Search

OBJECTIVE: Clozapine has been shown to be a cost-effective treatment for refractory psychosis among patients started on the medication in a hospital setting. The study examined service utilization and costs associated with clozapine treatment initiated in an outpatient clinic. METHODS: Subjects (N=28) included adult patients with a diagnosis of schizophrenia or schizoaffective disorder who began their clozapine treatment at an urban community mental health center. Subjects' charts were reviewed for information on service utilization in the year before and after starting clozapine, using an intent-to-treat approach. Hospitalization information was cross-checked against the Illinois Department of Human Services database. Costs were computed for hospitalization, medication, community outpatient services, and housing. RESULTS: Subjects' mean rate of hospitalization was reduced by more than half during the clozapine treatment year, and the mean number of days in the hospital decreased by more than two-thirds, from 23.5 days to 7.6 days. Mean hospitalization costs were reduced by more than half. Mean annual costs of medication rose from $648 in the year before clozapine treatment to $6,760 during the clozapine treatment year. Cost increases for medication, community services, and housing led to a marginal increase in the total cost of treatment. CONCLUSIONS: Patients initiating clozapine treatment on an outpatient basis showed a pattern of decreased hospitalization during the first year on clozapine. The cost savings associated with decreased hospitalization substantially, though not fully, offset the increased expense of clozapine during the first year of community-based treatment. [ABSTRACT FROM AUTHOR]

Objective: The study attempted to quantify the effect of receiving a disability pension check at the beginning of the month on the timing of substance-related hospitalizations in Department of Veterans Affairs (VA) facilities.Methods: All substance-related hospitalizations during fiscal year 2005 were identified in the VA National Psychosis Registry (13,402 hospitalizations among 8,813 individuals) and in a random sample of VA patients without serious mental illness (689 hospitalizations among 508 individuals). Multivariable logistic regression examined the impact of pension check receipt on timing of hospitalizations while controlling for other predictors of substance-related hospitalizations.Results: Receipt of a service-connected pension was associated with an increased risk of admission during the first two weeks of the month (odds ratio=1.08; 95% confidence interval=1.01-1.16).Conclusions: Staggering the disbursement of VA disability pensions (sending half the checks at the beginning and half in the middle of the month) might modestly reduce peak demand for substance-related inpatient services. [ABSTRACT FROM AUTHOR]

Since some of the data used for quality assurance purposes (i.e. rating scales) requires the active participation of clinicians, administrators use various mandates or incentives to insure its collection. However, although improving clinician compliance these measures may bias clinician responses. It is suggested that the concept of 'demand characteristics' originally developed by Orne to describe how non-specific aspects of the experimental setting shape what the human subject does may be applicable. For example a measure that might increase clinician compliance with completing GAF ratings on an inpatient unit might also influence the scores to make them coincide with the expectation that all patients are very ill when admitted and improved when discharged. Why such a phenomenon would be difficult to detect and what it might say about the relationship between managers and those they manage is also explored.

Objective Although practice guidelines for depression screening are evidence based, with their development relying on reviews of controlled studies, their adaptation and use as quality indicators have not been subject to rigorous study. This paper will therefore review the evidence supporting this practice.Methods A rational evaluation was carried out on both controlled studies and other sources of evidence related to the technical, clinical and policy assumptions underlying the use of depression screening guidelines as quality indicators.Results 1) Technical assumptions: depression screening could be used as a quality indicator. Current information technology does not allow accurate determination of who would benefit from being screened, whether they actually were screened, or the optimal percentage that should be screened. 2) Clinical assumptions: depression screening would improve outcomes. The evidence suggests that although depression screening might increase the diagnosis of depression, depressed patients so recognised tend to be less ill, less in need of treatment, or less likely to benefit from treatment, while screening, in the absence of other interventions, does not improve outcomes. 3) Policy assumptions: depression screening should be a focus of quality improvement. However, relative to other preventative measures, depression screening is a low priority. It does not meet usual cost-effectiveness criteria. There are more robust interventions for depression (i.e. collaborative care) that could be a focus of quality improvement efforts.Conclusion Although routine depression screening may be an acceptable practice guideline, its use as a quality measure is not supported.

Glaucoma's damage to peripheral vision compromises mobility to a greater extent than ocular pathology limiting central vision. Half of glaucoma is undiagnosed, as the majority of primary care physicians do not screen for glaucoma. Glaucoma is more prevalent in older adults with dementia than without dementia. This study tested the hypothesis that, in adults 60 and older with dementia, glaucoma screening failure is significantly higher than without dementia. An observational cross-sectional research design with a categorical outcome variable was used. Potential participants/caregivers were questioned regarding glaucoma diagnosis and treatment. Those denying glaucoma or treatment qualified for free screening. Participants (n = 103) were 75% African American (75 females, 28 males, average age 75 +/- 7.59). Thirty-three had dementia. Referral rate with dementia was significantly higher than without dementia (54% vs. 27%, chi(2) = 7.32, p = 0.0007) (95% CI = 0.304-0.816), affirming the study hypothesis. Lack of glaucoma screening and treatment follow-up by a majority of primary care physicians treating geriatric patients demonstrates a need for medical professionals to address function, particularly mobility, to discuss glaucoma's effects with patients/caregivers, and to consider measuring intraocular pressure.

This Open Forum reviews the literature on computerized systems that purport to either assess or improve clinical care in mental health. There is little empirical support for these claims. These limitations are in keeping with the author's own experience in developing and using such systems. In light of this evidence and experience, the author argues, nonquantitative methods of assessment can be not only complementary to use of computerized systems but possibly corrective. The author concludes with the caveat that if the only things you can change are the things you can measure, then perhaps the only things you are changing are measurements.

Objective: Illinois public hospitalizations over a ten-year period were studied to determine the impact of recent immigration. The study also explored clinical and demographic differences between immigrant groups and native-born Americans., Methods: Information was collected from the state hospital Clinical Information System for 1993, 1998, and 2003. Variables included age, sex, race, marital status, education, diagnosis, length of stay, birthplace, citizenship, primary language, English proficiency, and availability of a Social Security number. Logistic multiple regression was used to analyze trends in the proportion of psychiatric admissions of foreign-born patients, with foreign born as the dependent variable and year as the independent variable. Chi square analysis was used for trends across time., Results: In the hospitalized population, the proportion of immigrants was 7.3% in 1993, 10.9% in 1998, and 13.1% in 2003. With covariates adjusted for, the average increase of 8.0% per year in the odds of being foreign born was statistically significant (odds ratio=1.08, 95% confidence interval=1.06-1.10). Nevertheless, the proportion of foreign-born hospital admissions, including Asian and Mexican immigrants, was below their population ratio in Illinois. Mexican-origin immigrants constituted the largest group of admissions and were younger, less educated, had poorer English skills, and were more likely to be undocumented than other immigrants., Conclusions: The percentage of foreign-born patients admitted was lower than their percentage in the overall population. In previous immigration waves, immigrants were hospitalized at disproportionately higher rates than nonimmigrants. The gap is slowly narrowing as new admissions are increasingly likely to be foreign born, suggesting that public psychiatric hospitals should prepare for these changing populations.

Computer technology now allows clinical administrators to collect and analyze large data sets for performance monitoring. Despite the obvious usefulness of this technology, there are limitations. The indices that we can measure are at best proxies that might correlate with good clinical care but can also become dissociated from it in a variety of ways. First, there may not be a relationship throughout the entire continuum between the indicator and what we really value. Second, change in an indicator may not be associated with comparable change in the underlying value. Thirdly, the valence of an indicator can change depending on the context. Fourth, the very act of measuring an indicator can change its valence. Although, from a research perspective there may be technical solutions to these problems, in the real world where clinical care and politics meet, this may not be possible. Indices become reified. Measures become benchmarks and benchmarks quotas. Average is not a statistical phrase but a judgment and below average a term of approbation. To maximize the benefits of computerized monitoring, administrators need to be sensitive to this political dimension.

The wide scale use of expensive atypical antipsychotic medications has led to a dramatic increase in the proportion of direct costs schizophrenia being allocated for medications. Although there is evidence that the atypical antipsychotic, clozapine, may lead to cost savings in patients with refractory schizophrenia the cost-effectiveness of the other atypical antipsychotics remains in question. We therefore reviewed the published, long-term randomized, prospective cost-effectiveness treatment studies that compared an atypical to a typical antipsychotic. There were serious methodological problems with all. In general, those that were based on efficacy trials showed an advantage for atypicals while those based on effectiveness studies found the opposite. It appears that to the extent that studies mimic "real world" conditions they fail to support the cost-effectiveness of the atypical antipsychotics.

For almost 50 years, typical antipsychotics were the mainstay of pharmacological treatment for schizophrenia. However, during the last decade, the widespread use of expensive atypical antipsychotic medications has led to a dramatic increase in the proportion of the direct costs of schizophrenia being allocated for medications. Although there is evidence that the atypical antipsychotic clozapine may lead to cost savings in patients with refractory schizophrenia, the cost-effectiveness of the other atypical antipsychotics remains in question. Therefore, long-term randomised, prospective cost-effectiveness studies that compared an atypical to a typical antipsychotic have been reviewed in this paper. There were serious methodological problems with all the studies. In general, those that were based on efficacy trials showed an advantage for atypicals, whereas those based on effectiveness studies found the opposite. It seems that, to the extent that studies mimic real world conditions, they fail to support the cost-effectiveness of the atypical antipsychotics.

This study assessed the influence of service systems integration on employment outcomes for persons with mental illness. A survey was sent to all 125 key program staff that worked for community mental health treatment agencies or vocational rehabilitation agencies. The survey found that referral and employment rates were low; but that these rates were related to characteristics of the interagency systems integration. Community mental health staff referred 448 individuals for employment services. Staff from vocational rehabilitation agencies accepted only 26% of these referrals and found work for just 11%; 7% were employed six months later. Also, 39% of respondents reported that the linkage agreement between their agencies was never established. This study suggests the need for more effective strategies for integrating mental health treatment and vocational rehabilitation systems.

This study examined whether lawyers' attributions of responsibility for mental illnesses affect their decisions about involuntary treatment. A survey that was mailed in 2003 to Illinois lawyers involved in involuntary commitment elicited recommendations for involuntary treatment for characters presented in vignettes. The survey also sought respondents' attributions of personal responsibility for the onset and recurrence of mental illnesses. A total of 89 lawyers responded to the survey, a response rate of 48 percent. Decisions to hospitalize persons with mental illness involuntarily increased significantly with the level of risk of harm and were significantly related to attributions of responsibility for the recurrence of mental illness. Decisions to recommend involuntary medication were not related to attributions of responsibility.

A measure of the tendency to mismanage money was developed in an evaluation of a representative payee program for individuals with serious mental illnesses. A conceptual model was composed to guide item development, and items were tested, revised, added, and rejected in three waves of data collection. Rasch analyses were used to examine measurement properties. The resulting Money Mismanagement Measure (M3) consisted of 28 items with a Rasch person reliability at .72. Restriction of range was likely responsible for the low Rasch reliability. Validity analyses supported the construct validity of the M3. Subsequently, a cross-validation study was conducted on an untreated sample not as susceptible to range restriction. The M3 produced a Rasch person reliability = .85 with good validity. The M3 fills a gap that can facilitate research in the understudied area of money mismanagement.

Mothers with mental illnesses, who are homeless, as well as their children, are highly vulnerable and need specialized services. This retrospective study describes the experience of the Thresholds Mothers' Project in serving 24 homeless mothers. Benchmarks suggest that the mothers and their children benefited from the program. A year after intake, 79% were still engaged in services and were all living in either independent apartments or in supportive housing. The majority of the children in their mother's care at intake were still living with them 1 year later, 77%. The Mothers' Project provides an exemplary model of how to serve this vulnerable population.

Persons with mental illnesses who are released from jail or prison are at high risk of psychiatric decompensation and re-arrest. This paper describes an ACT jail linkage program for this population that won an American Psychiatric Association Gold Award (2001). Based on interviews with its first 24 participants, we illustrate how they experience factors that contribute to recidivism and decompensation. Pre- and post-data are examined to explore program outcomes. Results suggest that it is possible to identify, engage, and retain people in treatment who struggle with many risk factors. We conclude that this program should be expanded and replicated.

This study examined whether psychiatrists' attributions of responsibility for mental illnesses affect their decisions about involuntary hospitalization. A survey that was mailed in 2002 to members of the Illinois Psychiatric Society elicited recommendations for involuntary commitment for vignette characters. The survey also sought respondents' attributions of personal responsibility for the onset and recurrence of mental illnesses. A total of 432 psychiatrists responded to the survey. Decisions to involuntarily hospitalize persons with mental illness increased significantly with the level of risk of harm and varied significantly between psychiatric diagnoses. Attributions of responsibility were not related to commitment decisions.

The author questions both the scientific evidence and potential effect of the current trend to change the language used to describe certain serious mental illnesses (schizophrenia, schizoaffective disorder, or bipolar affective disorder) to "brain diseases." It is argued that changing nomenclature will not be effective in reducing stigma unless the treatment and financial circumstances of the seriously mentally ill are improved. Finally, it is suggested that we need to expand our understanding and treatment of "physical illnesses" to encompass the social and psychological dimensions, not narrow our view of psychiatric illnesses.

Representative Payeeship (RP) is intended to help individuals who are unable to manage disability payments appropriately to meet their basic living needs. This paper reviews the literature on whether RP is effective among individuals with mental disorders. We also review RP's mental health effects and its use as leverage in achieving behavioral goals. RP appears to be effective in helping clients meet their basic living needs; it also may decrease hospitalization and improve treatment compliance. Finally, we propose a research design to disentangle the role of clinical leverage from the more basic money-management function of RP.

Objective: Representative payee programs can improve the community tenure of persons with mental illness by ensuring that their basic needs, such as housing, are met. The authors conducted a survey to assess the extent to which representative payee programs are provided by community mental health centers and the criteria used in enrolling clients in these services., Methods: Community mental health centers under contract to the Illinois Department of Human Services participated in a census survey. Survey questions concerned provision of representative payee programs, service characteristics, and criteria for enrollment in the programs., Results: Representative payee programs were directly provided by 59 percent of the 95 community mental health centers in the sample. More than a third of clients who were receiving intensive services had a representative payee. More than three times as many such clients had a representative payee when agencies provided representative payee programs directly rather than through referrals of family members. Frequently cited criteria for enrollment in a representative payee program included a lack of financial skills (89 percent), a lack of rent money (52 percent), substance abuse (50 percent), homelessness (33 percent), and frequent (37 percent) or long-term (30 percent) hospitalization. The majority of the representative payee programs (76 percent) provided this service to clients who received representative payee services under the mandate of the Social Security Administration., Conclusions: Given the high proportion of clients of agencies that directly provided representative payee services who were assigned to a representative payee, all community mental health centers that provide intensive services should also directly provide representative payee services in order to improve access to representative payee services.

Objective: In response to provisions of the Omnibus Budget Reconciliation Act of 1987 that sought to reduce the number of mentally ill persons in nursing homes, the Illinois Department of Human Services in 1989 developed small-scale residential treatment programs known as community integrated living arrangements. This study examined satisfaction with residential services and days of hospitalization among residents of these facilities., Methods: Seventy-four residents from nine randomly selected community integrated living arrangement facilities were surveyed with the Quality of Life Interview to determine their satisfaction with their residence. Data on hospitalization before and after program placement were obtained from residents' charts and from an Illinois Department of Human Services database on utilization of state-operated facilities., Results: Residents of community integrated living arrangement facilities had a mean rating of satisfaction with their residence of 5.2, "mostly satisfied," on a scale from 1 to 7. Residents with continuous supervision and those with intermittent supervision were equally pleased with their living arrangements. Residents' hospital use decreased from a mean of 47.7 days during the year before program placement to 5.3 days during their first year in the program., Conclusions: The level of satisfaction with the community integrated living arrangement residences was fairly high and was comparable to levels reported in related research on independent living arrangements. The decrease in residents' hospital use in the year after program placement suggests that the community integrated living arrangements help maintain severely mentally ill individuals in the community.

Using computerized pharmacy, laboratory, and hospitalization data from a large state psychiatric hospital system, this study examined physician responses to laboratory studies obtained in the course of therapeutic drug monitoring. Computerized monitoring modules based on physician-developed guidelines identified out-of-range laboratory values and searched for appropriate corresponding physician responses within clinically driven, mathematically adjusted time frames. Valproate monitoring in four metropolitan hospitals showed that appropriate physician responses were associated with shorter hospital stays for patients and were predictive of length of stay in a multiple regression analysis (p<.001). After physicians received didactic feedback, the percentage of appropriate responses to low serum valproate levels increased.

Because survival time varies greatly in dementia, it is difficult for dementia patients to meet a key criterion for the Medicare Hospice Benefit, a six-month survival time. In a previous study, the authors examined guidelines for admitting dementia patients to hospice; the National Hospice Organization (NHO) guidelines were found to work well in identifying appropriate candidates for hospice among dementia patients. This was especially true for those patients whose deficits had progressed in an ordinal fashion consistent with Functional Assessment Staging (FAST) and who had reached stage 7C. The purpose of this study was to examine the utility of the NHO guidelines in identifying dementia patients who are appropriate for hospice; the limitations of these guidelines regarding non-ordinal patients; and the importance of the actual care plans used--as opposed to our previous study, which only examined initial treatment plans. Forty-five dementia patients enrolled in Hospice of the Great Lakes in Illinois were studied longitudinally over two years; this included a follow-up period of at least six months for all patients. Measures included: survival time; FAST; a medical complications checklist, which consisted of common complications of end-stage dementia; and co-morbid medical conditions and aggressive care, which consisted of feeding tubes, antibiotics, and Foley catheters used during the course of the study. Patients who had reached Stage 7C at intake had a mean survival time of 4.1 months; and the majority (71 percent) died within six months. Non-ordinal patients lived significantly longer at a mean of 10.9 months (p < .01), and and the minority (30 percent) died within six months. Foley catheters decreased survival time; and the use of antibiotics did not make a difference. This study echoed our previous findings regarding the usefulness of NHO guidelines in identifying dementia patients with a survival time of six months or less, specifically those at stage 7C or greater. The findings also suggest that the nature of the palliative care plan influences survival time.

Objective: Representative payee programs help severely mentally ill individuals manage money from their Social Security payments to cover expenses for necessities and to avoid homelessness and rehospitalization. This study examined a representative payee program operated by a community mental health center to determine the criteria used by clinicians and ease managers to refer clients to the program and to learn whether participation in the program was associated with reductions in hospitalization., Methods: The retrospective study included 56 individuals with severe mental illness who were enrolled in the representative payee program at Community Counseling Centers of Chicago for one year and who also had received services from the agency for at least one year before enrollment. Criteria used to refer clients to the representative payee program were determined through chart reviews. Data on state hospitalizations before and after enrollment were available for the entire sample; additional data on Medicaid-funded private hospitalizations were available for a subset of 33 clients., Results: The most common criteria for enrollment in the representative payee program were comorbid substance abuse or dependence (49 percent), a history of homelessness (33 percent), and frequent hospitalizations (32 percent). During the year of participation in the representative payee program, the mean number of days spent in state hospitals decreased markedly compared with the year before enrollment, from 68 days to seven days. A similar reduction was noted in the number of days spent in state and private hospitals, from 97 days to 15 days., Conclusions: Findings from this pre- and postintervention retrospective study are tentative in the absence of a more rigorous design. However, the results suggest that the representative payee program is quite effective in reducing hospital stays.

This study compared the characteristics of 56 clients with severe mental illness in a community mental health agency's representative payeeship program with those of 54 clients who did not participate in the program. Based on data from a two-year period, participants in the representative payee program were characterized by disability or financial distress, indicated by a diagnosis of schizophrenia, homelessness, lack of rent money, and lack of financial skills; long-term dependence on income from Social Security and services provided by the mental health system, evidenced by receipt of Supplemental Security Income and frequent hospitalizations; and lack of financial independence, as reflected by inability to earn income from employment and lack of financial support from family.

Objective: The authors' goal was to study the recommended dose schedule for risperidone., Method: They obtained computerized pharmacy data on 1,283 inpatients with the diagnoses of schizophrenia or schizoaffective disorder who were treated with risperidone. Continuance on risperidone was defined as remaining on the drug for 16 days or until discharge., Results: The majority of the patients (84%) continued on resperidone. Use of the recommended dose schedule decreased greatly over time. Patients were more likely to continue on risperidone if they had a higher maximum dose (5.7 mg/day versus 4.7 mg/day), a longer number of days to maximum dose (5.7 days versus 3.9 days), and a maximum rise in dose of 0.5-2 mg/day., Conclusions: These findings suggest that the recommended dose schedule should be altered to one that recommends a less rapid titration (over 6 days to a week) and that the dose increments consist of 0.5-2 mg/day.

Background: The more commonly used screening instruments for substance abuse were largely developed for addictive populations. We compared several alcohol and drug abuse scales to determine their efficiency and validity for psychiatric patients., Method: The subjects were 100 consecutively admitted patients to a public psychiatric facility. DSM-III-R diagnoses, obtained from the alcohol and drug scales of the SCID-P, were the criterion measure. Methods of reliability included inter-rater agreement, estimates of internal consistency, and repeat test administration. Sensitivity, specificity and more infrequently used accuracy indices, such as likelihood ratios and Receiver Operating Characteristic (ROC) analysis, were utilized to assess scale validity., Results: First, the reliability of all scales was high. Second, the instruments generally demonstrated highly acceptable levels of screening accuracy. Third, the intake evaluation was as reliable and valid as screening after admission on the unit. Finally, instruments were least discriminating for current problems (past 30 days)., Conclusions: Lifetime measures were found to be reliable and valid for public psychiatric patients but further research is need on increasing the accuracy of screening for current substance abuse problems and the effectiveness of multiple screening approaches.

The volume of certain brain structures, particularly those in the anterior medial temporal lobe, may be reduced to a greater extent in hyponatremic/hypo-osmolemic polydipsic schizophrenics than other schizophrenic patients. To explore if volume reduction is specific to this particular brain region, and if it is fundamentally associated with polydipsia, we imaged the anterior hippocampi/subicula and adjacent temporal lobes in normal males (n = 10) and polydipsic schizophrenic patients with (n = 7) and without (n = 6) hypo-osmolemia. Bilateral hippocampal/subicular (p < .01), but not temporal lobe (p < .30), volumes were diminished in the hypo-osmolemics relative to the other two groups, who resembled each other on these measures. No recognized or putative factor could explain these findings. Thus anterior medial temporal lobe structures appear to be preferentially diminished in hypo-osmolemic polydipsic schizophrenics. Additional studies are needed to more precisely define these anatomic differences and their relationship to these patients' impaired water excretion and severe mental illness.