Change in framingham risk score in patients with schizophrenia: a post hoc analysis of a randomized, double-blind, 6-week trial of ziprasidone and olanzapine

OBJECTIVE

To examine the change in Framingham risk score (FRS) arising from short-term treatment with ziprasidone or olanzapine.

METHOD

Hospitalized adults with a primary DSM-IV diagnosis of schizophrenia or schizo-affective disorder were randomly assigned to 6 weeks of double-blind treatment with ziprasidone or olanzapine from November 21, 1998 to September 28, 2000. Data on fasting lipid levels were collected at screening and endpoint, and blood pressure was measured at screening and baseline and weekly until week 6 of treatment (or last visit). FRS for patients aged ≥30 years was calculated using an algorithm derived from the Framingham Heart Study. Baseline-to-endpoint least-squares mean changes in age-adjusted FRS by gender were compared using analysis of covariance (baseline adjusted).

RESULTS

Men who received olanzapine demonstrated a mean increase in their total cholesterol levels (+18.5 mg/dL; N = 53) and low-density lipoprotein cholesterol levels (+13.0 mg/dL; N = 45), whereas men who received ziprasidone demonstrated a mean decrease in their total cholesterol levels (-8.5 mg/dL; N = 44) and low-density lipoprotein cholesterol levels (-7.2 mg/dL; N = 40) (p = .0006 and p = .004, respectively). Additionally, men who received olanzapine showed an increase in baseline FRS (+7.69%; N = 53), whereas men who received ziprasidone showed a decrease in baseline FRS (-11.06%; N = 42) (p = .09). In women, treatment differences in FSR numerically favored ziprasidone but were not statistically significant. Neither treatment had a significant effect on blood pressure.

CONCLUSION

In short-term treatment, olanza-pine was associated with a significant worsening of lipid profile compared with ziprasidone, with a consequent increase in FRS versus ziprasidone. These findings, coupled with the significant weight gain in patients treated with olanzapine versus ziprasidone, warrant investigation in longer-term trials.

Outcome assessment of an antipsychotic drug algorithm: effects of the Mississippi State Hospital algorithm project

OBJECTIVE

This study evaluated a state psychiatric hospital's algorithm for prescribing antipsychotic drugs for inpatients with schizophrenia to determine whether its emphasis on cost efficiency is compatible with quality of care.

METHODS

Outcomes were compared for patients who received medication that was algorithm adherent or nonadherent. Risperidone and ziprasidone were first-step oral antipsychotics. Documentation of clinical rationale was acceptable for nonpreferred drug use. Outcomes of interest were length of hospitalization and "much improved" or "very much improved" status on the Clinical Global Impression severity scale (CGI-S).

RESULTS

Of 401 patients, 70% were male. The CGI-S modal rating of severity was "markedly ill." Duration of illness was longer for patients given algorithm-nonadherent (17.6±9.7 years) versus -adherent (14.9±11.6 years, p=.013) medication. No statistically significant between-group differences were observed for mean length of stay (51.4±35.5 days versus 43.8±27.4 days, adjusted difference p=.18) or median improvement time (adherent, 41 days; nonadherent, 42 days; CI=34-48 days for both group medians).

CONCLUSIONS

Prescription algorithm adherence was not associated with significantly increased length of inpatient stay or delayed time to improvement.

A pilot study of antipsychotic prescribing decisions for acutely-Ill hospitalized patients

BACKGROUND

Evidence on antipsychotic prescribing decisions is limited. This pilot study quantified factors considered in choosing an antipsychotic and evaluated the influence of metabolic status on treatment decisions.

METHODS

Prescribing decisions by 4 psychiatrists were examined based on 80 adult patients initiated on antipsychotic medication diagnosed with schizophrenia, schizoaffective disorder or bipolar disorder by DSM-IV criteria, who were admitted to an acute inpatient psychiatric program of an urban Veterans Affairs Medical Center. The primary analysis examined the association between antipsychotic treatment choice and predictions of symptom control and metabolic risk. Secondary analyses included comparison of the chosen and next best treatments in predicted symptom control and metabolic risk, the frequency of reasons cited for drug choice, and the association between treatment choice and patients' baseline metabolic parameters. Mean differences and odds-ratios (OR) with 95% confidence intervals were used to compare relationships between treatment choice, ratings of risk and metabolic data.

RESULTS

Antipsychotic choice correlated significantly with ratings of predicted symptom control (OR = .92, p = 0.02) and metabolic risk (OR = .88, p = 0.01). Mean differences between the chosen and next best drugs were significant but small in predicted symptom control (F = 2.81, df = 3, 76; p<0.05) compared with larger differences in anticipated metabolic risk (F = 14.80, df = 3, 76; p = 0.0001). Nevertheless, among 24 identified reasons influencing drug selection, anticipated metabolic risk of chosen antipsychotics was cited less often than efficacy measures. In contrast to psychiatrists' expectations of metabolic risk with selected treatments, we found that patients' actual baseline BMI, fasting glucose, blood pressure, and Framingham risk levels did not necessarily predict antipsychotic treatment choice independent of other factors.

CONCLUSION

In the context of an acute psychiatric hospitalization, pilot data suggest that predictions of symptom control and metabolic risk correlated significantly with antipsychotic choice, but study psychiatrists were willing to assume relative degrees of metabolic risk in favor of effective symptom control. However, prescribing decisions were influenced by numerous patient and treatment factors. These findings support the potential utility of the ATCQ questionnaire in quantifying antipsychotic prescribing decisions. Further validation studies of the ATCQ questionnaire could enhance translation of research findings and application of treatment guidelines.

Findings of a U.S. national cardiometabolic screening program among 10,084 psychiatric outpatients

OBJECTIVE

A national cardiometabolic screening program for patients in a variety of public mental health facilities, group practices, and community behavioral health clinics was funded by Pfizer Inc. between 2005 and 2008.

METHODS

A one-day, voluntary metabolic health fair in the United States offered patients attending public mental health clinics free cardiometabolic screening and same-day feedback to physicians from a biometrics testing third party that was compliant with the Health Insurance Portability and Accountability Act.

RESULTS

This analysis included 10,084 patients at 219 sites; 2,739 patients (27%) reported having fasted for over eight hours. Schizophrenia or bipolar disorder was self-reported by 6,233 (62%) study participants. In the overall sample, the mean waist circumference was 41.1 inches for men and 40.4 inches for women; 27% were overweight (body mass index [BMI] 25.0-29.9 kg/m(2)), 52% were obese (BMI >or=30.0 kg/m(2)), 51% had elevated triglycerides (>or=150 mg/dl), and 51% were hypertensive (>or=130/85 mm Hg). In the fasting sample, 52% had metabolic syndrome, 35% had elevated total cholesterol (>or=200 mg/dl), 59% had low levels of high-density lipoprotein cholesterol (<40 mg/dl for men or <50 mg/dl for women), 45% had elevated triglycerides (>or=150 mg/dl), and 33% had elevated fasting glucose (>or=100 mg/dl). Among the 1,359 fasting patients with metabolic syndrome, 60% were not receiving any treatment. Among fasting patients who reported treatment for specific metabolic syndrome components, 33%, 65%, 71%, and 69% continued to have elevated total cholesterol, low levels of high-density lipoprotein, high blood pressure, and elevated glucose levels, respectively.

CONCLUSIONS

The prevalence of metabolic syndrome and cardiometabolic risk factors, such as overweight, hypertension, dyslipidemia, and glucose abnormalities, was substantial and frequently untreated in this U.S. national mental health clinic screening program.

Findings of a U.S. national cardiometabolic screening program among 10,084 psychiatric outpatients

OBJECTIVE

A national cardiometabolic screening program for patients in a variety of public mental health facilities, group practices, and community behavioral health clinics was funded by Pfizer Inc. between 2005 and 2008.

METHODS

A one-day, voluntary metabolic health fair in the United States offered patients attending public mental health clinics free cardiometabolic screening and same-day feedback to physicians from a biometrics testing third party that was compliant with the Health Insurance Portability and Accountability Act.

RESULTS

This analysis included 10,084 patients at 219 sites; 2,739 patients (27%) reported having fasted for over eight hours. Schizophrenia or bipolar disorder was self-reported by 6,233 (62%) study participants. In the overall sample, the mean waist circumference was 41.1 inches for men and 40.4 inches for women; 27% were overweight (body mass index [BMI] 25.0-29.9 kg/m(2)), 52% were obese (BMI >or=30.0 kg/m(2)), 51% had elevated triglycerides (>or=150 mg/dl), and 51% were hypertensive (>or=130/85 mm Hg). In the fasting sample, 52% had metabolic syndrome, 35% had elevated total cholesterol (>or=200 mg/dl), 59% had low levels of high-density lipoprotein cholesterol (<40 mg/dl for men or <50 mg/dl for women), 45% had elevated triglycerides (>or=150 mg/dl), and 33% had elevated fasting glucose (>or=100 mg/dl). Among the 1,359 fasting patients with metabolic syndrome, 60% were not receiving any treatment. Among fasting patients who reported treatment for specific metabolic syndrome components, 33%, 65%, 71%, and 69% continued to have elevated total cholesterol, low levels of high-density lipoprotein, high blood pressure, and elevated glucose levels, respectively.

CONCLUSIONS

The prevalence of metabolic syndrome and cardiometabolic risk factors, such as overweight, hypertension, dyslipidemia, and glucose abnormalities, was substantial and frequently untreated in this U.S. national mental health clinic screening program.

Risk of discontinuation of atypical antipsychotic agents in the treatment of schizophrenia

OBJECTIVES

To compare discontinuation rates of atypical antipsychotic agents in patients with schizophrenia.

METHOD

Adult Maryland Medicaid patients with schizophrenia were categorized based on initial atypical antipsychotic drug received: aripiprazole (n=446); olanzapine (n=1705); quetiapine (n=1467); risperidone (n=1580); and ziprasidone (n=700). Discontinuation was measured using refill patterns, allowing 14-day gaps between refill dates. Using olanzapine as the reference drug, the hazard of discontinuation within the first year of follow-up was compared across atypicals using Cox proportional hazard models adjusted for demographic and clinical covariates. Sensitivity analysis tested the robustness of results by using different definitions of the index date.

RESULTS

At one-year follow-up, most patients discontinued their antipsychotic medication (90.4% adjusted mean discontinuation). The hazard ratio (HR) for discontinuing therapy in patients starting treatment on aripiprazole, risperidone, or ziprasidone was not significantly different from olanzapine [HR 1.047, 0.973 and 0.990, respectively]. Quetiapine was associated with significantly higher hazard of discontinuation [HR 1.130] than olanzapine. Covariates associated with significantly lower discontinuation were being male [HR 0.899], older age [HR 0.997] and being on concurrent medication when initiating therapy [HR 0.225]; having a previous hospitalization was associated with significantly higher discontinuation hazard [HR 1.276]. Results were robust in the sensitivity analysis.

CONCLUSIONS

Discontinuation rates were high at one-year follow-up and did not differ significantly for patients on aripiprazole, olanzapine, risperidone, or ziprasidone. The higher hazard of discontinuation associated with quetiapine when compared to olanzapine is consistent with that observed in Phase I of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE).

Patient satisfaction with an injection device for multiple sclerosis treatment

OBJECTIVES

To develop a measure of treatment satisfaction assessing attributes specific to injected interferon-beta-1a (IFN-beta-1a) for multiple sclerosis (MS), and to test pain and instrument sensitivity to change among patients changing injection devices.

MATERIALS AND METHODS

The MS Treatment Concerns Questionnaire (MSTCQ) was developed and tested with pain assessments before and 3 months after patients changed devices from Rebiject to Rebiject II.

RESULTS

The MSTCQ was organized with two domains: Injection System Satisfaction and Side Effects (three subscales: Injection Site Reactions, Global Satisfaction, and Flu-Like Symptoms). Significant improvements (P = 0.002 to P < 0.001) occurred with the new injection device in all MSTCQ subscales (except Flu-Like Symptoms), and all pain measures (P < 0.0001). Clinically meaningful improvement was demonstrated in all scales, except Flu-Like Symptoms, by effect sizes (0.23-0.59).

CONCLUSIONS

These statistically significant and clinically meaningful improvements in MSTCQ and pain measures show the value of technologically advanced devices in domains of concern to patients.

Profiling hospitals for length of stay for treatment of psychiatric disorders

Managed behavioral health care organizations (MBHOs) often profile hospitals on length of stay (LOS) and other performance measures. However, previous research has suggested that most of the variation in utilization for general medical conditions is attributable to case-mix indicators and random sources rather than individual providers. Hospital discharge data are used to estimate hierarchical linear models, where hospitals and physicians within hospitals are treated as a random effect. The goal was to determine the intraclass correlation coefficient (ICC) for psychiatric LOS for hospitals and for physicians before and after making case-mix adjustments. After controlling for case-mix, the hospital ICCs for depression, schizophrenia, and bipolar disorder show that 32%, 36%, and 11% of the variation in LOS, respectively, can be attributed to hospitals, while 7%, 5%, and 6% of the variation in LOS, respectively, can be attributed to physicians or provider practice. Unlike health services for other conditions, the variation in LOS for inpatient psychiatric treatment of depression and schizophrenia is quite dependent upon hospitals.

Patterns of medical resource and psychotropic medicine use among adult depressed managed behavioral health patients

Medical and pharmacy utilization patterns were examined among 782 depressed patients seen by independent clinicians through a Managed Behavioral Health Organization using behavioral, medical and pharmacy claims spanning 2 years. Two-thirds received psychiatric care in the medical and mental health sector concurrently, 43% had comorbid medical disorders, 61% received psychotropic medications, and 54% were on antidepressants. Fewer depressed medically comorbid patients used medical services while in mental health treatment than before or after treatment, while the per patient costs remained the same. For those with chronic conditions, medical utilization and costs remained the same. A quarter of depressed patients received mental health treatment before seeing a mental health specialist, and a quarter remained in treatment in the medical sector after treatment in the mental health sector. Despite increases in mental health services access made available through managed behavioral health organizations, patients continue receiving mental health treatment in the medical sector.

Clinical practice variations in prescribing antipsychotics for patients with schizophrenia

Few studies have examined the variations among individual physicians in prescribing antipsychotics for schizophrenia. This study examined clinical practice variations in the route and dosage of antipsychotic medication prescribed for inpatients with schizophrenia by 11 different psychiatrists. The sample consisted of 130 patients with a DSM-III-R diagnosis of schizophrenia who had received inpatient care at a state hospital or Veterans Affairs medical center in the southeastern United States in 1992-1993. Mixed-effects regression models were developed to explore the influence of individual physicians and hospitals on route of antipsychotic administration (oral or depot) and daily antipsychotic dose, controlling for patient case-mix variables (age, race, sex, duration of illness, symptom severity, and substance-abuse diagnosis). The average daily antipsychotic dose was 1092 +/- 892 chlorpromazine mg equivalents. Almost half of the patients (48%) were prescribed doses above or below the range recommended by current practice guidelines. The proportion of patients prescribed depot antipsychotics was significantly different at the 2 hospitals, as was the antipsychotic dose prescribed at discharge. Individual physicians and patient characteristics were not significantly associated with prescribing practices. These data, which were obtained before clinical practice guidelines were widely disseminated, provide a benchmark against which to examine more current practice variations in antipsychotic prescribing. The results raise several questions about deviations from practice guidelines in the pharmacological treatment of schizophrenia. To adequately assess quality and inform and possibly further develop clinical practice guideline recommendations for schizophrenia, well-designed research studies conducted in routine clinical settings are needed.

Remission, residual symptoms, and nonresponse in the usual treatment of major depression in managed clinical practice

BACKGROUND

Although published guidelines recommend the continuation of treatment for depression until full remission of symptoms and restoration of functioning, little is known about how often remission is achieved in usual practice and the precipitants of treatment termination when treatment outcome has not been optimal.

METHOD

A naturalistic study design examined 1859 patients receiving treatment for DSM-III-R major depression between 1995 and 1997 in the national provider network of a managed behavioral health organization (MBHO). Symptom and impairment ratings by clinicians were used to group patients into full remission, partial remission, and no response. Claims data were used to characterize treatment and identify comorbid medical conditions.

RESULTS

According to clinician ratings, approximately 27% to 39% of patients achieved full remission. Medical and substance use comorbidity and hospital admission were more common in those with a partial response to treatment. Only half of patients without a treatment response received a trial of medication during their treatment. Patient choice was the most common reason for termination of treatment, although nearly 40% of clinicians concurred with patients' decisions even when symptoms had not improved.

CONCLUSION

Although rates of full remission were comparable to those in clinical trials of antidepressants, results suggest that clinicians may fail to recommend continuation and maintenance treatment consistent with best practice guidelines and that unsuccessful treatment often does not include antidepressant medication.

Predictive models and the effectiveness of strategies for improving outpatient follow-up under managed care

OBJECTIVES

This study tested the accuracy of models for predicting rehospitalization in a managed behavioral health organization and tested the effectiveness of different care management strategies for enhancing outpatient treatment follow-up.

METHODS

In a controlled study, patients with an inpatient mental health or substance use admission received one of three types of care management, distinguished by the level of care managers' involvement in discharge planning and postdischarge outreach: usual (N=31), enhanced (N=94), and intensive (N=74). The groups were compared with each other and with a cohort admitted in the year before the study that received usual care management (N=192) to determine whether differences existed in time to outpatient follow-up, amount of postdischarge care, and rehospitalization at 30, 60, and 180 days.

RESULTS

No differences between groups were found. The majority of patients (69 percent) received outpatient care within 30 days of discharge. Prediction models using logistic regression suggested that the number of clinical and sociodemographic risk factors identified by care managers was related to the rate of rehospitalization at 60 and 180 days. Patients authorized to receive intermediate care (partial hospitalization or residential care) and those who failed to attend intermediate care if it was authorized were more likely than other patients to be rehospitalized at 30, 60, and 180 days.

CONCLUSIONS

Outpatient follow-up after psychiatric hospitalization did not improve with increasingly intensive discharge planning and outreach. Improvement in prediction of risk of rehospitalization may increase opportunities to provide intensive interventions for difficult-to-engage patients.

Two-year outcomes of fee-for-service and capitated medicaid programs for people with severe mental illness

OBJECTIVE

To examine the effects of two models of capitation on the clinical outcomes of Medicaid beneficiaries in the state of Colorado.

DATA SOURCE

A large sample of adult, Medicaid beneficiaries with severe mental illness drawn from regions where capitation contracts were (1) awarded to local community mental health agencies (direct capitation), (2) awarded to a joint venture between local community mental health agencies and a large, private managed behavioral health organization, and (3) not awarded and care continued to be reimbursed on a fee-for-service basis.

STUDY DESIGN

The three samples were compared on treatment outcomes assessed over 2 years (total n = 591).

DATA COLLECTION METHODS

Study participants were interviewed by trained, clinical interviewers using a standardized protocol consisting of the GAF, BPRS, QOLI, and CAGE.

PRINCIPAL FINDINGS

Outcomes were comparable across most outcome measures. When outcome diffrences were evident, they tended to favor the capitation samples.

CONCLUSIONS

Medicaid capitation in Colorado does not appear to have negatively affected the outcomes of people with severe mental illness during the first 2 years of the program. Furthermore, the type of capitation model was unrelated to outcomes in this study.

The relationship between treatment access and spending in a managed behavioral health organization

OBJECTIVE

This study replicated an earlier study that showed a linear relationship between level of treatment access and behavioral health spending. The study reported here examined whether this relationship varies by important characteristics of behavioral health plans.

METHODS

Access rates and total spending over a five- to seven-year period were computed for 30 behavioral health plans. Regression analysis was used to estimate the relationship between access and spending and to examine whether it varied with the characteristics of benefit plans.

RESULTS

A linear relationship was found between level of treatment access and behavioral health spending. However, the relationship closely paralleled that found in the earlier study only for benefit plans with an employee assistance program linked to the managed behavioral health organization and for plans that do not allow the use of out-of-network providers.

CONCLUSIONS

The results of this study replicate those of the earlier study in showing a linear relationship between access and spending, but they suggest that the magnitude of this relationship may vary according to key plan characteristics.

The impact of prior authorization on outpatient utilization in managed behavioral health plans

This study examines how preauthorization affects outpatient behavioral health utilization under managed care by comparing plans with similar benefits, but differing in the number of visits authorized. The authors compare plans primarily authorizing in increments of 5 visits to plans authorizing in increments of 10 visits. They analyze the likelihood of terminating outpatient service between the two groups using conditional logistic regression. Results suggest that patients whose treatment is authorized in increments of 5 sessions are nearly 3 times more likely to terminate treatment at exactly the fifth visit than if their treatment is authorized in increments of 10 sessions conditional on being in treatment until the 5th visit. The likelihood of termination peaks in both the 5- and 10-session authorization at the 10th visit, but the difference is not statistically significant. The authorization effect differs by provider type and is weaker among psychiatrists than among nonphysician providers.

Does managing behavioral health care services increase the cost of providing medical care?

This study examined the possibility that managing behavioral health care services achieves savings by cost shifting--by denying care or impeding access to care--and in that way encouraging patients to seek needed behavioral health care in the medical care system. In 1993, a large industrial company carved out employee behavioral health care from its unmanaged, indemnity medical care benefits and offered employees an enhanced benefit package through a managed behavioral health care company. This study compared the use and cost of behavioral health care and medical care services for two years before the carve-out and for three years afterward. The rate of behavioral health care usage remained the same or increased after the carve-out, while the cost of providing the care decreased. Controlling for trends that began before the inception of managed behavioral health, medical care costs decreased for those using behavioral health care services. No evidence supporting cost shifting was found.

Symptom heterogeneity in comorbid alcohol disorder

The heterogeneity of signs and symptoms of alcohol disorder was examined in a community sample of 1,955 persons with either alcohol disorder alone or alcohol disorder plus one of four categories of major mental disorder (antisocial personality disorder, schizophrenia, affective disorder, anxiety disorder). When all diagnostic categories were combined, persons with comorbid mental and alcohol disorders showed evidence of more severe alcohol-related symptoms than did persons with alcohol disorder alone. Distinct symptom patterns distinguished the four diagnostic groups, reflecting heterogeneity in the manifestation of comorbid alcohol disorder. Most notably, comorbid antisocial personality disorder and schizophrenia were associated with higher levels of alcohol consumption and more severe social consequences of alcohol use. These findings substantiate the need for development of specialized dual diagnosis programs and suggest that additional specialization may be required to address diagnostic group differences in the characteristics of comorbid alcohol disorder.

The association between body mass and health care expenditures

With several studies estimating the health care costs attributable to obesity-related medical conditions, the economic consequences of being overweight are beginning to come into focus. The present study complements this growing body of literature by directly estimating health care costs across a broad range of body mass index values. Data were obtained from the 1987 National Medical Expenditure Survey (NMES) public use data tapes and retrospective analyses conducted on NMES Household Survey data only. The analyses included a total of 16,217 individuals between the ages of 18 and 65. Four classes of health care utilization and expenditures were derived using the NMES data: (1) use of any health care service and total health care expenditures, (2) use of inpatient services and inpatient expenditures, (3) use of outpatient services and outpatient expenditures, and (4) use of prescription medication and medication expenditures. Estimates based on our findings suggested strong relationships between body mass and the likelihood of using health care services and between body mass and average annual health care expenditures for both men and women. Increased body mass was associated with increased expenditures. However, this association was greater among males than among females and did not hold for individuals in the lowest body mass category. Ideal body mass was associated with 6.3% to 36.1% lower annual health care expenditures among females and 3.6% to 18.2% lower health care expenditures among males. The results of this set of analyses suggest that health care expenditures increase as weight deviates from the ideal-that is, health care expenditures among both underweight and overweight individuals in the United States were increased in relation to ideal weight. Separate analyses including weight-related diseases such as diabetes and hypertension indicated that body mass increased health care expenditures largely by increasing the risk for these costly chronic medical conditions.

An instrument for measurement of outcomes of care for schizophrenia. Issues in development and implementation

To advance effectiveness research in mental health, we need common, standardized, validated instruments that can be used easily in routine practice settings. The Schizophrenia Outcomes Module is a relatively brief, comprehensive instrument for monitoring and assessing the outcomes of treatment for schizophrenia in clinical care settings. The module was developed with the guidance of a multiinstitutional, multidisciplinary expert panel; the clinical and theoretical considerations that framed the expert panel's deliberations and determined the module's content and characteristics are described. Initial field testing of the instrument involved longitudinal observation of 100 individuals with schizophrenia over a 6-month period. To our knowledge, it is the only brief and easily administered instrument that encompasses the four major outcome domains defined by the National Institute of Mental Health's Plan for Research on the Severely Mentally Ill. As such, it is a promising tool for effectiveness research in schizophrenia.

Awareness of illness in schizophrenia and outpatient treatment adherence

We present a brief measure of awareness of illness in schizophrenia and test whether awareness is related to perceived need for and adherence to outpatient psychiatric treatment. A prospective design assessed treatment adherence, awareness of the signs and symptoms of schizophrenia, symptoms, neurocognitive status, and substance abuse at baseline and 6-month follow-up in 89 persons with schizophrenia. Results indicate that persons with greater awareness perceived greater need for outpatient treatment and evidenced better adherence to outpatient treatment when adherence and awareness were measured concurrently. Awareness was not related to adherence at 6-month follow-up. In addition, neurocognitive impairment was associated with lower overall adherence to treatment when reported by collaterals at baseline and 6-month follow-up. Neurocognitive impairment was, however, associated with higher self-reported adherence to medication, which suggests that neurocognitive status may bias adherence reporting in persons with schizophrenia.

Substance abuse, community service use, and symptom severity of urban and rural residents with schizoprhenia

OBJECTIVE

This study examined the relationships of substance abuse, use of community-based services, and symptom severity among rural and urban residents with schizophrenia in the six months after discharge from short-term inpatient care.

METHODS

At baseline and six-month follow-up, symptom severity of 139 subjects was assessed using the Brief Psychiatric Rating Scale (BPRS), and substance abuse status was determined using the Structured Clinical Interview for DSM-III-R (SCID). Subjects' reports of mental health service use were confirmed by record review.

RESULTS

Although, on average, BPRS scores indicated symptom improvement between baseline and follow-up, symptoms worsened for 27 percent of subjects. Multivariate analysis, adjusted for baseline symptom severity, indicated poorer outcomes for rural residents, substance abusers, and subjects who did not use community services. Symptoms of rural substance abusers who used no community services were worse at follow-up than those of any other subgroup. Nearly half of all subjects had less than monthly contact with community services. The greater likelihood of symptom worsening among rural residents was attributed to their less frequent use of community services.

CONCLUSIONS

The findings reinforce the importance of ensuring involvement in community-based services for individuals with comorbid schizophrenia and substance use disorders. Promotion of service use by persons with a dual diagnosis may be particularly critical to the well-being of rural residents with schizophrenia.

Medication noncompliance and substance abuse among patients with schizophrenia

OBJECTIVE

The study examined the effect of medication noncompliance and substance abuse on symptoms of schizophrenia.

METHODS

Short-term inpatients with a diagnosis of schizophrenia were enrolled in a longitudinal outcomes study and continued to receive standard care after discharge. At baseline and six-month follow-up, Brief Psychiatric Rating Scale (BPRS) scores and data on subjects' reported medication compliance, drug and alcohol abuse, usual living arrangements, and observed side effects were obtained. The number of outpatient contacts during the follow-up period was obtained from medical records. Relationships between the dependent variables-medication noncompliance and follow-up BPRS scores-and the independent variables were analyzed using logistic and linear regression models.

RESULTS

Medication noncompliance was significantly associated with substance abuse. Subjects who abused substances, had no outpatient contact, and were noncompliant with medication had significantly greater symptom severity than other groups.

CONCLUSIONS

Substance abuse is strongly associated with medication noncompliance among patients with schizophrenia. The combination of substance abuse, medication noncompliance, and lack of outpatient contact appears to define a particularly high-risk group.

Treatment costs and use of community mental health services for schizophrenia by age cohorts

OBJECTIVE

Research on schizophrenia has tended to ignore patterns and costs of mental health service use in late life. The present study examined the types of mental health services used and their costs for several age-defined cohorts in a large community mental health system.

METHOD

The data covered all users of the mental health system included in the San Diego county billing information system in fiscal years 1986 and 1990. Community mental health service use and codes were modeled as a function of patient demographic characteristics, diagnosis, and age. The patients were grouped into the following age categories: 18-29, 30-44, 45-54, 55-64, 65-74, and > or = 75 years of age.

RESULTS

The total costs for schizophrenia were higher than those for other psychiatric disorders, and they were also age dependent. In both fiscal years, the costs of schizophrenia were higher for the youngest and oldest cohorts than for the patients in the 30-65-year range.

CONCLUSIONS

The economic burden of late-life schizophrenia to the public mental health system is at least as high as that of schizophrenia in younger adults.

Managed care in the public mental health system

The movement towards managed care in the public mental health system has surpassed efforts to develop a systematic literature concerning its theory, practice, and outcome. In particular little has been written about potential challenges and difficulties in translating managed care systems from their origins in the private sector to the delivery of public sector mental health services. This paper provides an overview of managed care definitions, organizational arrangements, administrative techniques, and roles and responsibilities using a theoretical framework adopted from economics referred to as principal-agent theory. Consistent with this theory, we assert that the primary function of the managed care organization is to act as agent for the payor and to manage the relationships between payors, providers, and consumers. From this perspective, managed care organizations in the public mental health system will be forced to manage an extremely complex set of relationships between multiple government payors, communities, mental health providers, and consumers. In each relationship, we have identified many challenges for managed care including the complexity of public financing, the vulnerable nature of the population served, and the importance of synchronization between managed care performance and community expectations for the public mental health system. In our view, policy regarding the role of managed care in the public mental health system must evolve from an understanding of the dynamics of government-community-provider-consumer "agency relationships".

Comorbid substance use disorder: prevalence, patterns of use, and course

Research on the prevalence, patterns, and course of substance use disorders in severe mental illness gives key insights into the complex interaction of substance use and mental disorder. Understanding the literature on comorbidity has implications for the design of clinical services and for the direction of future research in the field.

The California Adult Performance Outcome Survey: preliminary evidence on reliability and validity

Recent legislation in California mandated the development of an outcome measure suitable for measuring changes in quality of life associated with treatment in the public mental health system. The measure, known as the California Adult Performance Outcome Survey (CAPOS), relies on clinician and client reports of objective and subjective indicators of quality of life. The present study sought to determine whether the clinician-administered CAPOS would agree with that administered by trained research assistants, and whether the CAPOS would agree with an established quality of life measure. A sample of sixty-four severely mentally ill subjects were assessed by their regular mental health provider using the CAPOS. One week later they were assessed by a trained research assistant using the CAPOS and Lehman's Quality of Life Interview (QOLI). For most outcome domains, the CAPOS exhibited moderate to excellent agreement across occasions and raters. Correlations with the QOLI indicated a good degree of overlap among corresponding domains. Outcome measurement procedures for routine use in clinical settings are in their infancy. The CAPOS appears promising in this role because of its brevity, ease of administration, and adequate interrater reliability. The CAPOS affords state and local mental health authorities with an efficient means of tracking key quality of life indicators within the public mental health system.

A longitudinal study of substance use and community violence in schizophrenia

The authors report the findings of a longitudinal study testing the hypothesis that substance use leads to subsequent violence in the community. Subjects were 103 patients with a Structured Clinical Interview for DSM-III-R diagnosis of schizophrenia or schizoaffective disorder who were seen in an outpatient clinic for the treatment of schizophrenia. Data on substance use and violent behavior were collected by review of medical records. Results indicated that use of drugs and alcohol was associated with increased odds of concurrent and future violent behavior when compared with persons with schizophrenia and no substance use. Odds of violence were particularly elevated for individuals having a pattern of polysubstance use involving illicit substances.

Violent and destructive behavior among the severely mentally ill in rural areas: evidence from Arkansas' community mental health system

A comparison of rates of violence among admissions to the Arkansas State Hospital system between urban and rural areas tested the hypothesis that thresholds for admission to the hospital were greater in rural than in urban areas. Data on violent and destructive behavior were recorded from the medical records of 609 patients. Logistic regression was used to model the presence or absence of violent behavior in urban and rural admissions controlling for selected demographic and clinical characteristics. Results indicated that rural patients showed increased likelihood of violent and destructive behavior prior to admission supporting the hypothesis that barriers to mental health services in rural areas may be creating differential thresholds of service access and utilization. The increased rate of violence was particularly evident in those using substances prior to admission in rural areas suggesting that community management of the violent, substance abusing patient may be particularly difficult for rural areas.

Remission and relapse of substance use disorders in schizophrenia. Results from a one-year prospective study

Recent studies of the effectiveness of specialized programs that treat substance use disorders in schizophrenia have obtained promising results but have not involved control groups. Interpretation of these apparently positive results is problematic because remission and relapse rates of substance use disorders have not been reported in this population. The present study reports 1-year rates of substance abuse and dependence remission and relapse in a sample of schizophrenics taken from the Epidemiologic Catchment Area study. Results indicated that the prevalence of substance use disorders in schizophrenia remained constant over the year primarily because rates of remission were balanced by rates of relapse. Individuals who developed abuse or dependence over the year were younger, male, and showed increases in depression and risk for hospitalization over the year. Individuals who remitted abuse or dependence were older, female, and showed decreases in depression over the year. Dual diagnosis treatment programs have recently reported higher rates of remission than were evidenced in this sample, thus providing preliminary support for the effectiveness of these treatments.

Shifting the responsibility for payment for state hospital services to community mental health agencies

OBJECTIVE

In 1990 the state of Arkansas shifted financial responsibility for state hospital services to community mental health centers; through a policy known as "bed buy-back," centers now authorize all state hospital admissions and prospectively purchase bed days for their patients. Characteristics of patients hospitalized before and after implementation of the policy were examined to determine how the policy affected hospital admission rates, types of patients admitted, and the amount of contact between CMHC and hospital staff about admitted patients, as well as how these elements were affected differently in rural and urban areas.

METHODS

Changes in the types of patients admitted over the 13 months before and 14 months after the change in financing were studied through retrospective chart review of 648 patients. Administrative data were used to examine changes in numbers of admissions for 30 months before and 26 months afterward. Data were analyzed by piecewise regression, least-squares, and logistic regression analyses.

RESULTS

After financial decentralization, state hospital use was reduced in both urban and rural areas, although the reduction in urban areas was proportionally greater. Contrary to expectation, admissions were not limited to the most severely ill, disruptive, or substance-abusing patients, nor were they more likely to be readmitted. For patients who were admitted, communication between the community and the state hospital was greater than before financial decentralization.

CONCLUSIONS

Shifting financial responsibility for patient care significantly reduced state hospital use, did not affect patient mix, and apparently increased coordination of care between community and hospital. Whether bed buy-back has affected the kind or quality of services delivered in the community awaits further study.

Correlates of patterns of substance abuse among patients with schizophrenia

OBJECTIVE

Most previous research on substance abuse among patients with schizophrenia has not considered the types of substances abused or the confounding influences of polysubstance abuse. The authors' goals were to identify patterns of substance abuse among a sample of subjects with schizophrenia and to determine demographic and clinical correlates of these patterns.

METHODS

Subjects with schizophrenia were identified from the Epidemiologic Catchment Area study data base, which also provided information on the types of substances abused and on selected demographic and clinical characteristics. Latent class analysis was used to group subjects based on their patterns of substance abuse. Logistic regression was used to identify demographic and clinical correlates of the patterns.

RESULTS

Three latent classes based on patterns of substance abuse were identified: no substance abuse, abuse of alcohol and cannabis, and polysubstance abuse. Subjects with either of the two patterns of substance abuse were more likely to be younger and male and to have depressive symptoms.

CONCLUSIONS

The results do not support a link between abuse of specific substances and specific clinical symptoms but do suggest a general link between substance abuse and affective disturbance among schizophrenic patients.

Characteristics associated with legal status change among psychiatric patients

Typically research on civil commitment has simply compared voluntary and involuntary psychiatric patients and has ignored the process of legal status change. The present study examined patient characteristics associated with legal status change during different points of patients' hospital stays. Results indicated that patients with greater improvement, patients with more severe diagnoses, and non-minority patients were more likely to transition to voluntary status, but only when these transitions occurred early in the hospitalization. Later in the hospitalization, the presence of living arrangements involving family and friends was associated with higher rates of transition to voluntary status.

Prevalence estimates of substance abuse in schizophrenia and their correlates

Published estimates of the prevalence of substance abuse in schizophrenia were correlated with several aspects of the studies in which they were obtained. Higher estimates of alcohol and stimulant abuse were found in studies published more recently. Rates of alcohol abuse were particularly high in one rural investigation. Rates of stimulant abuse were highest when patients were asked directly about use of stimulants. Increased prevalence estimates in more recent years could not be attributed to method of assessing substance abuse, method of defining substance abuse, or characteristics of the study sample.