Examining the relationship of concurrent obesity and tobacco use disorder on the development of substance use disorders and psychiatric conditions: Findings from the NESARC-III

Background

Multimorbidity is linked to worse health outcomes than single health conditions. However, recent studies show that obesity may reduce the risk of developing substance use disorders (SUDs), particularly in vulnerable populations. We investigated how comorbid obesity and tobacco use disorder (TUD) relate to the risk of SUDs and psychiatric conditions.

Methods

Data was used from 36,309 individuals who completed the National Epidemiological Survey on Alcohol and Related Conditions - Wave III. Individuals who met the DSM-5 criteria for TUD in the last year were defined as the TUD group. Obesity was defined as having a body mass index (BMI) greater than 30 kg/m2. Using this information, individuals were grouped into categories, with people being identified as either having obesity, TUD, both obesity and TUD, or not having either obesity or TUD (comparison). Groups were compared against their comorbid diagnoses of either an additional SUD or psychiatric conditions.

Results

Controlling for demographic characteristics, we found that individuals with obesity including those individuals with TUD, had lower rates of comorbid SUD diagnosis than individuals with TUD alone. Additionally, individuals with combined TUD and obesity, and those with TUD alone, had the highest rates of comorbid psychiatric disorder diagnosis.

Conclusions

The current study aligns with previous research suggesting that obesity may reduce risk of substance use disorders, even in individuals who have other risk factors promoting harmful substance use (e.g., tobacco use). These findings may inform targeted intervention strategies for this clinically relevant subpopulation.

Joining psychiatric care and faith healing in a prayer camp in Ghana: randomised trial

BACKGROUND

Care of people with serious mental illness in prayer camps in low-income countries generates human rights concerns and ethical challenges for outcome researchers. Aims To ethically evaluate joining traditional faith healing with psychiatric care including medications (Clinical trials.gov identifier NCT02593734).

METHOD

Residents of a Ghana prayer camp were randomly assigned to receive either indicated medication for schizophrenia or mood disorders along with usual prayer camp activities (prayers, chain restraints and fasting) (n = 71); or the prayer camp activities alone (n = 68). Masked psychologists assessed Brief Psychiatric Rating Scale (BPRS) outcomes at 2, 4 and 6 weeks. Researchers discouraged use of chaining, but chaining decisions remained under the control of prayer camp staff.

RESULTS

Total BPRS symptoms were significantly lower in the experimental group (P = 0.003, effect size -0.48). There was no significant difference in days in chains.

CONCLUSIONS

Joining psychiatric and prayer camp care brought symptom benefits but, in the short-run, did not significantly reduce days spent in chains. Declaration of interest None.

Incarceration histories of homeless veterans and progression through a national supported housing program

There is increasing concern that adults with a past history of incarceration are at particular disadvantage in exiting homelessness. Supported housing with case management has emerged as the leading service model for assisting homeless adults; however there has been limited examination of the success of adults with past history of incarceration in obtaining housing within this paradigm. Data were examined on 14,557 veterans who entered a national supported housing program for homeless veterans, the Housing and Urban Development-Veterans Affairs Supportive Housing program (HUD-VASH) during 2008 and 2009, to identify characteristics associated with a history of incarceration and to evaluate whether those with a history of incarceration are less likely to obtain housing and/or more likely to experience delays in the housing attainment process. Veterans who reported no past incarceration were compared with veterans with short incarceration histories (≤ 1 year) and those with long incarceration histories (>1 year). A majority of participants reported history of incarceration; 43 % reported short incarceration histories and 22 % reported long incarceration histories. After adjusting for baseline characteristics and site, history of incarceration did not appear to impede therapeutic alliance, progression through the housing process or obtaining housing. Within a national supported housing program, veterans with a history of incarceration were just as successful at obtaining housing in similar time frames when compared to veterans without any past incarceration. Supported housing programs, like HUD-VASH, appear to be able to overcome impediments faced by formerly incarcerated homeless veterans and therefore should be considered a a good model for housing assistance programs.

Cigarette smoking, psychopathology and cognitive function in first-episode drug-naive patients with schizophrenia: a case-control study

BACKGROUND

Although patients with chronic schizophrenia have substantially higher smoking rates than either the general population or patients with other mental illnesses, drug-naive patients with a first episode of schizophrenia have received little systemic study. This study examined smoking rates, the association between smoking and symptom severity and cognitive function in Chinese first-episode schizophrenia (FES) patients using cross-sectional and case-control designs.

METHOD

Two hundred and forty-four drug-naive FES patients and 256 healthy controls matched for gender, age and education completed the Fagerström Test for Nicotine Dependence (FTND) and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Patients were also rated on the Positive and Negative Symptom Scale (PANSS).

RESULTS

The rate and quantity of smoking were not significantly higher among FES patients compared to the general population. Among patients, smokers scored higher than non-smokers on the total PANSS and the positive symptom subscale scores. There were no significant associations between cognitive function and smoking in either FES patients or healthy controls.

CONCLUSIONS

In contrast to studies in patients with chronic schizophrenia, drug-naive FES patients did not smoke more frequently than the general population. Furthermore, patients with psychotic disorders who smoked did not exhibit significant cognitive differences compared with those who did not smoke. However, smoking may have other detrimental effects on physical and mental health, for example on positive symptoms.

Fast food consumption and increased caloric intake: a systematic review of a trajectory towards weight gain and obesity risk

Consumption of fast food, which have high energy densities and glycemic loads, and expose customers to excessive portion sizes, may be greatly contributing to and escalating the rates of overweight and obesity in the USA. Whether an association exists between fast food consumption and weight gain is unclear. Sixteen studies (six cross sectional, seven prospective cohort, three experimental) meeting methodological and relevance criteria were selected for inclusion in this systematic review. While more research needs to be conducted specifically in regard to effects of fast food consumption among subpopulations such as children and adolescents, sufficient evidence exists for public health recommendations to limit fast food consumption and facilitate healthier menu selection. As the fast food industry continues to increase both domestically and abroad, the scientific findings and corresponding public health implications of the association between fast food consumption and weight are critical.

Stages in the implementation of innovative clinical programs in complex organizations

Organizational processes can have an important impact on the introduction of innovative treatments into practice. Conceptual frameworks from organization theory and experiences implementing several hundred specialized mental health programs in the Department of Veterans Affairs (VA) over the past 15 years are used to illustrate stages and processes in the implementation of new treatment models. Four phases in the implementation of new treatments in complex organizational settings are described: a) the decision to implement, b) initial implementation, c) sustained implementation, and d) termination or transformation. Key strategies for moving research into practice include constructing decision-making coalitions, linking new initiatives to legitimate goals and values, quantitative monitoring of implementation and performance, and the development of self-sustaining communities of practice as well as learning organizations. Effective dissemination of new treatment methods requires different organizational strategies at different phases of implementation.

Using a computerized patient database to evaluate guideline adherence and measure patterns of care for major depression

This study examined the translation of recommendations from the Agency for Health Care Policy and Research (AHCPR) guidelines for major depression into measures derived from a computerized database to assess guideline conformance and patterns of care for major depression. Patients (n = 208) were identified who were hospitalized for major depression and had two or more outpatient mental health appointments within 6 months of discharge from an academically affiliated Veterans Affairs Medical Center. Measures were based on AHCPR guideline recommendations or developed independently. Conformance could be measured for three guideline recommendations. Of patients on single-agent antidepressant therapy, 87% received dosages within the recommended range. Sixty-nine percent received the recommended number of follow-up visits. Specific condition-related treatment interventions were identified in 32% of patients with concurrent alcoholism. Dual diagnoses of depression and drug or alcohol abuse were not deterrents to prescribing benzodiazepines. Despite its limitations, computerized database analyses provided efficient measures of guideline adherence.

Impact of clozapine prescription on inpatient resource utilization

Although clozapine has been demonstrated to be clinically superior to typical neuroleptics in refractory schizophrenia, it is also more expensive. It had been hoped that the increased costs associated with its use would be offset by decreases in the utilization of other expensive resources, especially inpatient care. All patients who had clozapine initiated during an inpatient hospitalization within the VA for schizophrenia over a 4-year period (N = 1415) were matched with a comparison group (N = 2,830) on key service utilization variables and other possible confounding demographic and clinical variables using propensity scoring-an accepted statistical method, although still relatively little used in psychiatry. By using centralized VA databases, subsequent inpatient resource utilization for the 3 years after index discharge was examined. Veterans exposed to clozapine while inpatients recorded 33 (36%) more inpatient days in the subsequent 3 years after discharge than the comparison group (124 +/- 190 days vs. 91 +/- 181 days, p = .0002). When all patients exposed to clozapine were divided according to whether they had received 1 year of clozapine treatment after discharge, those that received less than 1 year's treatment recorded significantly more inpatient days than either those maintained on clozapine or controls. These results suggest that in actual practice clozapine treatment may cost substantially more than treatment with conventional neuroleptics.

Detecting improvement in quality of life and symptomatology in schizophrenia

Instrument-based scores are often used as outcome measures. However, little is known about what changes in scores mean in terms of a clinical assessment of improvement or deterioration. The purpose of this report was to determine how much change in standard instrument scores represents a clinically detectable improvement or deterioration. The Veterans Affairs (VA) Cooperative Study of Clozapine in Refractory Schizophrenia evaluated 423 patients on clozapine or haloperidol. Symptoms and quality of life scales were completed at baseline; 6 weeks; and 3, 6, and 12 months. Among patients judged as "improved" by clinicians, the average percentage changes were a 21 percent decrease in Positive and Negative Syndrome Scale (PANSS) scores and a 26 percent increase in Quality of Life Scale (QLS) scores across all followup periods. The change in mean seven-point item scores were -0.46 (PANSS) and 0.23 (QLS). A major gain in clinically assessed improvement to "much better" was associated with a 45 percent decline in PANSS scores and 50 percent increase in QLS scores (change in mean seven-point item scores -0.88 and 0.92, respectively). Thus, modest changes in psychometric scales assessing symptoms and quality of life reflect clinically detectable improvement.

The proportion of veterans among homeless men: a decade later

BACKGROUND

The purpose of this report is to evaluate the risk of homelessness among veterans as compared to non-veterans, and to ascertain whether the exceptionally high risk of homelessness among post-Vietnam era veterans first observed in 1987 was still evident one decade later.

METHOD

Data from the 1996 National Survey of Homeless Assistance Providers and Clients and the 1996 Current Population Survey were used to examine the risks of homelessness among veteran men as compared to non-veteran men, stratified by age and race.

RESULTS

The present results show that the cohort of veterans aged 20-34 that was most at risk in the 1980s, although no longer the youngest, still has the highest risk for homelessness. In 1996, the youngest cohort of veterans is also over-represented, but not to the extent found among young men 10 years before. Veterans over the age of 55 showed no increased risk of homelessness as compared to non-veterans.

CONCLUSIONS

The observed cohort effect, which demonstrates an especially high risk of homelessness among veterans of the immediate post-Vietnam era, even as they age, may reflect the continuing influence of the early problems in recruiting for the All Volunteer Force (AVF). In contrast to the national draft, which promised a fair representation of the entire population of draft-eligible young men, the AVF also had the potential to attract young men with fewer alternative opportunities.

Mental and physical health and acculturation among Hispanic Vietnam Veterans

This study tested the associations between acculturation and mental and physical health among Hispanic Vietnam veterans. Secondary data analyses of the National Vietnam Veterans Readjustment Survey, an epidemiological study of a representative sample of veterans who served during the Vietnam era (N = 1,195), were conducted. An acculturation index was constructed using standard acculturation measures (range, 0-13), and its predictive validity was tested using nine outcome measures of physical health and eight measures of mental health. Among Puerto Rican and Mexican-American veterans, the scores on the acculturation index ranged from 0 to 12. Hispanic veterans were distributed across the acculturation continuum as follows: 0 to 3 (24%), 4 to 7 (59%), 8 to 12 (17%). The acculturation scores were not associated with mental or physical health risks for Hispanic veterans. Mexican Americans and Puerto Ricans did not differ in mental or physical health risk compared with non-Hispanic whites. The association between acculturation and mental and physical health among Hispanics may not be generalized to Hispanic veterans. Hispanics who have been through an intensive assimilating experience, such as being in the military, appear to have health outcomes similar to whites.

Perceived needs and service use of Spanish speaking monolingual patients followed at a Hispanic clinic

This study compared Spanish speaking monolingual patients at a Hispanic Clinic, with Hispanics and non-Hispanics at a conventional mental health center. A questionnaire in English and Spanish surveyed sociodemographic characteristics and subjectively reported health needs. The monolingual Hispanic Clinic patients perceived a significantly greater need for help with health and benefits, and better access to physical health care providers. Hispanics seen at the Hispanic Clinic report more difficulties managing medications than the other groups suggesting that this problem is not adequately addressed by receiving services in a culturally sensitive clinic, possibly due to the persistent effect of language barriers and low level of education. Additional interventions may be needed to address this problem.

Service delivery and community: social capital, service systems integration, and outcomes among homeless persons with severe mental illness

OBJECTIVES

This study evaluated the influence of features of community social environment and service system integration on service use, housing, and clinical outcomes among homeless people with serious mental illness.

STUDY SETTING

A one-year observational outcome study was conducted of homeless people with serious mental illness at 18 sites.

DATA SOURCES

Measures of community social environment (e.g., social capital) were based on local surveys and voting records. Housing affordability was assessed with housing survey data. Service system integration was assessed through interviews with key informants at each site to document interorganizational transactions. Standardized clinical measures were used to assess clinical and housing outcomes in face-to-face interviews.

RESEARCH DESIGN

Structural equation modeling was used to determine the relationship between (1) characteristics of the social environment (social capital, housing affordability); (2) the level of integration of the service system for persons who are homeless in each community; (3) access to and use of services by individual clients; and (4) successful exit from homelessness or clinical improvement.

PRINCIPAL FINDINGS

Social capital was associated with greater service systems integration, which was associated in turn with greater access to assistance from a public housing agency and to a greater probability of exiting from homelessness at 12 months. Housing affordability also predicted exit from homelessness. Neither environmental factors nor systems integration predicted outcomes for psychiatric problems, substance abuse, employment, physical health, or income support.

CONCLUSION

Community social capital and service system integration are related through a series of direct and indirect pathways with better housing outcomes but not with superior clinical outcomes for homeless people with mental illness. Implications for designing improved service systems are discussed.

Buprenorphine for opiate addiction: potential economic impact

This study evaluated the potential economic impact of the buprenorphine/naloxone combination in the context of practice in the United States of America. In comparison to treatment provided through methadone clinics, buprenorphine/naloxone therapy in office practice may be associated with increased medication, physician, and nursing costs, but reduced costs for dispensing, toxicology screens, counseling and administration. It may also result in markedly reduced costs for patients, especially travel costs, resulting in net savings for society as a whole. A review of controlled studies suggest that buprenorphine/naloxone is not likely to be any more or less effective than methadone, but since it will be less expensive in the long run, it may be more cost-effective than methadone when provided to comparable groups of patients. Because of the convenience of office-based treatment, buprenorphine/naloxone may increase access to opiate substitution for some addicts. To the extent that treatment is provided to additional high-cost patients who are involved in extensive criminal activity or who undergo multiple detoxifications each year, net cost savings could be substantial. To the extent that treatment is extended to better adjusted addicts who are employed, married and experience fewer adverse effects from their addiction, costs could increase. The total cost impact will depend on which addict sub-populations make greatest use of the treatment opportunity presented by buprenorphine/naloxone.

A model of patients' satisfaction with treatment for posttraumatic stress disorder

There is little empirical knowledge about the contribution of treatment effectiveness to patient satisfaction, particularly in the area of mental health. We conducted this study to assess the satisfaction of 3,646 veterans who received treatment from March 1996-April 1997 at specialized inpatient and residential posttraumatic stress disorder programs at Departments of Veterans Affairs in 35 locations. We used structural equation modeling to evaluate and extend a model of connections among pretreatment characteristics, treatment structure, treatment effectiveness and patient satisfaction. The results suggest three implications for mental health administration and program planning: (1) any valid comparison of programs requires that differences in patient characteristics be taken into account, (2) satisfaction and effectiveness are largely separate indices of quality, and (3) shortening the length of stay to contain cost is likely to lower patient satisfaction.

The effect of institutional fiscal stress on the use of atypical antipsychotic medications in the treatment of schizophrenia

This paper examines the effects of medical center budget stress on the use of expensive atypical antipsychotic medications for the treatment of schizophrenia in the Department of Veterans Affairs (VA). VA prescription drug records were collected for patients diagnosed with schizophrenia. Generalized estimation equations were used to identify patient and facility characteristics (especially fiscal stress) that are associated with the use of atypical antipsychotics. Of the 34,925 patients in the final sample, over half received an atypical antipsychotic, usually either olanzapine or risperidone. Unexpectedly, increased fiscal stress was associated with increased likelihood of receiving atypical antipsychotics. Among patients who receive atypicals, however, fiscal stress was associated with reduced likelihood of receiving the more expensive atypicals (clozapine and olanzapine) but positively associated with receiving the least expensive atypical (risperidone). Institutional fiscal pressure does not seem to reduce the broad availability of these medications overall but does affect which drug is prescribed.

Impact of clozapine on completed suicide

OBJECTIVE

Clozapine has been found to be superior to typical neuroleptics in ameliorating the symptoms of refractory schizophrenia. This study evaluated clozapine's effect on the rate of death due to suicide.

METHOD

All patients over a 4-year period who initiated treatment with clozapine while hospitalized within the Department of Veterans Affairs (VA) system (N=1,415) were matched with a schizophrenic control group (N=2,830) by propensity scoring-a widely accepted statistical method that has been used relatively little in psychiatric research. Centralized VA databases and a national death registry were used to identify all deaths within the two groups, along with listed causes, for the 3 years after discharge.

RESULTS

Veterans exposed to clozapine while inpatients were significantly less likely to die during the follow-up period than those in the control group, but this was entirely attributable to the much lower rate of death due to respiratory disorders in the clozapine group. There were no significant differences in rates of suicide or accidental death.

CONCLUSIONS

These results fail to support the hypothesis that clozapine treatment is associated with significantly fewer deaths due to suicide.

From clinical trials to real-world practice: use of atypical antipsychotic medication nationally in the Department of Veterans Affairs

BACKGROUND

Although clinical trials evaluate pharmacotherapeutic interventions under highly controlled conditions, there remains a need to evaluate medication use in actual practice.

METHODS

Patients prescribed atypical antipsychotic medications in the VA system during a 4-month period in 1999 (n = 73,981) were classified into 32 groups on the basis of clinical diagnosis and recent level of inpatient use. Variation was examined across groups in drug costs, agents, dosages, and duration of use. The potential impact of these medications on VA costs was estimated by calculating medication costs and subtracting estimated inpatient savings.

RESULTS

A majority of patients were diagnosed with schizophrenia (57.2%), but substantial off-label use of these medications to treat other psychiatric illnesses was also evident (42.8%). Compared with published trials reporting average annual costs from $3,000 to $7,000, average annualized pharmacy costs were only $1,395 per patient because of a 58.5% VA price discount; relatively low dosing, especially for people with diagnoses other than schizophrenia; and medication prescription coverage for only 75% of the days in the study period. The sample averaged only 6.96 inpatient days; as a result, potential inpatient savings were limited. Assuming 0% to 18% inpatient savings, annual net drug costs are estimated to range from $500 to $1,152 per patient.

CONCLUSIONS

Medication costs in actual practice can be substantially lower than in clinical trials. Atypical antipsychotic medications in actual VA practice incur net costs estimated at $500 to $1,152 per patient per year with substantial variation across clinical subgroups.

Quality of life in schizophrenia: a comparison of instruments. Department of Veterans Affairs Cooperative Study Group on Clozapine in Refractory Schizophrenia

Health-related quality of life in schizophrenia can be assessed by direct patient response or by a rating based on a structured interview. This study compares both types of instruments using a series of five standards: (1) sensitivity to change over time, (2) sensitivity to treatment effect, (3) correlation with symptom severity, (4) correlation with global clinical ratings, and (5) correlation with other measures of health-related quality of life. Four hundred and twenty-three inpatients with schizophrenia participating in a clinical trial comparing clozapine and haloperidol (VA Cooperative Study in Health Services #17) were evaluated using multiple measures of health-related quality of life (Lehman Quality of Life Interview; Heinrichs-Carpenter-Hanlon Quality of Life Scale; Strauss-Carpenter Level of Function scale, and clinical response.) The Quality of Life Interview showed less sensitivity to change and treatment effect, as well as lower correlations with all other measures than the Quality of Life Scale and the Level of Function scale. The latter scales showed high sensitivity to both change and treatment effect, and moderate-high correlations with other measures and with each other. The Quality of Life Scale and the Level of Function scale rater assessments appeared to be substantially more sensitive to subtle change and treatment effects than the patient-reported Quality of Life Interview for clinical trials. Health-related quality of life in schizophrenia is a more heterogeneous concept than previously appreciated.

Impact of efforts to reduce inpatient costs on clinical effectiveness: treatment of posttraumatic stress disorder in the Department of Veterans Affairs

BACKGROUND

There have been major reductions in the availability of inpatient psychiatric care in the United States in recent years.

OBJECTIVE

The objective of this study was to evaluate the clinical impact of cost-cutting changes in the delivery of inpatient psychiatric care.

DESIGN

This was a nonequivalent control group pre/post design.

SUBJECTS

Outcome data on 6,397 veterans treated between 1993 and 2000 at 35 specialized VA inpatient and residential programs for posttraumatic stress disorder (PTSD) were used to compare changes in effectiveness (measured as patient improvement from admission to 4 months after discharge) at programs that either shortened their average length of stay or converted from a hospital-based program to a low-cost residential rehabilitation program. For comparison, outcome data are also presented over the same years from both inpatient PTSD programs and residential PTSD programs that did not experience program change.

MEASURES

Measures addressed baseline characteristics and 4-month postdischarge outcome measures of PTSD symptoms, substance abuse, violent behavior, and employment.

RESULTS

Analyses of covariance showed no significant change in outcomes at inpatient programs that either reduced their length of stay or did not change at all. However, effectiveness declined on some measures at inpatient programs that converted to residential treatment during this period but improved at residential treatment programs that had been established before this period of change.

CONCLUSIONS

Although there was no deterioration in effectiveness related to reduced length of inpatient stay, programs that converted to a residential model showed decreased effectiveness.

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.

Consumer experience with payeeship provided by a community mental health center

We surveyed 28 participants in a program in which the clinical therapist and money manager were different staff members. Patients reported strong therapeutic alliances with both the money manager and treating therapist as assessed by the Working Alliance Inventory. Alliance scores for the two providers were highly correlated (p = .68) and not significantly different from each other. Most patients endorsed overall satisfaction with the money management service, and report program-related benefits in housing, achieving abstinence, avoiding financial predators and budgeting arrangements. A significant minority endorsed some feeling of coercion, and coercion was associated with a weaker therapeutic alliance.

Neuroleptic use in the treatment of Post-Traumatic Stress Disorder

BACKGROUND

There have been few studies of the use of neuroleptics in the treatment of Post-Traumatic Stress Disorder (PTSD). This study uses data from two large outcome studies to: (1) examine demographic and treatment characteristics associated with neuroleptic prescription in the treatment of PTSD, and (2) compare the outcomes of neuroleptic-treated patients with those not receiving neuroleptics.

METHODS

A secondary analysis of an observational outcome study of 831 inpatients and 554 outpatients (all males) receiving treatment at the VA for combat-related PTSD was performed. Patients were classified as having either received neuroleptics during the following year or not. Sociodemographic characteristics, treatment and medication history and detailed information about PTSD symptoms were obtained at baseline and 12 months. First, the two groups were compared with respect to the demographic and clinical variables. We then conducted a series of separate paired t-tests to determine whether there was significant improvement from baseline to follow up in each group and a series of analyses of covariance that compared outcomes in the two groups, adjusting for baseline differences.

RESULTS

Approximately 9% of inpatients and 10% of outpatients were treated with neuroleptics. Patients who received neuroleptics had both more psychiatric and more social impairment. They also demonstrated more severe PTSD (especially intrusive symptoms) despite having similar combat exposure. Outcomes after one year for the group treated with neuroleptics were not significantly different from the group not treated with neuroleptics.

CONCLUSIONS

Neuroleptic use in the treatment of PTSD is targeted at more seriously ill patients and was not associated with substantial improvement.

Homeless mothers with severe mental illnesses and their children: predictors of family reunification

Although many homeless women lose physical custody of children, prior studies have not examined predictors of reunification. To explore factors associated with separation and potential resources for reunification, baseline data from 1,542 homeless women with mental illness were used to identify unique characteristics of separated mothers. Separated mothers demonstrated greater vulnerabilities than accompanied mothers did, but more resources than women who are not mothers did. Of 698 separated mothers, 118 (17%) were reunited with children at 12 months. Changes in housing, psychosis, substance use and therapeutic relationships predicted reunification. Results suggest that programs for homeless mothers with severe mental illness can affect changes that promote family reunification.

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

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

Military discharge status of homeless veterans with mental illness

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

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

STUDY SETTING

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

DATA SOURCES

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

DESIGN

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

KEY FINDINGS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Benzodiazepine use in posttraumatic stress disorder among veterans with substance abuse

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

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

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

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

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

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

OBJECTIVE

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

DATA SOURCES/STUDY SETTING

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

STUDY DESIGN

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

DATA COLLECTION/EXTRACTION METHODS

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

PRINCIPAL FINDINGS

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

CONCLUSIONS

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

Posttraumatic stress disorder among Hispanic Vietnam veterans

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

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

Mortality among homeless and nonhomeless mentally ill veterans

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

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

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

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

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

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

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

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