, 4819 Emperor Blvd Ste 125, Durham, NC 27703, United States,Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd, Chapel Hill, NC 27599-7590, United States
| | - Alan R. Ellis
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd, Chapel Hill, NC 27599-7590, United States,Department of Social Work, North Carolina State University, CB 7639, 1911 Building, Raleigh, NC 27695-7639, United States
| | - Jesse C. Lichstein
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr., Chapel Hill, NC 27599-7411, United States
| | - C. Annette DuBard
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd, Chapel Hill, NC 27599-7590, United States,Community Care of North Carolina, 2300 Rexwoods Dr., Ste 200, Raleigh, NC 27607, United States
| | - Joel F. Farley
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina, Kerr Hall, Chapel Hill, NC 27599-7573, United States
| | - Carlos T. Jackson
- Community Care of North Carolina, 2300 Rexwoods Dr., Ste 200, Raleigh, NC 27607, United States
| | | | - Joseph P. Morrissey
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr., Chapel Hill, NC 27599-7411, United States,Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd, Chapel Hill, NC 27599-7590, United States
| | - Marisa Elena Domino
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr., Chapel Hill, NC 27599-7411, United States; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd, Chapel Hill, NC 27599-7590, United States.
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15
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Garcia ME, Schillinger D, Vittinghoff E, Creasman JM, Knapp P, Newcomer JW, Mangurian C. Nonpsychiatric Outpatient Care for Adults With Serious Mental Illness in California: Who Is Being Left Behind? Psychiatr Serv 2017; 68:689-695. [PMID: 28245706 PMCID: PMC10975499 DOI: 10.1176/appi.ps.201600284] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Although primary care is associated with better outcomes, many individuals with serious mental illness do not receive general medical services. This study examined patient-level factors associated with not having outpatient general medical visits among individuals with serious mental illness in California. METHODS The study analyzed administrative, pharmacy, and billing data for 56,895 Medicaid-enrolled adults with serious mental illness treated in community mental health clinics between October 1, 2010, and September 20, 2011. Poisson regression estimated independent associations between predictor variables and outpatient general medical visits. RESULTS One-third of participants (34%) had no outpatient general medical visits during the study. In multivariate analyses, younger adults (ages 18-27) were less likely than older groups to have such a visit (adjusted relative risk [ARR]=1.07 and 1.19, respectively, for ages 28-47 and 48-67). Women were more likely than men to have such a visit (ARR=1.29). Compared with whites, blacks were less likely to have an outpatient general medical visit (ARR=.93). Rural dwellers were less likely than urban dwellers to have such a visit (ARR=.64). Persons with drug or alcohol use disorders were less likely than those without such disorders to have an outpatient general medical visit (ARR=.95), and those with schizophrenia were less likely than those with any other psychiatric disorder examined to have such a visit. CONCLUSIONS Individuals with serious mental illness had low use of outpatient general medical services. Integrated care models are needed to engage these individuals and eliminate disparities in morbidity and mortality.
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Affiliation(s)
- Maria E Garcia
- Dr. Garcia and Dr. Schillinger are with the Department of Medicine, Dr. Vittinghoff is with the Department of Epidemiology and Biostatistics, Ms. Creasman is with the Clinical and Translational Science Institute, and Dr. Mangurian is with the Department of Psychiatry, all at the University of California, San Francisco, School of Medicine (e-mail: ). Dr. Garcia, Dr. Schillinger, and Dr. Mangurian are also with Zuckerberg General Hospital, San Francisco. Dr. Knapp is with the Department of Psychiatry and Behavioral Sciences, University of California, Davis. Dr. Newcomer is with the Department of Integrated Medical Science, The Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton
| | - Dean Schillinger
- Dr. Garcia and Dr. Schillinger are with the Department of Medicine, Dr. Vittinghoff is with the Department of Epidemiology and Biostatistics, Ms. Creasman is with the Clinical and Translational Science Institute, and Dr. Mangurian is with the Department of Psychiatry, all at the University of California, San Francisco, School of Medicine (e-mail: ). Dr. Garcia, Dr. Schillinger, and Dr. Mangurian are also with Zuckerberg General Hospital, San Francisco. Dr. Knapp is with the Department of Psychiatry and Behavioral Sciences, University of California, Davis. Dr. Newcomer is with the Department of Integrated Medical Science, The Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton
| | - Eric Vittinghoff
- Dr. Garcia and Dr. Schillinger are with the Department of Medicine, Dr. Vittinghoff is with the Department of Epidemiology and Biostatistics, Ms. Creasman is with the Clinical and Translational Science Institute, and Dr. Mangurian is with the Department of Psychiatry, all at the University of California, San Francisco, School of Medicine (e-mail: ). Dr. Garcia, Dr. Schillinger, and Dr. Mangurian are also with Zuckerberg General Hospital, San Francisco. Dr. Knapp is with the Department of Psychiatry and Behavioral Sciences, University of California, Davis. Dr. Newcomer is with the Department of Integrated Medical Science, The Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton
| | - Jennifer M Creasman
- Dr. Garcia and Dr. Schillinger are with the Department of Medicine, Dr. Vittinghoff is with the Department of Epidemiology and Biostatistics, Ms. Creasman is with the Clinical and Translational Science Institute, and Dr. Mangurian is with the Department of Psychiatry, all at the University of California, San Francisco, School of Medicine (e-mail: ). Dr. Garcia, Dr. Schillinger, and Dr. Mangurian are also with Zuckerberg General Hospital, San Francisco. Dr. Knapp is with the Department of Psychiatry and Behavioral Sciences, University of California, Davis. Dr. Newcomer is with the Department of Integrated Medical Science, The Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton
| | - Penelope Knapp
- Dr. Garcia and Dr. Schillinger are with the Department of Medicine, Dr. Vittinghoff is with the Department of Epidemiology and Biostatistics, Ms. Creasman is with the Clinical and Translational Science Institute, and Dr. Mangurian is with the Department of Psychiatry, all at the University of California, San Francisco, School of Medicine (e-mail: ). Dr. Garcia, Dr. Schillinger, and Dr. Mangurian are also with Zuckerberg General Hospital, San Francisco. Dr. Knapp is with the Department of Psychiatry and Behavioral Sciences, University of California, Davis. Dr. Newcomer is with the Department of Integrated Medical Science, The Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton
| | - John W Newcomer
- Dr. Garcia and Dr. Schillinger are with the Department of Medicine, Dr. Vittinghoff is with the Department of Epidemiology and Biostatistics, Ms. Creasman is with the Clinical and Translational Science Institute, and Dr. Mangurian is with the Department of Psychiatry, all at the University of California, San Francisco, School of Medicine (e-mail: ). Dr. Garcia, Dr. Schillinger, and Dr. Mangurian are also with Zuckerberg General Hospital, San Francisco. Dr. Knapp is with the Department of Psychiatry and Behavioral Sciences, University of California, Davis. Dr. Newcomer is with the Department of Integrated Medical Science, The Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton
| | - Christina Mangurian
- Dr. Garcia and Dr. Schillinger are with the Department of Medicine, Dr. Vittinghoff is with the Department of Epidemiology and Biostatistics, Ms. Creasman is with the Clinical and Translational Science Institute, and Dr. Mangurian is with the Department of Psychiatry, all at the University of California, San Francisco, School of Medicine (e-mail: ). Dr. Garcia, Dr. Schillinger, and Dr. Mangurian are also with Zuckerberg General Hospital, San Francisco. Dr. Knapp is with the Department of Psychiatry and Behavioral Sciences, University of California, Davis. Dr. Newcomer is with the Department of Integrated Medical Science, The Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton
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Gill SK, Saini G, Relova RM, Lee T, Yasmin S, Drag L. Health Care Utilization of Veterans With Serious Mental Illness. Fed Pract 2017; 34:S14S-S19S. [PMID: 30766307 PMCID: PMC6375500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Outreach regarding veteran-specific factors can help determine which targeted interventions reduce the need for chronic mental illness inpatient hospitalization.
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Affiliation(s)
- Supria K Gill
- is a postdoctoral psychology resident at Kaiser Permanente Vacaville Medical Center and adjunct faculty at Palo Alto University. is a clinical research coordinator at Stanford University School of Medicine. is research health scientist, is staff psychiatrist and deputy chief of service for mental health, and is a staff psychiatrist and inpatient mental health director, all at the VA Palo Alto Health Care System. is a staff neuropsychologist at Stanford Hospitals and Clinics in Palo Alto, all in California
| | - Gopin Saini
- is a postdoctoral psychology resident at Kaiser Permanente Vacaville Medical Center and adjunct faculty at Palo Alto University. is a clinical research coordinator at Stanford University School of Medicine. is research health scientist, is staff psychiatrist and deputy chief of service for mental health, and is a staff psychiatrist and inpatient mental health director, all at the VA Palo Alto Health Care System. is a staff neuropsychologist at Stanford Hospitals and Clinics in Palo Alto, all in California
| | - Rona Margaret Relova
- is a postdoctoral psychology resident at Kaiser Permanente Vacaville Medical Center and adjunct faculty at Palo Alto University. is a clinical research coordinator at Stanford University School of Medicine. is research health scientist, is staff psychiatrist and deputy chief of service for mental health, and is a staff psychiatrist and inpatient mental health director, all at the VA Palo Alto Health Care System. is a staff neuropsychologist at Stanford Hospitals and Clinics in Palo Alto, all in California
| | - Tina Lee
- is a postdoctoral psychology resident at Kaiser Permanente Vacaville Medical Center and adjunct faculty at Palo Alto University. is a clinical research coordinator at Stanford University School of Medicine. is research health scientist, is staff psychiatrist and deputy chief of service for mental health, and is a staff psychiatrist and inpatient mental health director, all at the VA Palo Alto Health Care System. is a staff neuropsychologist at Stanford Hospitals and Clinics in Palo Alto, all in California
| | - Sarah Yasmin
- is a postdoctoral psychology resident at Kaiser Permanente Vacaville Medical Center and adjunct faculty at Palo Alto University. is a clinical research coordinator at Stanford University School of Medicine. is research health scientist, is staff psychiatrist and deputy chief of service for mental health, and is a staff psychiatrist and inpatient mental health director, all at the VA Palo Alto Health Care System. is a staff neuropsychologist at Stanford Hospitals and Clinics in Palo Alto, all in California
| | - Lauren Drag
- is a postdoctoral psychology resident at Kaiser Permanente Vacaville Medical Center and adjunct faculty at Palo Alto University. is a clinical research coordinator at Stanford University School of Medicine. is research health scientist, is staff psychiatrist and deputy chief of service for mental health, and is a staff psychiatrist and inpatient mental health director, all at the VA Palo Alto Health Care System. is a staff neuropsychologist at Stanford Hospitals and Clinics in Palo Alto, all in California
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Yarborough BJH, Hanson GC, Perrin NA, Stumbo SP, Green CA. Colorectal Cancer Screening Completion Among Individuals With and Without Mental Illnesses: A Comparison of 2 Screening Methods. Am J Health Promot 2017; 32:925-931. [PMID: 29214818 DOI: 10.1177/0890117116686573] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE Cancer mortality is worse among people with psychiatric disorders. The purpose of this study was to compare facilitators and rates of colorectal cancer (CRC) screening between people with and without mental illnesses. DESIGN We conducted a secondary analysis using data from a general population cohort study (N = 92 445) that assessed effects of 2 types of CRC screening test kits-guaiac fecal occult blood testing (gFOBT) and fecal immunochemical testing (FIT)-on CRC screening completion. SETTING The setting was a health system that served approximately 485 000 members in urban and suburban Oregon and Washington. PARTICIPANTS Participants were health system members, categorized by mental illness diagnosis (psychotic disorders, non-psychotic unipolar depression, and no mental illness), who were age-eligible, at average risk of CRC, and were at least 366 days past their last gFOBT with no evidence of other CRC screening. MEASURES The outcome was time until completion of CRC screening. ANALYSIS We used Cox proportional hazard models. RESULTS FIT reduced CRC screening barriers for all the groups. Compared to people without mental illness diagnoses, those with psychotic disorders were equally likely to screen using FIT (hazard ratio [HR] = .95, p = .679) and those with depression were more likely (HR = 1.17, p = .006). CONCLUSIONS FIT can improve CRC screening rates among people with mental illnesses, particularly depression.
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Affiliation(s)
| | | | - Nancy A Perrin
- 1 Kaiser Permanente Northwest Center for Health Research, Portland, OR, USA
| | - Scott P Stumbo
- 1 Kaiser Permanente Northwest Center for Health Research, Portland, OR, USA
| | - Carla A Green
- 1 Kaiser Permanente Northwest Center for Health Research, Portland, OR, USA
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Rogers ES, Maru M, Kash-MacDonald M, Archer-Williams M, Hashemi L, Boardman J. A Randomized Clinical Trial Investigating the Effect of a Healthcare Access Model for Individuals with Severe Psychiatric Disabilities. Community Ment Health J 2016; 52:667-74. [PMID: 27137507 DOI: 10.1007/s10597-016-0009-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 04/07/2016] [Indexed: 11/24/2022]
Abstract
We conducted a randomized trial to examine a model for integrating primary care into a community mental health setting. Two hundred individuals were recruited and randomly assigned to receive primary care delivered by a nurse practitioner (n = 94) or services-as-usual (n = 106), assessed on health and mental health outcomes, and followed for 12 months. Intent-to-Treat and exposure analyses were conducted and suggest that participants who engaged with the nurse practitioner experienced gains in perceptions of primary care quality. Health benefits accrued for individuals having receiving nurse practitioner services in a mental health setting to address primary care needs.
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Affiliation(s)
- E Sally Rogers
- Center for Psychiatric Rehabilitation, Boston University, 940 Commonwealth Ave, West, Boston, MA, USA.
| | - Mihoko Maru
- Center for Psychiatric Rehabilitation, Boston University, 940 Commonwealth Ave, West, Boston, MA, USA.,Boston University School of Social Work, Boston, MA, USA
| | - Megan Kash-MacDonald
- Center for Psychiatric Rehabilitation, Boston University, 940 Commonwealth Ave, West, Boston, MA, USA.,Institute of Child Health, University College London (UCL), London, England
| | - Mariah Archer-Williams
- Center for Psychiatric Rehabilitation, Boston University, 940 Commonwealth Ave, West, Boston, MA, USA.,Sharp HealthCare, San Diego, CA, USA
| | - Lobat Hashemi
- Center for Psychiatric Rehabilitation, Boston University, 940 Commonwealth Ave, West, Boston, MA, USA.,Genzyme, Sanofi, Boston, MA, USA
| | - Judith Boardman
- Northeast Health Systems/Health and Education Services, Inc., Beverly, MA, USA.,Salem State University, Salem, MA, USA
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Brenner CJ, Shyn SI. Diagnosis and management of bipolar disorder in primary care: a DSM-5 update. Med Clin North Am 2014; 98:1025-48. [PMID: 25134871 DOI: 10.1016/j.mcna.2014.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This review discusses the diagnosis and detection of bipolar disorder in the primary care population with recent changes introduced by Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the pharmacotherapy and psychosocial management of this psychiatric condition.
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Affiliation(s)
- Carolyn J Brenner
- Department of Psychiatry and Behavioral Sciences, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA.
| | - Stanley I Shyn
- Department of Psychiatry and Behavioral Sciences, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA
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Blank MB, Himelhoch SS, Balaji AB, Metzger DS, Dixon LB, Rose CE, Oraka E, Davis-Vogel A, Thompson WW, Heffelfinger JD. A multisite study of the prevalence of HIV with rapid testing in mental health settings. Am J Public Health 2014; 104:2377-84. [PMID: 24524493 DOI: 10.2105/ajph.2013.301633] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We estimated HIV prevalence and risk factors among persons receiving mental health treatment in Philadelphia, Pennsylvania, and Baltimore, Maryland, January 2009 to August 2011. METHODS We used a multisite, cross-sectional design stratified by clinical setting. We tested 1061 individuals for HIV in university-based inpatient psychiatric units (n = 287), intensive case-management programs (n = 273), and community mental health centers (n = 501). RESULTS Fifty-one individuals (4.8%) were HIV-infected. Confirmed positive HIV tests were 5.9% (95% confidence interval [CI] = 3.7%, 9.4%) for inpatient units, 5.1% (95% CI = 3.1%, 8.5%) for intensive case-management programs, and 4.0% (95% CI = 2.6%, 6.1%) for community mental health centers. Characteristics associated with HIV included Black race, homosexual or bisexual identity, and HCV infection. CONCLUSIONS HIV prevalence for individuals receiving mental health services was about 4 times as high as in the general population. We found a positive association between psychiatric symptom severity and HIV infection, indicating that engaging persons with mental illness in appropriate mental health treatment may be important to HIV prevention. These findings reinforce recommendations for routine HIV testing in all clinical settings to ensure that HIV-infected persons receiving mental health services are identified and referred to timely infectious disease care.
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Affiliation(s)
- Michael B Blank
- Michael B. Blank and David S. Metzger are with the Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia. Seth S. Himelhoch is with the Department of Psychiatry, University of Maryland School of Medicine, Baltimore. Alexandra B. Balaji, Charles E. Rose, and James D. Heffelfinger are with the Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Lisa B. Dixon is with the Department of Psychiatry, Columbia University, New York, NY. Emeka Oraka is with ICF International, Atlanta. Annet Davis-Vogel is with the HIV/AIDS Prevention Research Division, University of Pennsylvania, Philadelphia. William W. Thompson is with the Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta
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Chwastiak LA, Davydow DS, McKibbin CL, Schur E, Burley M, McDonell MG, Roll J, Daratha KB. The effect of serious mental illness on the risk of rehospitalization among patients with diabetes. PSYCHOSOMATICS 2013; 55:134-43. [PMID: 24367898 DOI: 10.1016/j.psym.2013.08.012] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 08/28/2013] [Accepted: 08/29/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Medical-surgical rehospitalizations within a month after discharge among patients with diabetes result in tremendous costs to the US health care system. OBJECTIVE The study's aim was to examine whether co-morbid serious mental illness diagnoses (bipolar disorder, schizophrenia, or other psychotic disorders) among patients with diabetes are independently associated with medical-surgical rehospitalization within a month of discharge after an initial hospitalization. METHODS This cohort study of all community hospitals in Washington state evaluated data from 82,060 adults discharged in the state of Washington with any International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis indicating diabetes mellitus between 2010 and 2011. Data on medical-surgical hospitalizations were obtained from the Washington State Comprehensive Hospital Abstract Reporting System. Co-morbid serious mental illness diagnoses were identified based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes indicating bipolar disorder, schizophrenia, or other psychotic disorders. Logistic regression analyses identified factors independently associated with rehospitalization within a month of discharge. Cox proportional hazard analyses estimated time to rehospitalization for the entire study period. RESULTS After adjusting for demographics, medical co-morbidity, and characteristics of the index hospitalization, co-morbid serious mental illness diagnosis was independently associated with increased odds of rehospitalization within 1 month among patients with diabetes who had a medical-surgical hospitalization (odds ratio: 1.24, 95% confidence interval: 1.07, 1.44). This increased risk of rehospitalization persisted throughout the study period (up to 24 mo). CONCLUSIONS Co-morbid serious mental illness in patients with diabetes is independently associated with greater risk of early medical-surgical rehospitalization. Future research is needed to define and specify targets for interventions at points of care transition for this vulnerable patient population.
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Affiliation(s)
- Lydia A Chwastiak
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA.
| | - Dimitry S Davydow
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
| | | | - Ellen Schur
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Mason Burley
- Washington Institute for Mental Health Research and Training, Washington State University, Spokane, WA
| | - Michael G McDonell
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
| | - John Roll
- College of Nursing, Washington State University, Spokane, WA
| | - Kenn B Daratha
- College of Nursing, Washington State University, Spokane, WA; Providence Medical Research Center, Spokane, WA; Department of Medical Education & Biomedical Informatics, University of Washington School of Medicine, Seattle, WA
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22
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Cerimele JM, Chwastiak LA, Chan YF, Harrison DA, Unützer J. The presentation, recognition and management of bipolar depression in primary care. J Gen Intern Med 2013; 28:1648-56. [PMID: 23835789 PMCID: PMC3832714 DOI: 10.1007/s11606-013-2545-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Bipolar disorder is a mood disorder characterized by episodes of major depression and mania or hypomania. Most patients experience chronic symptoms of bipolar disorder approximately half of the time, most commonly subsyndromal depressive symptoms or a full depressive episode with concurrent manic symptoms. Consequently, patients with bipolar depression are often misdiagnosed with major depressive disorder. Individual patient characteristics and population screening tools may be helpful in improving recognition of bipolar depression in primary care. Health risk behaviors including tobacco use, sedentary activity level and weight gain are highly prevalent in patients with bipolar disorder, as are the comorbid chronic diseases such as diabetes mellitus and cardiovascular disease. Patients with bipolar illness have about an eight-fold higher risk of suicide and a two-fold increased risk of death from chronic medical illnesses. Recognition of bipolar depression and its associated health risk behaviors and chronic medical problems can lead to the use of appropriate interventions for patients with bipolar disorder, which differ in important ways from the treatments used for major depressive disorder. The above topics are reviewed in detail in this article.
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Affiliation(s)
- Joseph M Cerimele
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St, Box 356560, Seattle, WA, 98195-6560, USA,
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Ungar T, Goldman S, Marcus M. Reversed Shared Care in Mental Health: Bringing Primary Physical Health Care to Psychiatric Patients. ACTA ACUST UNITED AC 2013. [DOI: 10.7870/cjcmh-2013-022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Thomas Ungar
- North York General Hospital and University of Toronto
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Lemogne C, Nabi H, Melchior M, Goldberg M, Limosin F, Consoli SM, Zins M. Mortality associated with depression as compared with other severe mental disorders: a 20-year follow-up study of the GAZEL cohort. J Psychiatr Res 2013; 47:851-7. [PMID: 23590806 DOI: 10.1016/j.jpsychires.2013.03.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 03/19/2013] [Accepted: 03/19/2013] [Indexed: 11/19/2022]
Abstract
Individuals with severe mental disorders (SMD) have an increased risk of mortality from somatic diseases. This study examined whether this risk is different in persons with depressive disorders compared to those with other SMD (i.e. schizophrenia and bipolar disorder). In 1989, 20,625 employees of the French national gas and electricity company (15,011 men and 5614 women, aged 35-50) agreed to participate in the GAZEL cohort study. Three diagnosis groups were created based on sick leave spells from 1978 onwards: 1) no SMD, 2) depressive disorders and 3) other SMD. Dates and causes of death were available from January 1, 1990 to December 31, 2010. The association of diagnosis groups with mortality was estimated with hazard ratios (HR) and 95% confidence intervals (CI) computed using Cox regression. During a mean follow-up of 19.8 years, 1544 participants died, including 1343 from a natural cause, of which 258 died from cardiovascular diseases. After adjustment for age, gender, occupational status, alcohol consumption, smoking and body-mass index, participants with a history of sickness absence for SMD had a greater risk of natural mortality (HR: 1.24, CI: 1.08-1.43), cardiovascular mortality (HR: 1.49, CI: 1.08-2.05) and non-cardiovascular natural mortality (HR: 1.19, CI: 1.02-1.39). Compared to depressive disorders, other SMD were associated with an increased risk of natural mortality (HR: 1.94, CI: 1.17-3.22) and cardiovascular mortality (HR: 3.58, CI: 1.53-8.39). Job security and systematic medical follow-up may fall short of preventing premature death among workers with sickness absence due to SMD.
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Affiliation(s)
- Cédric Lemogne
- Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France.
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Wiechers IR, Freudenreich O. The Role of Consultation-Liaison Psychiatrists in Improving Health Care of Patients with Schizophrenia. PSYCHOSOMATICS 2013. [DOI: 10.1016/j.psym.2012.07.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Mitchell AJ, Lord O, Malone D. Differences in the prescribing of medication for physical disorders in individuals with v. without mental illness: meta-analysis. Br J Psychiatry 2012. [PMID: 23209089 DOI: 10.1192/bjp.bp.111.094532] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND There is some concern that patients with mental illness may be in receipt of inferior medical care, including prescribed medication for medical conditions. AIMS We aimed to quantify possible differences in the prescription of medication for medical conditions in those with v. without mental illness. METHOD Systematic review and random effects meta-analysis with a minimum of three independent studies to warrant pooling by drug class. RESULTS We found 61 comparative analyses (from 23 publications) relating to the prescription of 12 classes of medication for cardiovascular health, diabetes, cancer, arthritis, osteoporosis and HIV in a total sample of 1 931 509 people. In those with severe mental illness the adjusted odds ratio (OR) for an equitable prescription was 0.74 (95% CI 0.63-0.86), with lower than expected prescriptions for angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (ACE/ARBs), beta-blockers and statins. People with affective disorder had an odds ratio of 0.75 (95% CI 0.55-1.02) but this was not significant. Individuals with a history of other (miscellaneous) mental illness had an odds ratio of 0.95 (95% CI 0.92-0.98) of comparable medication with lower receipt of ACE/ARBs but not highly active antiretroviral therapy (HAART) medication. Results were significant in both adjusted and unadjusted analyses. CONCLUSIONS Individuals with severe mental illness (including schizophrenia) appear to be prescribed significantly lower quantities of several common medications for medical disorders, largely for cardiovascular indications, although further work is required to clarify to what extent this is because of prescriber intent.
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Affiliation(s)
- Alex J Mitchell
- Department of Psycho-oncology, Leicestershire Partnership Trust, Leicester LE5 0TD, UK.
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Chwastiak L, Tsai J, Rosenheck R. Impact of health insurance status and a diagnosis of serious mental illness on whether chronically homeless individuals engage in primary care. Am J Public Health 2012; 102:e83-9. [PMID: 23078477 DOI: 10.2105/ajph.2012.301025] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We evaluated the impact of a diagnosis of serious mental illness on use of a primary care provider (vs the emergency department [ED]) as a source of care by people who were chronically homeless. METHODS We used data from 750 chronically homeless adults enrolled in the 11-site Collaborative Initiative to Help End Chronic Homelessness and identified demographic and clinical characteristics independently associated with using a primary care provider rather than an ED. RESULTS The factor most strongly associated with using the ED as a regular source of medical care was previous-year lack of health insurance. Despite high rates of serious mental illness, neither a diagnosis of serious mental illness nor increased severity of psychiatric symptoms was associated with such use. CONCLUSIONS Findings suggest that people who are chronically homeless and have chronic medical illness would be more likely to access care if they had health insurance. Individual states' deciding not to expand Medicaid coverage will likely have a tremendous impact on the health outcomes and health care costs associated with this and other vulnerable populations.
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Affiliation(s)
- Lydia Chwastiak
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
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Abgrall-Barbry G, Lemogne C, Lamarque D, Leuret B, Bydlowski S, Jian R, Dantchev N, Consoli SM. Depressive Mood and Subsequent Cancer Diagnosis in Patients Undergoing a Colonoscopy. PSYCHOSOMATICS 2012; 53:356-62. [DOI: 10.1016/j.psym.2012.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 12/30/2011] [Accepted: 01/02/2012] [Indexed: 11/26/2022]
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Chwastiak LA, Rosenheck RA, Kazis LE. Association of psychiatric illness and obesity, physical inactivity, and smoking among a national sample of veterans. PSYCHOSOMATICS 2011; 52:230-6. [PMID: 21565594 DOI: 10.1016/j.psym.2010.12.009] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Revised: 06/19/2010] [Accepted: 06/23/2010] [Indexed: 10/14/2022]
Abstract
BACKGROUND Increased cardiovascular morbidity and mortality have been reported across a number of chronic psychiatric illnesses. Interventions to decrease cardiovascular risk have focused on single health behaviors. OBJECTIVE To evaluate the co-occurrence of multiple poor health behaviors that increase cardiovascular risk among veterans with psychiatric diagnoses. METHODS Using data from the 1999 Large Health Survey of Veterans (n=501,161), multivariate logistic regression was used to evaluate the associations between current smoking, no regular exercise, and obesity with each of six Axis I diagnoses. RESULTS There were statistically increased odds of co-occurrence of obesity, current tobacco use, and no regular exercise among veterans with each of the psychiatric diagnoses, with the exception of drug use disorders (which was not significantly different from 1). The highest odds were among veterans with schizophrenia, PTSD, and bipolar disorder [OR (95% CI) of 1.37 (1.29, 1.45); 1.26 (1.20, 1.32); and 1.19 (1.11, 1.25), respectively]. The OR for depression was not significant after adjustment for medical comorbidity. CONCLUSIONS Veterans with psychiatric illnesses, and particularly those with schizophrenia, PTSD, and bipolar disorder, are much more likely to have multiple poor health behaviors that increase their cardiovascular risk. Interventions to decrease cardiovascular risk among veterans with serious mental illness need to target multiple health behaviors.
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Affiliation(s)
- Lydia A Chwastiak
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06519, USA.
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Himelhoch S, Goldberg R, Calmes C, Medoff D, Slade E, Dixon L, Gallucci G, Rosenberg S. SCREENING FOR AND PREVALENCE OF HIV AND HEPATITIS C AMONG AN OUTPATIENT URBAN SAMPLE OF PEOPLE WITH SERIOUS MENTAL ILLNESS AND CO-OCCURRING SUBSTANCE ABUSE. JOURNAL OF COMMUNITY PSYCHOLOGY 2011; 39:231-239. [PMID: 23543939 PMCID: PMC3610566 DOI: 10.1002/jcop.20422] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND To assess rates of screening and testing of HIV and HCV among those with serious mental illness and co-occurring substance use disorders. METHODS One hundred fifty-three people with serious mental illness and cooccurring substance use disorders completed measures and were screened for HIV and HCV. RESULTS Six percent were HIV positive and 25% were HCV positive. Almost a quarter reported a history of injection drug use and 86% reported a history of unprotected sexual encounters. Compared to those without a diagnosis of Hepatitis C, those diagnosed with Hepatitis C were significantly more likely to have a sexually transmitted infection, (p = 0.01), have a lifetime history of injection drug use, (p < 0.001), and a lifetime history of sniffing drugs, (p = 0.01). CONCLUSIONS Given the high levels of infection of HIV and HCV and high levels of transmission risk factors efforts to improve screening and provide risk reduction counseling are warranted.
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Lin HC, Huang CC, Chen SF, Chen YH. Increased risk of avoidable hospitalization among patients with schizophrenia. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2011; 56:171-8. [PMID: 21443824 DOI: 10.1177/070674371105600307] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Some studies suggest that hospitalizations for certain conditions, called ambulatory care sensitive conditions (ACSCs), are potentially avoidable. However, almost no study has addressed the risk of ACSC hospitalizations specifically for patients with severe mental illness. Our study examines the risk of ACSC hospitalizations among patients with schizophrenia in Taiwan, using a 5-year, nationwide, population-based database. METHODS Our study included 2503 patients with schizophrenia and 20 024 matched patients without schizophrenia. Poisson regression analysis was then performed in which the number of ACSC hospitalizations from 2002 to 2006 (including ruptured appendix, asthma, cellulitis, congestive heart failure, diabetes, gangrene, hypokalemia, immunizable conditions, malignant hypertension, pneumonia, pyelonephritis, and perforated or bleeding ulcer) was regressed against the independent variable of whether or not a patient had a schizophrenia diagnosis in 2001. RESULTS Results show that 9.83% of patients with schizophrenia and 4.71% of patients in the comparison group experienced ACSC hospitalizations from 2002 to 2006. After adjusting for each patient's sex, age, level of urbanization, geographic location of residence within a community, and monthly income, patients with schizophrenia had a 3.26-fold higher (95% CI 3.00 to 3.54, P < 0.001) risk of experiencing ACSC hospitalizations than the comparison participants. After excluding the conditions of diabetes, hypertension, and asthma, patients with schizophrenia independently had a 2.46-fold higher risk of ACSC hospitalizations (95% CI 2.12 to 2.86, P < 0.001), compared with participants in the comparison group. CONCLUSIONS We conclude that schizophrenia patients are at a higher risk for hospitalizations owing to ACSCs, despite a national health insurance system providing universal coverage to citizens.
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Affiliation(s)
- Herng-Ching Lin
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan
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A qualitative study: barriers and facilitators to health care access for individuals with psychiatric disabilities. Psychiatr Rehabil J 2011; 34:285-294. [PMID: 21459744 DOI: 10.2975/34.4.2011.285.294] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This qualitative study was conducted as part of a larger randomized trial to examine barriers and facilitators to accessing and providing comprehensive primary health care for individuals with serious mental illnesses. We examined the perspectives of administrators and providers in a behavioral health organization surrounding the use of a nurse practitioner model of delivering primary healthcare. METHODS Ten key informant interviews were conducted and analyzed using qualitative data analysis software. Concepts and themes regarding access to and delivery of primary healthcare were inductively derived from the data. RESULTS Results confirmed significant issues related to chronic physical health problems among individuals with psychiatric disabilities and detailed a host of barriers to receiving health care as well as the perceived benefits of the nurse practitioner intervention. Financial challenges played a significant role in the organization's ability to make primary and mental health care integration a sustainable endeavor. In addition, staff faced increased burdens on their time due to adding a focus on physical health to their existing job duties. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE A nurse practitioner stationed in a behavioral healthcare setting is viewed by administrators and providers as extremely beneficial in addressing issues of access to comprehensive and integrated primary healthcare for individuals with severe psychiatric disabilities but sustaining such a model of care is not without organizational challenges.
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Banta JE, Andersen RM, Young AS, Kominski G, Cunningham WE. Psychiatric comorbidity and mortality among veterans hospitalized for congestive heart failure. Mil Med 2010; 175:732-41. [PMID: 20968262 DOI: 10.7205/milmed-d-10-00002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
A Behavioral Model of Health Services Utilization approach was used to examine the impact of comorbid mental illness on mortality of veterans admitted to Veterans Affairs medical centers in fiscal year 2001 with a primary diagnosis of congestive heart failure (n = 15,497). Thirty percent had a psychiatric diagnosis, 4.7% died during the index hospitalization, and 11.5% died during the year following discharge. Among those with mental illness, 23.6% had multiple psychiatric disorders. Multivariable logistic regression models found dementia to be positively associated with inpatient mortality. Depression alone (excluding other psychiatric disorders) was positively associated with one-year mortality. Primary care visits were associated with a reduced likelihood of both inpatient and one-year mortality. Excepting dementia, VA patients with a mental illness had comparable or higher levels of primary care visits than those having no mental illness. Patients with multiple psychiatric disorders had more outpatient care than those with one psychiatric disorder.
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Affiliation(s)
- Jim E Banta
- Loma Linda University School of Public Health, Department of Health Policy and Management, 24951 North Circle Drive, Loma Linda, CA 92350, USA
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Mitchell AJ, Lord O. Do deficits in cardiac care influence high mortality rates in schizophrenia? A systematic review and pooled analysis. J Psychopharmacol 2010; 24:69-80. [PMID: 20923922 PMCID: PMC2951596 DOI: 10.1177/1359786810382056] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We have previously documented inequalities in the quality of medical care provided to those with mental ill health but the implications for mortality are unclear. We aimed to test whether disparities in medical treatment of cardiovascular conditions, specifically receipt of medical procedures and receipt of prescribed medication, are linked with elevated rates of mortality in people with schizophrenia and severe mental illness. We undertook a systematic review of studies that examined medical procedures and a pooled analysis of prescribed medication in those with and without comorbid mental illness, focusing on those which recruited individuals with schizophrenia and measured mortality as an outcome. From 17 studies of treatment adequacy in cardiovascular conditions, eight examined cardiac procedures and nine examined adequacy of prescribed cardiac medication. Six of eight studies examining the adequacy of cardiac procedures found lower than average provision of medical care and two studies found no difference. Meta-analytic pooling of nine medication studies showed lower than average rates of prescribing evident for the following individual classes of medication; angiotensin converting enzyme inhibitors (n = 6, aOR = 0.779, 95% CI = 0.638-0.950, p = 0.0137), beta-blockers (n = 9, aOR = 0.844, 95% CI = 0.690-1.03, p = 0.1036) and statins (n = 5, aOR = 0.604, 95% CI = 0.408-0.89, p = 0.0117). No inequality was evident for aspirin (n = 7, aOR = 0.986, 95% CI = 0.7955-1.02, p = 0.382). Interestingly higher than expected prescribing was found for older non-statin cholesterol-lowering agents (n = 4, aOR = 1.55, 95% CI = 1.04-2.32, p = 0.0312). A search for outcomes in this sample revealed ten studies linking poor quality of care and possible effects on mortality in specialist settings. In half of the studies there was significantly higher mortality in those with mental ill health compared with controls but there was inadequate data to confirm a causative link. Nevertheless, indirect evidence supports the observation that deficits in quality of care are contributing to higher than expected mortality in those with severe mental illness (SMI) and schizophrenia. The quality of medical treatment provided to those with cardiac conditions and comorbid schizophrenia is often suboptimal and may be linked with avoidable excess mortality. Every effort should be made to deliver high-quality medical care to people with severe mental illness.
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Affiliation(s)
- Alex J Mitchell
- Department of Liaison Psychiatry, Leicester General Hospital, Leicester, UK.
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Association of psychiatric illness and all-cause mortality in the National Department of Veterans Affairs Health Care System. Psychosom Med 2010; 72:817-22. [PMID: 20639387 PMCID: PMC2950891 DOI: 10.1097/psy.0b013e3181eb33e9] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the independent association of seven psychiatric illnesses with all-cause mortality in a representative national sample of veterans, after adjustment for demographic factors, psychiatric and medical comorbidity, obesity, tobacco use, and exercise frequency. METHODS Analyses were conducted using data from the 1999 Large Health Survey of Veteran Enrollees (n = 559,985). Cox proportional hazards models were used to examine the relationship of seven psychiatric diagnoses with mortality. Date of all-cause mortality was determined from the Department of Veterans Affairs' Beneficiary Identification and Records Locator System. All-cause mortality rates were calculated as the total number of deaths in each group divided by the person-years of follow-up time in each group. RESULTS During the 9-year study period, 27% of the subjects (n = 131,396) died. Each of the psychiatric diagnoses was associated with significantly increased HR for all-cause mortality after adjusting for age, race, and gender. Hazard ratios ranged from 1.02 (95% confidence interval, 1.01, 1.04) for posttraumatic stress disorder to 1.97 (95% confidence interval, 1.89, 2.04) for alcohol use disorders. After adjustment for psychiatric and medical comorbidity, obesity, current smoking and exercise frequency, alcohol and drug abuse and dependence, and schizophrenia were statistically significantly associated with an increased risk of mortality. CONCLUSIONS In this study of a large representative national sample of veterans, schizophrenia and alcohol and drug use disorders were independently associated with an increased risk of all-cause mortality over a 9-year period.
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Receipt of preventive medical care and medical screening for patients with mental illness: a comparative analysis. Gen Hosp Psychiatry 2010; 32:519-43. [PMID: 20851274 DOI: 10.1016/j.genhosppsych.2010.04.004] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2009] [Revised: 04/18/2010] [Accepted: 04/21/2010] [Indexed: 12/31/2022]
Abstract
BACKGROUND There has been long-standing concern about the delivery of preventive and screening services to patients with mental illness. OBJECTIVE We aimed to examine whether the quality of preventive care received by patients with mental health conditions differs from that received by individuals who have no comparable mental disorder. Our hypothesis was that patients with mental illness would be in receipt of lower quality or lower frequency of preventive care. METHOD Studies that examined the quality of care in those with and without comorbid mental illness were reviewed and comparative data extracted. By using only comparative studies we hope to ascertain whether inequalities in care existed by virtue of psychiatric diagnoses (or closely affiliated factors). RESULTS We identified 26 studies that examined preventive care in individuals with vs. without psychiatric illness. From these eligible studies, 61 comparisons were documented across 13 health care domains. These included mammography, cervical smears, vaccinations, cholesterol screening, lifestyle counseling, colonoscopy. Twenty-seven comparisons revealed inferior preventive health care in those with mental illness, but 10 suggested superior preventive health care and 24 reached inconclusive findings. Inferior preventive care was most apparent in those with schizophrenia and in relation to osteoporosis screening, blood pressure monitoring, vaccinations, mammography and cholesterol monitoring. CONCLUSIONS We conclude there is strong evidence to suggest that the quality of preventive and screening services received by patients with mental illness is often lower, but occasionally superior to that received by individuals who have no comparable mental disorder. More work must be done to improve the quality of medical and preventive care for individuals with mental illness.
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Abstract
OBJECTIVE We examined whether having a psychiatric disorder among HIV-infected individuals is associated with differential rates of discontinuation of HAART and whether the number of mental health visits impact these rates. DESIGN This longitudinal study (fiscal year: 2000-2005) used discrete time survival analysis to evaluate time to discontinuation of HAART. The predictor variable was presence of a psychiatric diagnosis (serious mental illness versus depressive disorders versus none). SETTING Five United States outpatient HIV sites affiliated with the HIV Research Network. PATIENTS The sample consisted of 4989 patients. The majority was nonwhite (74.0%) and men (71.3%); 24.8% were diagnosed with a depressive disorder, and 9% were diagnosed with serious mental illness. MAIN OUTCOME MEASURES Time to discontinuation of HAART adjusting for demographic factors, injection drug use history, and nadir CD4 cell count. RESULTS Relative to those with no psychiatric disorders, the hazard probability for discontinuation of HAART was significantly lower in the first and second years among those with SMI [adjusted odds ratio: first year, 0.57 (0.47-0.69); second year, 0.68 (0.52-0.89)] and in the first year among those with depressive disorders [adjusted odds ratio: first year, 0.61 (0.54-0.69)]. The hazard probabilities did not significantly differ among diagnostic groups in subsequent years. Among those with psychiatric diagnoses, those with six or more mental health visits in a year were significantly less likely to discontinue HAART compared with patients with no mental health visits. CONCLUSION Individuals with psychiatric disorders were significantly less likely to discontinue HAART in the first and second years of treatment. Mental health visits are associated with decreased risk of discontinuing HAART.
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Copeland LA, Zeber JE, Wang CP, Parchman ML, Lawrence VA, Valenstein M, Miller AL. Patterns of primary care and mortality among patients with schizophrenia or diabetes: a cluster analysis approach to the retrospective study of healthcare utilization. BMC Health Serv Res 2009; 9:127. [PMID: 19630997 PMCID: PMC2723108 DOI: 10.1186/1472-6963-9-127] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Accepted: 07/26/2009] [Indexed: 11/10/2022] Open
Abstract
Background Patients with schizophrenia have difficulty managing their medical healthcare needs, possibly resulting in delayed treatment and poor outcomes. We analyzed whether patients reduced primary care use over time, differentially by diagnosis with schizophrenia, diabetes, or both schizophrenia and diabetes. We also assessed whether such patterns of primary care use were a significant predictor of mortality over a 4-year period. Methods The Veterans Healthcare Administration (VA) is the largest integrated healthcare system in the United States. Administrative extracts of the VA's all-electronic medical records were studied. Patients over age 50 and diagnosed with schizophrenia in 2002 were age-matched 1:4 to diabetes patients. All patients were followed through 2005. Cluster analysis explored trajectories of primary care use. Proportional hazards regression modelled the impact of these primary care utilization trajectories on survival, controlling for demographic and clinical covariates. Results Patients comprised three diagnostic groups: diabetes only (n = 188,332), schizophrenia only (n = 40,109), and schizophrenia with diabetes (Scz-DM, n = 13,025). Cluster analysis revealed four distinct trajectories of primary care use: consistent over time, increasing over time, high and decreasing, low and decreasing. Patients with schizophrenia only were likely to have low-decreasing use (73% schizophrenia-only vs 54% Scz-DM vs 52% diabetes). Increasing use was least common among schizophrenia patients (4% vs 8% Scz-DM vs 7% diabetes) and was associated with improved survival. Low-decreasing primary care, compared to consistent use, was associated with shorter survival controlling for demographics and case-mix. The observational study was limited by reliance on administrative data. Conclusion Regular primary care and high levels of primary care were associated with better survival for patients with chronic illness, whether psychiatric or medical. For schizophrenia patients, with or without comorbid diabetes, primary care offers a survival benefit, suggesting that innovations in treatment retention targeting at-risk groups can offer significant promise of improving outcomes.
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Affiliation(s)
- Laurel A Copeland
- VERDICT Research, South Texas Veterans Health Care System, San Antonio, TX, USA.
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