Search

Weight management is one of the most cited levers for preventing and managing many chronic conditions, particularly those considered to be "lifestyle modifiable." However, it is unclear how much weight is a driver of illness burden among people of color. This article sought to examine whether people of color are more likely to develop "lifestyle-modifiable" conditions, including diabetes, kidney disease, heart disease, lung disease, and hypertension, both individually and in combination (multimorbidity), in the absence of being obese.Using data from the 2019 Behavioral Risk Factors Surveillance System survey, we examined the risk of having these conditions among Black, Asian, Native American, Latino/a, and White respondents who reported being "normal weight" (For each individual condition, White respondents almost always had the lowest risk. On the other hand, Latino/a respondents had the highest rates of diabetes and kidney disease. Native American respondents had the highest rates of heart and lung disease. Black respondents had the highest rates of hypertension. Despite an otherwise healthy weight, Native American, Black, and Latino/a people were 2.5, 2.3, and 1.8 times, respectively, more likely to develop multiple chronic conditions that are typically considered "lifestyle modifiable," compared to White people.Disease prevention and management guidelines driven by the clinical experience of White people are insufficient for addressing the considerable illness burden that people of color continue to experience.

Objective This multisite randomized trial addressed risks and benefits of staying on long-acting injectable haloperidol or fluphenazine versus switching to long-acting injectable risperidone microspheres.

Published guidelines recommend metabolic monitoring for patients prescribed second-generation antipsychotic (SGA) medications. This study determined monitoring rates, and examined predictors of monitoring, for total cholesterol and weight among patients prescribed SGAs during a period when awareness of metabolic side effects was emerging, but prior to the wide promulgation of guidelines.This retrospective study used administrative data from four Veterans Health Administration facilities to examine monitoring rates for total cholesterol and weight during baseline and follow-up periods from October 1, 2000-September 30, 2003 among patients with schizophrenia initiating SGA treatment. The study used logistic regression to identify characteristics that predicted monitoring. Background monitoring rates during routine care were estimated using a resampling procedure.Initiating SGA treatment did not appear to trigger annual monitoring above estimated background rates of 54% for total cholesterol and 47% for weight. Patients with metabolic risk factors were monitored at higher rates independent of the start of treatment with an SGA.This paper provides a window into side effect monitoring practices prior to the widespread promulgation of guidelines and associated quality improvement efforts and serves as a benchmark for future interventions. Prior to publication of monitoring guidelines, patients initiating treatment with SGAs did not receive adequate metabolic monitoring routinely, nor did SGA treatment appear to trigger additional monitoring. Some studies that have assessed the impact of monitoring guidelines on clinical practice show only limited impact. Quality improvement strategies to increase metabolic monitoring over the rates seen here and in other studies should be developed and implemented.

This randomized trial addressed the risks and benefits of staying on antipsychotic polypharmacy or switching to monotherapy.Adult outpatients with schizophrenia taking two antipsychotics (127 participants across 19 sites) were randomly assigned to stay on polypharmacy or switch to monotherapy by discontinuing one antipsychotic. The trial lasted 6 months, with a 6-month naturalistic follow-up. Kaplan-Meier and Cox regression analyses examined time to discontinuation of assigned antipsychotic treatment, and random regression models examined additional outcomes over time.Patients assigned to switch to monotherapy had shorter times to all-cause treatment discontinuation than those assigned to stay on polypharmacy. By month 6, 86% (N=48) of those assigned to stay on polypharmacy were still taking both medications, whereas 69% (N=40) of those assigned to switch to monotherapy were still taking the same medication. Most monotherapy discontinuations entailed returning to the original polypharmacy. The two groups did not differ with respect to psychiatric symptoms or hospitalizations. On average, the monotherapy group lost weight, whereas the polypharmacy group gained weight.Discontinuing one of two antipsychotics was followed by treatment discontinuation more often and more quickly than when both antipsychotics were continued. However, two-thirds of participants successfully switched, the groups did not differ with respect to symptom control, and switching to monotherapy resulted in weight loss. These results support the reasonableness of prescribing guidelines encouraging trials of antipsychotic monotherapy for individuals receiving antipsychotic polypharmacy, with the caveat that patients should be free to return to polypharmacy if an adequate trial on antipsychotic monotherapy proves unsatisfactory.

OBJECTIVE: The authors surveyed a sample of Project Liberty crisis counseling recipients approximately 1.5 years after the terrorist attacks on September 11, 2001, to determine the proportion of respondents who screened positive for complicated grief, a recently identified condition marked by symptoms of continuing separation distress and accompanying bereavement-related traumatic distress. METHODS: A total of 149 service recipients drawn from eight high-volume providers responded to a telephone survey that included questions to screen for complicated grief. RESULTS: Approximately half of the recipients knew someone who had been killed in the attacks. Of those recipients, 44 percent screened positive for complicated grief. Individuals who lost a family member were more likely than those who lost an acquaintance to screen positive for complicated grief. Positive screens were associated with functional impairment independent of the presence of symptoms consistent with full or subthreshold major depression or posttraumatic stress disorder (PTSD). Thirty-two percent of those who screened positive for complicated grief did not meet even subthreshold criteria for major depression or PTSD. CONCLUSIONS: Results affirmed the importance of complicated grief as a unique condition and indicated the need to attend to the psychological consequences of bereavement in disaster-related mental health services. Language: en

This study determined the likelihood and predictors of Project Liberty counseling recipients' reporting their return to satisfactory life functioning 16 to 26 months after the September 11, 2001, attacks.Using anonymous brief paper-and-pencil questionnaires or structured telephone interviews, 452 respondents provided retrospective ratings of their functioning in five life domains during the month before the World Trade Center attacks and the month immediately before the assessment. Information on demographic characteristics and exposure to risk during the World Trade Center attacks also was obtained and used in logistic regression models. The 153 respondents who were interviewed by telephone also rated helpfulness of various coping strategies.In the five domains, 77 to 87 percent of the sample reported good to excellent functioning in the month before the attacks; 55 to 68 percent reported returning to at least the same level of daily functioning after the attacks. African Americans were two to four times more likely than respondents of all other races to report a return to good or excellent functioning after the attack in four domains. Compared with respondents who did not lose their job as a result of the attacks, those who did lose their job were less likely to return to good preattack functioning in two domains. Project Liberty counseling reportedly helped 90 percent of respondents return to predisaster levels of functioning.Responses to future terrorist attacks should consider demographic characteristics and the impact of the attack because they can affect return to preattack functioning. Counselors should support activities that facilitate positive responses and ameliorate negative psychological responses.

This study aimed to determine a pattern in the frequency with which individuals who manifested distress reactions resembling diagnostic syndromes of posttraumatic stress disorder (PTSD) and major depressive disorder accessed services provided by Project Liberty.Hierarchical cluster analysis was applied to 31 reactions to stress (event reactions) shown by 465,428 recipients of Project Liberty counseling, to determine how well event reactions mapped onto traditional diagnostic criteria. Service recipients were tracked when they first sought Project Liberty counseling during the 27 months after the attacks. Those who reported three or more reactions associated with these clusters were characterized as having possible diagnosable conditions.Strong consistent clusters corresponding to traumatic stress and depressive symptoms emerged, with 26 percent, 16 percent, and 8 percent of service recipients rated as having possible PTSD, major depressive disorder, or both, respectively. Taken together, this group constituted over 40 percent of service recipients served by Project Liberty almost every month throughout the 27 months of its existence.Event reactions, as reported by Project Liberty crisis counselors, many of whom were nonclinicians, mapped coherently onto diagnostic syndromes, suggesting that a checklist of such reactions may be useful to disaster counselors as a cost-effective screening and planning instrument. The steady entry over time into Project Liberty counseling by a substantial number of individuals experiencing high levels of distress underscores the need for providing long-term access to mental health services postdisaster.

Project Liberty provided brief crisis counseling to 753,015 residents of New York City and surrounding counties after the attacks on the World Trade Center. Most regained predisaster functioning after counseling. For those who did not, Project Liberty provided enhanced services by specially trained, licensed mental health professionals. Individuals receiving crisis counseling and enhanced services responded to confidential telephone interviews about 18 and 24 months, respectively, after the attacks. Impairment was compared between groups to determine whether enhanced services recipients reported improved functioning and fewer symptoms of depression, posttraumatic stress, and complicated grief.Crisis counseling recipients (N=153) were interviewed once and enhanced services recipients (N=76) were interviewed twice about symptomatology and daily functioning.The samples did not differ in age or gender. Significantly greater proportions of enhanced services recipients reported knowing someone who died as a result of the attacks, having been involved in rescue efforts, or having lost their job because of the attacks. Compared with crisis counseling respondents, enhanced services recipients at their first interview reported significantly more symptoms of depression, grief, and traumatic stress and significantly poorer daily functioning in five life areas. At follow-up, enhanced services respondents reported significant improvement in three of five functioning domains, significantly fewer symptoms of depression and grief, and marginally less traumatic stress.Recipients of enhanced services were more impaired than people who received only crisis counseling. On the basis of reports from service recipients, meaningful improvements in functioning and symptoms may be associated with the receipt of enhanced services.

Objectives: The validity of self-reports of drug use from individuals who abuse substances has been questioned. Results from studies examining the accuracy of such self-reports have been mixed, indicating the need for closer examinations of the factors associated with concordance between self-reported drug use and results of urine screens. Methods: As part of a larger study examining the effectiveness of interventions for people with co-occurring mental health and substance use disorders, we examined the agreement between self-report and urine screens for recent drug use. Results: Overall, the concordance between self-report and results from urine screens was high (80-84% agreement overall and 75–79% for the subset where the urine screen indicated recent drug use). Estimates for the likelihood of use of marijuana and cocaine within the past 30 days were 15% and 32%, respectively, based on urine screens, 25% and 35% based on self-report, and 28% and 43% based on information from both sources combi...

Sustained interactions and responses to social bids made by children with autism and verbal-age–matched children with mental retardation were recorded in two naturalistic settings. Children with autism produced fewer positive responses and more “no responses” than children with mental retardation; both groups were more likely to make positive responses to adults and not to respond to other children. Furthermore, although the frequency of conversations was not different for the two groups, children with autism were significantly less likely to engage in sustained play compared to children with mental retardation. Results suggest that children with autism are able to master the more rote and need-oriented social skills, such as simple conversation, but may not develop other forms of social interactions, like play.

We characterized prescribing in Connecticut's State public mental health system to assess the feasibility of implementing an evidence-based medication algorithm. Medication records for a random sample of outpatients with diagnoses of schizophrenia spectrum disorders showed prescribing patterns similar to the entire United States. The base rate of changing antipsychotic medications was moderate. Over half of patients received decanoate medications, polypharmacy was nontrivial, and there was variability in prescribing patterns across physicians. Caucasian patients were more likely to receive an atypical antipsychotic and less likely to have a decanoate medication, and Latino patients were less likely to change medications. Because the base rate of changing medications was moderate and a considerable proportion of patients were prescribed newer antipsychotic medications, introducing a research-derived medication algorithm with newer atypical antipsychotics as first line agents may fit well with current practice. Further, implementing such an algorithm may reduce racial and ethnic disparities in prescribing patterns.

Wellness Self-Management (WSM) is a recovery-oriented, curriculum-based, and educationally focused practice designed to assist adults with serious mental health problems to make informed decisions and take action to manage symptoms effectively and improve their quality of life. WSM is an adaptation of the Illness Management and Recovery (IMR) model, a nationally recognized best practice for adults with serious mental health problems. WSM uses comprehensive personal workbooks for group facilitators and consumers and employs a structured and easy-to-implement group facilitation framework. Currently, more than 100 adult mental health agencies are implementing WSM, representing a broad array of program types, clinical conditions, and cultural populations. The authors describe the development, key features, delivery, adoption and sustaining of WSM

Public mental health authorities have access to large administrative databases. Advances in information technology now make it possible to use secondary analyses of these data to inform policy and clinical interventions. New York City and State mental health authorities developed an initiative using Medicaid claims and other administrative data to identify individuals with serious mental illness living in New York City (NYC) who are at risk of lapses in care. The NYC Mental Health Care Monitoring Initiative represents one of the first efforts to create “evidence-based policy.” The authors describe the initiative's background, development, and key collaborations. (Psychiatric Services 62:9–11, 2011)

Patients are being exposed to increasing levels of ionizing radiation, much of it from computed tomography (CT) scans.Adults without a cancer diagnosis who received 10 or more CT scans in 2010 were identified from North Carolina Medicaid claims data and were sent a letter in July 2011 informing them of their radiation exposure; those who had undergone 20 or more CT scans in 2010 were also telephoned. The CT scan exposure of these high-exposure patients during the 12 months following these interventions was compared with that of adult Medicaid patients without cancer who had at least 1 CT scan but were not in the intervention population.The average number of CT scans per month for the high-exposure population decreased over time, but most of that reduction occurred 6-9 months before our interventions took place. At about the same time, the number of CT scans per month also decreased in adult Medicaid patients without cancer who had at least 1 CT scan but were not in the intervention population.Our data do not include information about CT scans that may have been performed during times when patients were not covered by Medicaid. Some of our letters may not have been received or understood. Some high-exposure patients were unintentionally excluded from our study because organization of data on Medicaid claims varies by setting of care.Our patient education intervention was not temporally associated with significant decreases in subsequent CT exposure. Effecting behavior change to reduce exposure to ionizing radiation requires more than an educational letter or telephone call.

Previous studies have demonstrated a relationship between impairment in executive functioning and hospital and community tenure for people with schizophrenia. However, while it has been clearly established that comorbid substance abuse has a profound negative impact on the functioning of people with schizophrenia, no studies have examined the relative effect of cognitive impairment to substance use in predicting rehospitalization in this population. The present study examined the extent to which impairment on the Wisconsin Card Sorting Test (WCST) and substance abuse are correlated with lifetime psychiatric hospitalizations for outpatients with schizophrenia. Substance abuse was a significant predictor of prior hospitalizations and impairment on the WCST was a significant predictor of the months hospitalized. The findings suggest that both substance abuse and cognitive impairment need to be addressed in order to reduce hospitalizations and time in the hospital.

The New York State Office of Mental Health recently mandated that all adult outpatient clinics regularly monitor three health indicators--body mass index, blood pressure, and smoking status. After the population was defined, medical equipment was distributed. Regular training and quality improvement meetings were held to improve the electronic database for indicator data. Clinical directors were provided regular feedback on performance monitoring. Learning collaboratives allowed sharing of implementation strategies. After only four months of this coordinated effort, approximately 7,500 people with mental illnesses had been screened for the three health indicators across New York State.

Objective Satisfaction with 11 aspects of service quality and four domains of effectiveness was assessed for counseling services offered through Project Liberty after the September 11, 2001, attacks on the World Trade Center. Methods A total of 607 Project Liberty service recipients completed anonymous questionnaires, telephone interviews, or both. The 11 aspects of quality were counselor respect for client, willingness to listen, cultural sensitivity, speaking the same language as the client, amount of counseling time, convenience of meeting time and location, information received, whether the service would be used again, whether the service would be recommended to friends or family, and overall quality of service. The four effectiveness domains were daily responsibilities, relationships, physical health, and community involvement. Results At least 89 percent of service recipients rated Project Liberty as either good or excellent across 11 service quality dimensions and four effectiveness domains. The counselor's respect for clients and his or her cultural sensitivity were rated particularly favorably. Conclusions These ratings suggest that, from the viewpoint of these recipients of counseling services, Project Liberty counselors were largely successful in providing accessible, acceptable, and useful services after the World Trade Center disaster. Such evaluations can be conducted in a cost-effective manner and integrated with evidence-based practice to ultimately ensure that recipients of counseling receive the most efficient and effective interventions.

Recurrent hospitalizations represent a substantial and often preventable human and financial burden in the United States. In 2008 North Carolina initiated a statewide population-based transitional care initiative to prevent recurrent hospitalizations among high-risk Medicaid recipients with complex chronic medical conditions. In a study of patients hospitalized during 2010–11, we found that those who received transitional care were 20 percent less likely to experience a readmission during the subsequent year, compared to clinically similar patients who received usual care. Benefits of the intervention were greatest among patients with the highest readmission risk. One readmission was averted for every six patients who received transitional care services and one for every three of the highest-risk patients. This study suggests that locally embedded, targeted care coordination interventions can effectively reduce hospitalizations for high-risk populations.

Objective:The New York City Mental Health Care Monitoring Initiative uses Medicaid claims data to identify individuals with serious mental illness who are experiencing or at risk for gaps in services. In this study the authors assessed whether proposed service use algorithms accurately identified such individuals. Methods:A random sample of 500 individuals with serious mental illness was identified. Individuals belonged to specific high-need cohorts and met predefined claims-based criteria for potential service gaps. Clinical staff initiated reviews with prior service providers for 230 individuals. Results:Over a two-week period staff completed reviews for 188 cases (88%). In 66 cases (35%) the individual was fully engaged in care; 84 (45%) had a recent episode of disengagement that was appropriately addressed, and 38 (20%) were not receiving adequate services. Conclusions:The proposed service use algorithms successfully identified high-need individuals with serious mental illness at risk for gaps in serv...

To determine feasibility of implementation of a weight loss program for overweight Latinos with severe mental illness. In this quasi-experimental study, a 14-week behavioral weight loss course (extended) was implemented at one clinic. A one-time nutrition class (brief) was given at a sister clinic. Implementation feasibility was assessed by consent and participation rates. Weight was followed for 6 months. Consent rates were high [77 % (49/64) extended; 68 % (39/57) brief], and 88 % (43/49) of extended subjects participated and 88 % (38/43) completed follow-up. Weight loss did not differ between groups. A behavioral weight loss course is feasible to implement for this population.

Public mental health authorities have access to large administrative databases. Advances in information technology now make it possible to use secondary analyses of these data to inform policy and clinical interventions. New York City and State mental health authorities developed an initiative using Medicaid claims and other administrative data to identify individuals with serious mental illness living in New York City (NYC) who are at risk of lapses in care. The NYC Mental Health Care Monitoring Initiative represents one of the first efforts to create "evidence-based policy." The authors describe the initiative's background, development, and key collaborations.

OBJECTIVE: This study analyzed data from a randomized trial to examine the impact on medication adherence of integrated treatment delivered via assertive community treatment (ACT) versus standard clinical case management (SCCM). METHOD: Data from the original study included 198 study participants with co-occurring psychotic and substance use disorders who were randomly assigned to receive integrated treatment via ACT or SCCM and were followed for 3 years. We applied mixed-effects logistic regression to estimate group (ACT vs. SCCM) by time effects on a self-report measure of medication adherence. Adherence was dichotomized as 20% or more missed medication days (“poor adherence”) versus less than 20% missed medication days (“adequate adherence”). RESULTS: Participants who were assigned to ACT reported significant improvement in medication adherence compared with those assigned to SCCM. CONCLUSIONS: Integrated treatment delivered via ACT may benefit persons with co-occurring psychotic and substance use disorders who are poorly adherent to medications.

The aim of this study was to measure expert consensus on the implementation of Psychiatric Advance Directives (PADs) within the Veterans Health Administration. We conducted a two-round Delphi study with 55 panelists including consumers, caregivers, mental health providers and researchers. For a number of items where no positive or negative consensus was reached we found differences between the views of consumers and non-consumers, reflecting consumer’s preferences for nonmedical settings for completion and assistance with completion independent of the treatment team. Thus, the principle of consumer choice that applies to MHAD content should also be applied to the process of completion offered.

Objective: Individuals with diabetes and individuals with serious mental illness are more likely than the general population to die prematurely. The study examined the impact of diabetes on mortality among 197 individuals with co-occurring psychotic and substance use disorders who participated in a randomized controlled study of integrated mental health and substance abuse treatment. Methods: The authors examined Medicaid claims for evidence of diabetes and applied survival analyses to examine whether time from study entry until death was different for individuals with and without evidence of diabetes. Results: Of individuals with co-occurring psychotic and substance use disorders, 21% had evidence of diabetes. In a 12year period, 41% of those with evidence of diabetes died compared with 10% of those without evidence of diabetes. Conclusions: Interventions targeted for diabetes prevention and diabetes management are critical for persons with serious mental illness, particularly among those who also abuse substances. (Psychiatric Services 58:270–272, 2007)

Schizophrenia is associated with several chronic medical illnesses and a reduced life expectancy. This paper summarizes findings and recommendations from "The Mount Sinai Conference," held at the Mount Sinai School of Medicine in New York on October 17-18, 2002, and discusses the implications for improving medical monitoring of patients with schizophrenia who are managed in outpatient settings from the initiation of treatment. The Mount Sinai Conference involved a diverse panel of experts, including specialists on schizophrenia, obesity, diabetes, cardiology, endocrinology, and ophthalmology. Consensus recommendations included baseline measurement and regular monitoring of body mass index, blood glucose, lipid profiles, signs of prolactin elevation or sexual dysfunction, and movement disorders. Information from such measurements should be considered when selecting or switching antipsychotic agents and should trigger an evaluation of medication when abnormalities are detected.

Satisfaction with 11 aspects of service quality and four domains of effectiveness was assessed for counseling services offered through Project Liberty after the September 11, 2001, attacks on the World Trade Center.A total of 607 Project Liberty service recipients completed anonymous questionnaires, telephone interviews, or both. The 11 aspects of quality were counselor respect for client, willingness to listen, cultural sensitivity, speaking the same language as the client, amount of counseling time, convenience of meeting time and location, information received, whether the service would be used again, whether the service would be recommended to friends or family, and overall quality of service. The four effectiveness domains were daily responsibilities, relationships, physical health, and community involvement.At least 89 percent of service recipients rated Project Liberty as either good or excellent across 11 service quality dimensions and four effectiveness domains. The counselor's respect for clients and his or her cultural sensitivity were rated particularly favorably.These ratings suggest that, from the viewpoint of these recipients of counseling services, Project Liberty counselors were largely successful in providing accessible, acceptable, and useful services after the World Trade Center disaster. Such evaluations can be conducted in a cost-effective manner and integrated with evidence-based practice to ultimately ensure that recipients of counseling receive the most efficient and effective interventions.

Clients with co-occurring severe mental and substance use disorders are at high risk of institutionalization and other adverse outcomes. Although integrated mental health and substance abuse treatment is becoming a standard clinical approach for such clients, the optimal method for delivering integrated treatment remains unclear.This study compared integrated treatment delivered within two different models of community-based case management (assertive community treatment and standard clinical case management). A total of 198 clients in two urban sites who had co-occurring disorders and were homeless or unstably housed were randomly assigned to one of two treatment conditions and were followed for three years.Participants in both treatment conditions improved over time in multiple outcome domains, and few differences were found between the two models. Decreases in substance use were greater than would be expected given time alone. At the site that had higher rates of institutionalization, clients who received standard case management were more likely to be institutionalized. However, in the site that had lower rates of institutionalization, no differences in the rate of institutionalization were found between the two treatment conditions.Integrated treatment can be successfully delivered either by assertive community treatment or by standard clinical case management.

Sustained interactions and responses to social bids made by children with autism and verbal-age-matched children with mental retardation were recorded in two naturalistic settings. Children with autism produced fewer positive responses and more "no responses" than children with mental retardation; both groups were more likely to make positive responses to adults and not to respond to other children. Furthermore, although the frequency of conversations was not different for the two groups, children with autism were significantly less likely to engage in sustained play compared to children with mental retardation. Results suggest that children with autism are able to master the more rote and need-oriented social skills, such as simple conversation, but may not develop other forms of social interactions, like play.