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Objective: Type 2 diabetes is an important comorbid medical condition associated with schizophrenia. The objective of this study was to compare glycosylated hemoglobin (HbA(1c)) levels of patients who had type 2 diabetes and schizophrenia with those of patients who had type 2 diabetes and major mood disorders and those who had type 2 diabetes but who did not have severe mental illness., Methods: A sample of 300 patients with type 2 diabetes was recruited from community mental health centers in the greater Baltimore region and nearby primary care clinics. Of these, 100 had schizophrenia, 101 had a major mood disorder, and 99 had no identified severe mental illness. HbA(1c), the main outcome measure, was compared between the group with schizophrenia and the other two groups., Results: All three groups had HbA(1c) values above recommended levels. HbA(1c) levels were significantly lower among patients with schizophrenia than among patients who did not have severe mental illness but were not significantly different from those of patients who had major mood disorders. Patients for whom olanzapine was prescribed had higher HbA(1c) levels than those for whom other antipsychotic agents were prescribed., Conclusions: All three groups of patients require improved diabetes treatment to achieve acceptable HbA(1c) levels. There may be previously unrecognized benefits for diabetes management among persons with severe mental illnesses who are receiving regular mental heath care, but these individuals may also have risk factors that can influence diabetes outcomes and HbA(1c) levels.

People with serious mental illnesses (SMI) have a high prevalence of cigarette smoking. Details of their smoking and quitting behaviors are needed to create effective interventions. This study aims to describe the smoking and quitting histories, current behaviors, and motivations of an outpatient sample of smokers with SMI. A structured interview and Breathalyzer assessment were administered to 120 smokers from four diverse mental health settings. Participants' smoking and quitting self-report data are presented in combination with demographic and clinical variables; the results provide implications for smoking cessation, amelioration, and prevention interventions and for future research.

Objective: Family-to-Family Education Program (FFEP) is a 12-week course for family members of adults with serious mental illness (SMI). This study evaluates the effectiveness of FFEP for several family member outcomes., Method: The FFEP enrollees on a > or =3-month waiting list were eligible; 95 consenting family members agreed to four interviews (waitlist, pre-FFEP, post-FFEP, and 6 months post-FFEP) regarding subjective and objective burden, empowerment, and depression. Mixed effects ANOVA models tested hypotheses of decreased burden and increased empowerment after FFEP., Results: The FFEP was associated with reduced subjective burden (P < 0.01) and increased empowerment (P < 0.01) without changes in objective burden. Knowledge about SMI, understanding the mental health system, and self-care also improved. There was no significant decay at 6-month followup., Conclusion: This study provides evidence that FFEP is helpful to relatives of persons with SMI by reducing subjective burden and worry, and increasing empowerment, knowledge about SMI, understanding the mental health system, and self-care.

Advances in treatment technologies and development of evidence-based standards of care demand better methods for routine assessment of outcomes for schizophrenia in systems of care. This article describes the development and psychometrics of a new instrument to assess outcomes of routine care for persons with schizophrenia in service systems. Candidate items for the Schizophrenia Care and Assessment Program Health Questionnaire (SCAP-HQ) were drawn from existing measures. Domains covered include disease outcomes (symptoms, subjective medication effects, substance abuse), functional status, health status, quality of life, and public safety. A sample of 1,584 patients with schizophrenia or schizoaffective disorder who were recruited into a large prospective, naturalistic study on the course of treatment for schizophrenia completed the SCAP-HQ at baseline and 1 year later (n = 434), providing data for factor analysis, assessment of internal consistency, convergent validity, and responsiveness to change. A subsample of 121 patients completed a test-retest protocol. Fifteen scales were derived by factor analysis from 55 outcome items on the SCAP-HQ. These factors covered psychiatric symptoms, life satisfaction, instrumental activities of daily living, health-related disability, subjective medication side effects, vitality, legal problems, social relations, mental health-related disability, suicidality, drug and alcohol use, daily activities, victimization, violence, and employment. For most scales, standard psychometric parameters, including internal consistency and test-retest reliability, convergent validity, and responsiveness to change, were acceptable for application to large sample evaluations of care systems. This new measure represents an advance in the development of outcome measures for schizophrenia for use in large-scale studies of routine care.

Background: Unemployment remains a major consequence of schizophrenia and other severe mental illnesses. This study assesses the effectiveness of the Individual Placement and Support model of supportive employment relative to usual psychosocial rehabilitation services for improving employment among inner-city patients with these disorders., Methods: Two hundred nineteen outpatients with severe mental illnesses, 75% with chronic psychoses, from an inner-city catchment area were randomly assigned to either the Individual Placement and Support program or a comparison psychosocial rehabilitation program. Participants completed a battery of assessments at study enrollment and every 6 months for 2 years. Employment data, including details about each job, were collected weekly., Results: Individual Placement and Support program participants were more likely than the comparison patients to work (42% vs 11%; P<.001; odds ratio, 5.58) and to be employed competitively (27% vs 7%; P<.001; odds ratio, 5.58). Employment effects were associated with significant differences in cumulative hours worked (t(211) = -5.0, P =.00000003) and wages earned (t = -5.5, P =.00000003). Among those who achieved employment, however, there were no group differences in time to first job or in number or length of jobs held. Also, both groups experienced difficulties with job retention., Conclusions: As hypothesized, the Individual Placement and Support program was more effective than the psychosocial rehabilitation program in helping patients achieve employment goals. Achieving job retention remains a challenge with both interventions.

Objective: The study compared self-reported comorbid affective and anxiety disorder diagnoses and treatments of African-American and Caucasian subjects in a large sample of patients who had a diagnosis of schizophrenia., Methods: A total of 685 patients receiving treatment for schizophrenia were interviewed as part of the Schizophrenia Patient Outcomes Research Team study. The associations of race with past and current diagnoses and with current treatment for depression, mania, and anxiety disorders were assessed with multivariate analyses., Results: African Americans were significantly less likely than Caucasians to report having a past or current diagnosis of depression, manic-depression, or anxiety disorder and to be receiving current treatment for these disorders. Gender, education, and marital status were also associated with presence of a comorbid diagnosis and receipt of treatment., Conclusions: The study suggests the possibility of racial and other disparities in the diagnosis and treatment of patients with schizophrenia and comorbid affective and anxiety disorders. Although various causal explanations are plausible, all point toward the need for enhanced cross-cultural competence at all levels of mental health care, especially in the diagnosis and treatment of comorbid psychiatric illnesses.

Objective: The objective of this study was to identify predictors of the use and cost of ambulatory care services among Medicare recipients with schizophrenia., Methods: The design was a cross-sectional analysis of Medicare claims in 1991. The study subjects were a 5 percent random sample of all persons in the United States who had at least one Medicare service claim in 1991 and who were diagnosed as having schizophrenia in any care setting. Outcome measures included use and cost of any ambulatory care service, individual therapy, psychiatric somatotherapy, group therapy, or family therapy., Results: For nearly 25 percent of the total sample of 12,440, no claims were filed for ambulatory care services in 1991. The mean+/-SD number of ambulatory care visits during the year was 7.9+/-21. The most frequently used type of therapy was individual therapy (5+/-14 visits). The mean+/-SD yearly cost of care for persons who received ambulatory care services was $470+/-$1,028. Among persons under 65 years of age, Caucasians were about 1.5 times as likely as African Americans to have received an ambulatory care service and 1.3 times as likely to have received individual therapy. Persons who were 65 or older were less likely to have received any service. Among service recipients, costs of care were lower for African Americans and for older people., Conclusions: The use of Medicare-funded ambulatory care services by persons with schizophrenia varied by race and age. Further investigation is required to determine whether subgroups of individuals who do not have additional insurance coverage or access to services are receiving substandard care.

The purpose of this study was to determine whether demographic and clinical factors are associated with a diagnosis of depression among persons with schizophrenia and to determine the association of depression with subjective quality of life. A consecutively admitted sample of psychiatric inpatients diagnosed with schizophrenia (n = 123) were assessed for depression and quality of life. Logistic regression was used to determine factors associated with a diagnosis of depression. Multiple regression analyses were used to determine the relationship between depression and quality of life. The odds of being diagnosed with depression were seven times greater in Caucasians than in African-Americans, and three times greater in persons who were ever married. Depression was significantly associated with reduced life satisfaction in Caucasians but not African-Americans. This suggests the importance of race as a predictor of a diagnosis of depression in schizophrenia and the possibility of underdiagnosis of depression among African-Americans. The absence of the expected association between depression and quality of life in African-Americans casts doubt on the validity of the depression diagnosis using conventional diagnostic tools.

People with schizophrenia may be at increased risk for Type II diabetes because of the side effects of antipsychotic medication, poorer overall physical health, less healthy lifestyles, and poorer health care. The present study uses data bases collected by the Schizophrenia Patient Outcomes Research Team (PORT) to assess the prevalence and demographic and clinical correlates of diabetes within large populations of persons receiving treatment for schizophrenia. In the Schizophrenia PORT, Medicaid and Medicare data from 1991 and more recent interview data were collected regarding the comorbidity of schizophrenia and diabetes: prevalence, quality of life, physical health, and services utilization and costs. The study found that rates of diagnosed diabetes exceeded general population statistics well before the widespread use of the new antipsychotic drugs. Risk factors for diabetes were similar to those observed in the general population. The linkage of diabetes to poor physical health, medical morbidity, and increased service use and cost requires attention. This study of diabetes in the early 1990s suggests that even before the widespread use of the atypical antipsychotic drugs, diabetes was a major problem for persons with schizophrenia.

This study determined the prevalence of medical comorbidities in a cohort of persons receiving treatment for schizophrenia and the association of medical comorbidity with physical and mental health status. A total of 719 persons with schizophrenia sampled from a variety of community and treatment settings as part of the schizophrenia Patient Outcomes Research Team (PORT) participated in a survey interview. Multiple regression analyses were used to assess sociodemographic factors associated with the number of current medical comorbidities and the association of medical comorbidity count with patient ratings of physical health, mental health, symptoms, and quality of life. The majority of patients reported at least one medical problem. Problems with eyesight, teeth, and high blood pressure were most common. A greater number of current medical problems independently contributed to worse perceived physical health status, more severe psychosis and depression, and greater likelihood of a history of a suicide attempt. This study underscores the need to attend to somatic health care for persons with schizophrenia as well as the linkage of physical and mental health status.

Objective: Data from the Schizophrenia Patient Outcomes Research Team project were examined to determine the extent to which families of adults with schizophrenia receive services and whether training staff in the provision of family services increases service availability., Methods: For patients with a diagnosis of schizophrenia, paid claims for family therapy were identified in 1991 in a nationally representative sample of Medicare data and one state's Medicaid data. In a field study in two states, 530 patients were asked about services received by their families. A quasiexperimental dissemination of a family intervention was done at nine agencies; staff at four agencies received a standard didactic presentation, and staff at five received that standard presentation paired with intensive training., Results: In the representative national Medicare sample of 15,425 persons with schizophrenia, .7 percent (N=108) had an outpatient claim for family therapy. This figure was 7.1 percent in the Medicaid sample of 5,393 persons with schizophrenia in one state. Of the 530 patients in the field study who reported having contact with their families, 159 (30 percent) reported that their families had received information, advice, or support about their illness, and 40 (8 percent) responded that their families had attended an educational or support program. At the four agencies where staff received only didactic training, no changes in family services were found after one year. Three of the five agencies where staff participated in intensive training enhanced their family services., Conclusions: A minority of families of persons with schizophrenia receive information about the illness from providers. Implementation of model family interventions is possible with considerable technical assistance. A gap exists between best practices and standard practices for families of persons with schizophrenia.

Background: This experiment evaluated the effectiveness of an innovative program of assertive community treatment (ACT) for homeless persons with severe and persistent mental illnesses., Methods: One hundred fifty-two homeless persons with severe and persistent mental illness were randomized to either the experimental ACT program or to usual community services. Baseline assessments included the Structured Clinical Interview for DSM-III-R, Quality-of-Life Interview, Colorado Symptom Index, and the Medical Outcomes Study 36-Item Short Form Health Survey. All assessments (except the Structured Clinical Interview) were repeated at the 2-, 6-, and 12-month follow-up evaluations., Results: Subjects in the ACT program used significantly fewer psychiatric inpatient days, fewer emergency department visits, and more psychiatric outpatient visits than the comparison subjects. The ACT subjects also spent significantly more days in stable community housing, and they experienced significantly greater improvements in symptoms, life satisfaction, and perceived health status., Conclusions: Relative to usual community care, the ACT program for homeless persons with severe and persistent mental illness shifts the locus of care from crisis-oriented services to ongoing outpatient care and produces better housing, clinical, and life satisfaction outcomes.

Objective: The study examined whether rehospitalization of patients with severe and persistent mental illness could be predicted by patients' quality of life. The predictive ability of two clinical factors associated with rehospitalization--history of hospitalizations and severity of symptoms--was also examined., Methods: A total of 559 patients were assessed at two follow-up points, two and 12 months after an index hospital discharge. Patients who were rehospitalized and those who were not rehospitalized between the two follow-up points were compared on subjective and objective quality of life, symptom severity at first follow-up, and previous rehospitalization. Multivariate analysis was used to determine the best predictors of rehospitalization., Results: Compared with patients who were not rehospitalized, those who were rehospitalized had more severe symptoms and were more likely to have a history of hospitalization. Rehospitalized patients reported more dissatisfaction with family relations and were more likely to report an arrest in the past two months. The two groups did not differ in other quality-of-life domains and in global quality of life., Conclusions: The best predictors of rehospitalization were previous rehospitalization, more severe symptoms, and dissatisfaction with family relations. Interventions should promote positive relationships between patients with severe mental illness and their families to reduce the risk of relapse and rehospitalization.

The impact on services and outcomes of the local mental health authorities (LMHAs) developed under the RWJF Program on Chronic Mental Illness (CMI) was evaluated in Baltimore, Cincinnati, Columbus, and Toledo. Two cohorts of clients with CMI discharged from an episode of acute 24-hour care were recruited in each city: the first cohorts were drawn shortly after the demonstration began and the second, two years later. The LMHAs in the three Ohio cities increased case management for the second cohorts at two months, but not at 12 months, after hospital discharge. The second cohorts in Baltimore and Cincinnati experienced lower turnover among case managers during the year after discharge, but there was no significant improvement in client outcomes. Creation of LMHAs may be a necessary, but not sufficient, step toward improving outcomes and should be followed by improvement in the quantity and quality of services.

The impact of interventions on the quality of life (QOL) experienced by persons with severe and persistent mental illnesses (SPMI) has attracted considerable political, clinical and research attention over the past decade, and continues to do so. This study examines the convergent validity of two commonly used QOL measures for this group of patients, the Lehman Quality of Life Interview and the Heinrichs-Carpenter Quality of Life Scale, computing the correlations between comparable constructs from the two measures administered at the same time and 2 months apart. Correlations were positive and significant although low to moderate in magnitude. Considering the considerable differences in the methods of assessment employed by the two measures, the lack of precise congruence between their constructs, and the 2-month time interval, these findings support their convergent validity. Various conceptual issues regarding the validity and interpretation of QOL assessments for persons with SPMI are discussed.