Rural and urban differences in patients with a dual diagnosis

OBJECTIVES

To evaluate the differences between two cohorts of patients with severe mental illness (schizophrenia-spectrum or bipolar disorder) and co-occurring substance-use disorders, living in either predominantly rural areas or urban areas.

METHODS

Two study groups of patients with a dual diagnosis, recruited using the same criteria, were evaluated, including 225 patients from New Hampshire and 166 patients from two cities in Connecticut. The two study groups were compared on demographic characteristics, housing, legal problems, psychiatric and substance use diagnoses, substance use and abuse, psychiatric symptoms, and quality of life.

RESULTS

Patients in the Connecticut study group had higher rates of cocaine-use disorder, more involvement in the criminal justice system, more homelessness, and were more likely to be from minority backgrounds. The Connecticut group also had a higher proportion of patients with schizophrenia and more severe symptoms, as well as lower rates of marriage, educational attainment, and work than the New Hampshire study group. Alcohol-use disorder was higher in the New Hampshire group. Subsequent analyses within the Connecticut group indicated that although African American patients had higher rates of cocaine-use disorder than white patients, cocaine disorder and not minority status was most strongly related to criminal involvement and homelessness.

CONCLUSIONS

Because of the substances abused and the greater degree of psychiatric illness severity, patients with a dual diagnosis who are living in urban areas may require greater ancillary services, such as residential programs, Assertive Community Treatment, and jail diversion programs in order to treat their disorders successfully.

Impact of VA bed closures on use of state psychiatric services

This study examined whether inpatient bed reductions at a Department of Veterans Affairs (VA) medical center increased VA patients' use of state mental health agency services. Veterans residing in two Connecticut cities who used VA psychiatric services during fiscal years 1993 through 1998 (n = 2,943) were identified from computerized files. Then their records were merged with state files. Coinciding with the time of VA bed closures, the proportion of VA patients who used any state services increased from 2.6%, 2.8%, and 2.7% from 1993 through 1995 to 3.6%, 3.5%, and 3.6% from 1996 through 1998 (p < .03). These changes reflect increased likelihood of state outpatient service use, but not inpatient services. No statistically significant changes occurred in the cost of state services used by VA patients. Bed closure impact may be reflected in increased cross-system service use, which may be a useful indicator of unmet needs resulting from system changes.

Outcomes after initial receipt of social security benefits among homeless veterans with mental illness

OBJECTIVE

This study examined the relationship between receiving disability payments and changes in health status, community adjustment, and subjective quality of life.

METHODS

The study evaluated outcomes among homeless mentally ill veterans who applied for Social Security Disability Insurance or Supplemental Security Income through a special outreach program. Veterans who were awarded benefits were compared with those who were denied benefits; their sociodemographic characteristics, clinical status, and social adjustment were evaluated just before receiving the initial award decision and again three months later.

RESULTS

Beneficiaries (N=50) did not differ from those were denied benefits (N=123) on any baseline sociodemographic or clinical characteristics. However, beneficiaries were more willing to delay gratification, as reflected in scores on a time preference measure. Three months after the initial decision, beneficiaries had significantly higher total incomes and reported a higher quality of life. They spent more on housing, food, clothing, transportation, and tobacco products but not on alcohol or illegal drugs. No differences were found between groups on standardized measures of psychiatric status or substance abuse.

CONCLUSIONS

Receipt of disability payments is associated with improved subjective quality of life and is not associated with increased alcohol or drug use.

Referral and housing processes in a long-term supported housing program for homeless veterans

OBJECTIVE

The study examined client characteristics, case management variables, and housing features associated with referral, entry, and short-term success in a Department of Veterans Affairs (VA) national intensive case management and rental assistance program for homeless veterans.

METHODS

Information collected from homeless veterans at the time of initial outreach contact and from case managers during the housing search was used to create logistic regression models of referral into the program and successful completion of several stages in the process of obtaining stable independent housing.

RESULTS

Overall, only 8 percent of the more than 65,000 eligible veterans contacted by outreach workers were referred to the program. Those referred were more likely to be female, to have more sources of income, to have recently used VA services (including residential treatment), and to have serious mental health problems. Once in the program, 64 percent of veterans eventually moved into an apartment, and 84 percent of those who obtained an apartment were stably housed one year later. In general, activities of case managers, such as accompanying the veteran to the public housing authority and securing additional sources of income, were associated with success in the housing process. The therapeutic alliance, clients' housing preferences, and the quality of housing were unrelated to retention of housing.

CONCLUSIONS

This supported housing program was judged appropriate for a small percentage of eligible veterans. However, a large proportion of clients were successful in attaining permanent housing, which lends support to the effectiveness of the supported housing approach.

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

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

Homeless veterans' satisfaction with residential treatment

OBJECTIVE

Because little is known about homeless individuals' satisfaction with mental health services or the association between satisfaction and measures of treatment outcome, the study examined those issues in a group of homeless veterans.

METHODS

Demographic and clinical data were obtained from intake assessments conducted before veterans' admission to residential treatment facilities under contract with the Department of Veterans Affairs Health Care for Homeless Veterans program, a national outreach and case management program. Clients completed a satisfaction survey and the Community-Oriented Programs Environment Scale, which asks them to rate dimensions of the treatment environment. Outcome data came from discharge outcome summaries completed by VA case managers.

RESULTS

Overall satisfaction with residential treatment services was high among the 1,048 veterans surveyed. Greater satisfaction was associated with more days of drug abuse and more days spent institutionalized in the month before intake and with an intake diagnosis of drug abuse. Regression analyses indicated that satisfaction was most strongly related to clients' perceptions of several factors in the treatment environment. Policy clarity, clients' involvement in the program, an emphasis on order, a practical orientation, and peer support were positively related to satisfaction; staff control and clients' expression of anger were negatively related. Satisfaction was significantly associated with case managers' discharge ratings of clinical improvement of drug problems and psychiatric problems.

CONCLUSIONS

Homeless veterans are more satisfied in environments they perceive to be supportive, orderly, and focused on practical solutions. The results indicate that client satisfaction is not related to treatment outcomes strongly enough to serve as a substitute for other outcome measures.

Improving access to disability benefits among homeless persons with mental illness: an agency-specific approach to services integration

OBJECTIVES

This study evaluated a joint initiative of the Social Security Administration (SSA) and the Department of Veterans Affairs (VA) to improve access to Social Security disability benefits among homeless veterans with mental illness.

METHODS

Social Security personnel were colocated with VA clinical staff at 4 of the VA's Health Care for Homeless Veterans (HCHV) programs. Intake assessment data were merged with SSA administrative data to determine the proportion of veterans who filed applications and who received disability awards at the 4 SSA-VA Joint Outreach Initiative sites (n = 6709) and at 34 comparison HCHV sites (n = 27 722) during the 2 years before and after implementation of the program.

RESULTS

During the 2 years after the initiative began, higher proportions of veterans applied for disability (18.9% vs 11.1%; P < .001) and were awarded benefits (11.4% vs 7.2%, P < .001) at SSA-VA Joint Initiative sites.

CONCLUSION

A colocation approach to service system integration can improve access to disability entitlements among homeless persons with mental illness. Almost twice as many veterans were eligible for this entitlement as received it through a standard outreach program.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effectiveness and cost of specific treatment elements in a program for homeless mentally ill veterans

OBJECTIVES

The study examined relationships between specific treatment elements and their costs and ten outcome measures using data from a longitudinal outcome study of a Veterans Affairs program for homeless mentally ill veterans.

METHODS

Baseline and outcome data over an eight-month period were analyzed for 406 homeless veterans with psychiatric and substance use disorders who were treated in VA's Homeless Chronically Mentally Ill Veterans Program. Multivariate techniques were used to examine the relationship between ten measures of outcome and six treatment elements: program entry via community outreach, the number of contacts with program clinicians, the number of referrals for other services, duration of program involvement, number of days of residential treatment, and increased public support payments.

RESULTS

Each of the six treatment elements was significantly related to improvement on at least one of the ten outcome measures. The number of clinical contacts with program staff and the number of days in residential treatment were associated with improvement in the greatest number of outcome domains. However, improvement associated with residential treatment was far more costly than improvement related to other treatment elements.

CONCLUSION

This study provides evidence of the effectiveness of a multimodal approach to the treatment of homeless mentally ill persons. However, results indicate that special attention should be paid to to differences in the cost of improvement associated with various treatment elements.

Disability compensation and work among veterans with psychiatric and nonpsychiatric impairments

OBJECTIVE

This study examined the relationship of Department of Veterans Affairs disability compensation payments and employment among veterans with psychiatric disorders and veterans whose impairments were nonpsychiatric.

METHODS

Data from a 1987-1988 national survey of Vietnam-era veterans (N = 1,634) were used to evaluate the relationship between compensation payments and employment. The employment activity of veterans whose application for benefits was rejected was compared with that of veterans who were awarded benefits. Multivariate analytic techniques were used to control for health status and other factors that also influence an individual's decision to work.

RESULTS

Veterans who received compensation of less than $500 a month were no less likely to work than were rejected applicants. Overall, the effect of compensation payment was significant but modest: each additional $100 a month was associated with a 2 percent decline in the number of veterans who worked, a decline of an hour a week in the number of hours worked, and a reduction of $1,000 a year in estimated employment income. No significant differences were observed in the relationship between disability payments and employment among veterans with psychiatric disorders and those with other functional impairments.

CONCLUSIONS

The association of disability compensation with nonparticipation in the labor force is generally small, except at high levels of payment, and is no greater for veterans with psychiatric disorders than for those with nonpsychiatric impairments.

Issues in estimating the cost of innovative mental health programs

This paper reviews problems encountered in estimating the unit cost of services provided by innovative mental health programs and illustrates methods for addressing these problems. Generally, the cost of a health care service is determined by identifying all resources used in its production and the cost of those resources. These costs are divided by appropriate workload measures to determine the cost per unit of service or per client. Issues that must be addressed include: 1) direct program costs; 2) indirect costs (including administration and capital costs); 3) program resources used to support research and other non-program activities; and 4) identification of "typical" workloads as the program is implemented. Application of these methods is illustrated with data from a multi-site study of intensive psychiatric community care conducted at nine Department of Veterans Affairs Medical Centers in the Northeast. A sensitivity analysis revealed that estimates of program costs vary by 59% over the entire program, and from 17%-168% at individual sites, depending on which cost estimation methods were included. The average cost of case management in this program varied considerably across sites, primarily reflecting differences in caseload size and staffing levels. Adjusting for inflation, the cost of this program falls below the cost of other published intensive community programs.

Multisite experimental cost study of intensive psychiatric community care

A 2-year experimental cost study of 10 Intensive Psychiatric Community Care (IPCC) programs was conducted at Department of Veterans Affairs (VA) medical centers in the Northeast. High hospital users were randomly assigned to either IPCC (n = 454) or standard VA care (n = 419) at four neuropsychiatric (NP) and six general medical and surgical (GMS) hospitals. National computerized data were used to track all VA health care service usage and costs for 2 years following program entry. At 9 of the 10 sites, IPCC treatment resulted in reduced inpatient service usage. Overall, for IPCC patients compared with control patients, average inpatient usage was 89 days (33%) less while average cost per patient (for IPCC inpatient, and outpatient services) was $15,556 (20%) less. Additionally, costs for IPCC patients compared with control patients were $33,295 (29%) less at NP sites but were $6,273 (15%) greater at GMS sites. At both NP and GMS sites, costs were lower for IPCC patients in two subgroups: veterans over age 45 and veterans with high levels of inpatient service use before program entry. No interaction was noted between the impact of IPCC on costs and other clinical or sociodemographic characteristics. Similarly, no linear relationship was observed between the intensity of IPCC services and the impact of IPCC on VA costs, although the two sites that did not fully implement the IPCC program had the poorest results. With these sites excluded, the total cost of care for IPCC patients at GMS sites was $579 (3%) more per year than that for the control patients.

The proportion of veterans among homeless men

This study used data from four surveys conducted in 1986/87 to identify age-race cohorts of homeless men in which veterans are overrepresented. The overall proportion of veterans among homeless men (41%) was somewhat higher than that in the general population (34%). This overrepresentation is largely attributable to the disproportionate representation of veterans in the youngest age cohort (20 to 34 years) of homeless White men. Veterans in this group are 4.76 times more likely to be homeless than nonveterans. Other national data on this cohort reveal higher rates of unemployment, substance abuse, and antisocial personality among veterans than among nonveterans.

Who should receive high-cost mental health treatment and for how long?

The use of some recently developed and promising mental health treatments is likely to be restricted by their high cost. Cost-effectiveness studies, however, suggest that high treatment costs may be offset by associated reductions in inpatient service use. In view of the considerable variation in the cost of inpatient treatment for the mentally ill, it may be cost-efficient to use high-cost treatments for frequent hospital users but not for others. To illustrate this principle, we examine 9-year trends in inpatient costs incurred by schizophrenia patients discharged from Department of Veterans' Affairs medical centers across the country in fiscal year (FY) 1982. Even in the absence of specific intervention, average inpatient costs in this sample fell 49 percent, from $7,368 per patient in FY 1983 to $3,770 per patient in FY 1990, reducing the potential for inpatient cost offsets over time. Sensitivity analyses of potential inpatient cost offsets were conducted using a range estimate both for the cost of treatment and for resulting reductions in inpatient expense. Assuming effectiveness in a middle range, high-cost intervention was projected to be cost-neutral for the 25 percent of the sample with the highest rates of baseline hospital use for a duration of 1-3 years. Although our specific model had low predictive power, the projection of cost offsets in large mental health systems deserves further examination and may prove to be one useful criterion, in addition to clinical effectiveness, for selecting patients to receive expensive treatment.