Showing papers by "Robert A. Rosenheck published in 2004"
TL;DR: It is concluded that veterans’ pursuit of mental health services appears to be driven more by their guilt and the weakening of their religious faith than by the severity of their PTSD symptoms or their deficits in social functioning.
Abstract: One of the most pervasive effects of traumatic exposure is the challenge that people experience to their existential beliefs concerning the meaning and purpose of life. Particularly at risk is the strength of their religious faith and the comfort that they derive from it. The purpose of this study is to examine a model of the interrelationships among veterans' traumatic exposure, posttraumatic stress disorder (PTSD), guilt, social functioning, change in religious faith, and continued use of mental health services. Data are drawn from studies of outpatient (N = 554) and inpatient (N = 831) specialized treatment of PTSD in Department of Veterans Affairs programs. Structural equation modeling is used to estimate the parameters of the model and evaluate its goodness of fit to the data. The model achieved acceptable goodness of fit and suggested that veterans' experiences of killing others and failing to prevent death weakened their religious faith, both directly and as mediated by feelings of guilt. Weakened religious faith and guilt each contributed independently to more extensive use of VA mental health services. Severity of PTSD symptoms and social functioning played no significant role in the continued use of mental health services. We conclude that veterans' pursuit of mental health services appears to be driven more by their guilt and the weakening of their religious faith than by the severity of their PTSD symptoms or their deficits in social functioning. The specificity of these effects on service use suggests that a primary motivation of veterans' continuing pursuit of treatment may be their search for a meaning and purpose to their traumatic experiences. This possibility raises the broader issue of whether spirituality should be more central to the treatment of PTSD, either in the form of a greater role for pastoral counseling or of a wider inclusion of spiritual issues in traditional psychotherapy for PTSD.
267 citations
TL;DR: Severity of psychiatric symptoms was negatively associated with a recovery orientation, and use of a variety of standard services were positively associated withA polarized view of biomedical and recovery perspectives on mental illness may be unfounded, given that these perspectives appear to be mutually reinforcing.
Abstract: OBJECTIVE: The concept of recovery has received increasing emphasis in the delivery of services to persons with schizophrenia. This study was an initial effort to develop an empirically based model of factors associated with a recovery orientation. METHODS: The authors reanalyzed data from 825 persons with schizophrenia who were assessed in the Schizophrenia Patient Outcomes Research Team (PORT) client survey. Multiple regression models were used to identify client and service use variables associated with each of four domains identified as important to a recovery orientation: life satisfaction, hope and optimism, knowledge about mental illness and services, and empowerment. RESULTS: In each regression model, the strongest relationship was observed between recovery orientation and lower severity of depressive symptoms. Both receipt of family psychoeducation and fewer side effects of medications were significantly and positively related to three of the four recovery domains. Psychotic symptoms were associa...
249 citations
TL;DR: The proportion of patients with schizophrenia with a stable regimen of antipsychotic monotherapy who developed diabetes or were hospitalized for ketoacidosis was determined and clozapine and olanzapine have greater diabetes risk, but the attributable risk of diabetes mellitus with atypical antipsychotics is small.
Abstract: OBJECTIVE: The purpose of the study was to determine the proportion of patients with schizophrenia with a stable regimen of antipsychotic monotherapy who developed diabetes or were hospitalized for ketoacidosis. METHOD: Patients with schizophrenia for whom a stable regimen of antipsychotic monotherapy was consistently prescribed during any 3-month period between June 1999 and September 2000 and who had no diabetes were followed through September 2001 by using administrative data from the Department of Veterans Affairs. Cox proportional hazards models were developed to identify the characteristics associated with newly diagnosed diabetes and ketoacidosis. RESULTS: Of the 56,849 patients identified, 4,132 (7.3%) developed diabetes and 88 (0.2%) were hospitalized for ketoacidosis. Diabetes risk was highest for clozapine (hazard ratio=1.57) and olanzapine (hazard ratio=1.15); the diabetes risks for quetiapine (hazard ratio=1.20) and risperidone (hazard ratio=1.01) were not significantly different from that fo...
192 citations
TL;DR: Treatment with antidepressants is associated with highest conversion hazards among children aged 10 to 14 years, and patient age is an effect modifier on the risk of antidepressant-associated manic conversion.
Abstract: Background Antidepressant drug therapy can precipitate mania in vulnerable individuals, but little is known about the effects of age on this phenomenon. Objective To pharmacoepidemiologically evaluate the risk of conversion to mania by antidepressant class and patient age. Design, Setting, and Patients Using an administrative national database of more than 7 million privately insured individuals, linked outpatient and pharmacy claims were analyzed for mental health users aged 5 to 29 years (N = 87 920). Main Outcome Measures The proportion and cumulative hazard of manic conversion were analyzed by antidepressant class and subject age among children, adolescents, and young adults with an anxiety or nonbipolar mood disorder in the United States between January 1, 1997, and December 31, 2001. Manic conversion was defined as a new diagnosis of bipolar illness. Results During median follow-up of 41 weeks (range, 8-251 weeks), manic conversion occurred in 4786 patients (5.4%). Multivariate analyses using time-dependent Cox proportional hazards models indicated that an increased risk of manic conversion was associated with antidepressant category vs no antidepressant exposure (hazard ratios: 2.1 for selective serotonin reuptake inhibitors, P P P = .002). Antidepressant × age interactions revealed inverse age effects for selective serotonin reuptake inhibitors and other antidepressants (β = −.05; P P = .25). Peripubertal children exposed to antidepressants were at highest risk of conversion (number needed to harm: 10 [95% confidence interval, 9-12] among 10- to 14-year-olds vs 23 [95% confidence interval, 21-25] among 15- to 29-year-olds). Conclusions Patient age is an effect modifier on the risk of antidepressant-associated manic conversion. Treatment with antidepressants is associated with highest conversion hazards among children aged 10 to 14 years.
182 citations
TL;DR: The authors proposed a class of inverse intensity-of-visit process-weighted estimators in marginal regression models for longitudinal responses that may be observed in continuous time, which can handle arbitrary patterns of missing data as embedded in a subject's visit process.
Abstract: Summary. A frequent problem in longitudinal studies is that subjects may miss scheduled visits or be assessed at self-selected points in time. As a result, observed outcome data may be highly unbalanced and the availability of the data may be directly related to the outcome measure and/or some auxiliary factors that are associated with the outcome. If the follow-up visit and outcome processes are correlated, then marginal regression analyses will produce biased estimates. Building on the work of Robins, Rotnitzky and Zhao, we propose a class of inverse intensity-of-visit process-weighted estimators in marginal regression models for longitudinal responses that may be observed in continuous time. This allows us to handle arbitrary patterns of missing data as embedded in a subject's visit process. We derive the large sample distribution for our inverse visit-intensity-weighted estimators and investigate their finite sample behaviour by simulation. Our approach is illustrated with a data set from a health services research study in which homeless people with mental illness were randomized to three different treatments and measures of homelessness (as percentage days homeless in the past 3 months) and other auxiliary factors were recorded at follow-up times that are not fixed by design.
148 citations
TL;DR: Depressive disorders among perinatal women are highly prevalent and may have profound impact on infants and children, more work is needed to enhance detection and referral at public-sector obstetric clinics.
Abstract: OBJECTIVE: This study assessed rates of detection and treatment of minor and major depressive disorder, panic disorder, and posttraumatic stress disorder among pregnant women receiving prenatal care at public-sector obstetric clinics. METHODS: Interviewers systematically screened 387 women attending prenatal visits. The screening process was initiated before each woman's examination. After the visit, patients were asked whether their clinician recognized a mood or anxiety disorder. Medical records were reviewed for documentation of psychiatric illness and treatment. RESULTS: Only 26 percent of patients who screened positive for a psychiatric illness were recognized as having a mood or anxiety disorder by their health care provider. Moreover, clinicians detected disorders among only 12 percent of patients who showed evidence of suicidal ideation. Women with panic disorder or a lifetime history of domestic violence were more likely to be identified as having a psychiatric illness by a health care provider a...
142 citations
TL;DR: Children who were treated by a mental health specialist were less likely to drop out of treatment and had a larger number of visits, and Severity of illness, psychiatric hospitalization, and managed care insurance coverage were associated with lower risk of dropout and greater intensity of care.
Abstract: Objective: This study examined use of mental health services among children and adolescents with private insurance who were entering treatment. Variations in service use were examined by age, gender, diagnosis, recent psychiatric hospitalization, and type of insurance. Differences between children who received treatment from mental health professionals and those who were treated by primary care physicians were also examined. Methods: Drawn from a large database, the sample comprised 11,659 new users of mental health services. Service use was defined as the total number of days children were retained in treatment and the total number of mental health contacts recorded. Results: The overall mean number of visits within a six-month period was 3.9. The average duration of treatment was 75.36 days. Children who were treated by a mental health specialist were less likely to drop out of treatment and had a larger number of visits. Severity of illness, psychiatric hospitalization, and managed care insurance coverage were also associated with lower risk of dropout and greater intensity of care. Conclusions: Children’s access to services does not guarantee sustained involvement in treatment. To more fully address the nature of service use among children, a closer look at specific barriers to continued involvement in services is needed. (Psychiatric Services 55:1022–1028, 2004)
136 citations
TL;DR: When caregivers of patients with bipolar illness experience a high burden, patient outcome is adversely affected because the relationship is mediated through families' affective response and patients' medication adherence.
Abstract: OBJECTIVE: This study evaluated the direct and indirect effects of family burden and affective response on medication adherence and outcome among patients with bipolar disorder. METHODS: Data were examined for 126 patients who were consecutively admitted to the psychiatric service at a university-affiliated hospital and who met research diagnostic criteria for bipolar I or II disorder or for schizoaffective disorder, manic type, and their family caregivers. A total of 101 pairs of patients and family caregivers (80 percent) completed 15 months of study and were included in the analyses. Patients and their identified caregivers were assessed within two weeks of either discharge from the index inpatient admission or initiation of outpatient treatment (baseline assessment). Patients and caregivers were also assessed seven and 15 months after the baseline assessment. Structural equation modeling was used to evaluate caregivers' influences on patients' medication adherence seven months after baseline and on cl...
132 citations
TL;DR: A latent pattern mixture model (LPMM) is proposed, where the mixture patterns are formed from latent classes that link the longitudinal response and the missingness process and suggests the presence of four latent classes linking subject visit patterns to homeless outcomes.
Abstract: A frequently encountered problem in longitudinal studies is data that are missing due to missed visits or dropouts. In the statistical literature, interest has primarily focused on monotone missing data (dropout) with much less work on intermittent missing data in which a subject may return after one or more missed visits. Intermittent missing data have broader applicability that can include the frequent situation in which subjects do not have common sets of visit times or they visit at nonprescheduled times. In this article, we propose a latent pattern mixture model (LPMM), where the mixture patterns are formed from latent classes that link the longitudinal response and the missingness process. This allows us to handle arbitrary patterns of missing data embodied by subjects' visit process, and avoids the need to specify the mixture patterns a priori. One assumption of our model is that the missingness process is assumed to be conditionally independent of the longitudinal outcomes given the latent classes. We propose a noniterative approach to assess this key assumption. The LPMM is illustrated with a data set from a health service research study in which homeless people with mental illness were randomized to three different service packages and measures of homelessness were recorded at multiple time points. Our model suggests the presence of four latent classes linking subject visit patterns to homeless outcomes.
100 citations
TL;DR: Prescribers for patients receiving more than one antipsychotic were frequently able to cite plausible and specific target symptoms they were attempting to address with this practice.
Abstract: BACKGROUND: Prescribing more than 1 antipsychotic is common but has received little supportive evidence in the literature. This study was designed to systematically survey clinicians about their rationale for prescribing more than 1 antipsychotic for specific patients. METHOD: Patients with schizophrenia (diagnosed according to ICD-9 criteria from October 1, 1999, to September 30, 2000) at 2 Veterans Administration (VA) medical centers and their prescriptions for anti-psychotics (filled within the VA system from June 1, 2000, through September 30, 2000) were identified from administrative databases. Clinicians for each patient with more than 1 antipsychotic prescription were interviewed using a structured questionnaire. After summarizing offered explanations, we compared patients prescribed 2 atypicals with those prescribed an atypical and a conventional. RESULTS: The treatment of 66 patients was reviewed. The 4 most common reasons for coprescription were reducing positive symptoms (61%), reducing negative symptoms (20%), decreasing total amount of medication (9%), and reducing extrapyramidal symptoms (5%). In 65% of patients (41/63), psychiatric symptoms were thought to have been refractory to antipsychotic monotherapy. In 39% of patients (N = 26), antipsychotic coprescription was intended to be transitional, but in only 46% of these patients (N = 12) had this transition been completed after 6 to 12 months. CONCLUSION: Prescribers for patients receiving more than one antipsychotic were frequently able to cite plausible and specific target symptoms they were attempting to address with this practice.
89 citations
TL;DR: It is found that among homeless clients with severe mental illness, clients with a history of incarceration have more serious problems and show somewhat less improvement in some community adjustment domains.
Abstract: OBJECTIVE: This study examined the clinical problems and treatment outcomes of homeless people with severe mental illness and a history of incarceration. METHODS: Between May 1994 and June 1998, a total of 5,774 people entered assertive community treatment case management services in the Access to Community Care and Effective Services and Supports (ACCESS) demonstration program at 18 sites in nine states. This study used data from reassessments at 12 months after program entry. Analysis of variance was used to compare baseline status and 12-month outcomes for clients with a lifetime incarceration history of less than six months, of six months or more, and no incarceration history. The outcomes assessed were housing status, employment status, psychiatric problems, alcohol problems, drug problems, and criminal justice involvement. RESULTS: Two-thirds of the ACCESS clients had a history of incarceration, with about one-third having less than six months of incarceration and about one-third having six months o...
TL;DR: Results indicate that the majority of the veteran sample had experienced some improvement in their ability to cope with their chronic illness, decreasing their use of violence and substance abuse but still were experiencing high levels of symptomatology.
Abstract: This study is a 6-year longitudinal study of 51 treatment-seeking male veterans with combat-related posttraumatic stress disorder. Measures of PTSD and psychiatric symptomatology, social functioning, and program impact were assessed at admission to an inpatient treatment program, at 18 months, and 6 years later. Previous studies had shown that the treatment program's impact on course of illness had been negligible. The sample showed an extremely high mortality rate of 17% over 6 years. The remaining veterans showed improvement in violence and alcohol and drug use, but an increase in hyperarousal symptoms and social isolation. Nearly three-fourths had had an inpatient hospitalization. Veterans' self-ratings, in contrast, indicated significant improvement in all areas of functioning except employment, as well as an overall positive view of the impact of the program on their lives. Results indicate that the majority of the veteran sample had experienced some improvement in their ability to cope with their chronic illness, decreasing their use of violence and substance abuse but still were experiencing high levels of symptomatology. The extremely high mortality rate, however, provides a somber reminder of the seriousness of this disorder.
Journal Article•
TL;DR: It is concluded that using reversed items with disturbed patients can cause confusion that reduces reliability, and the use of Rasch analysis over TST in health research is supported since it indicated ways to reduce respondent burden while maintaining reliability and improving validity.
Abstract: This study examined whether Rasch analysis could provide more information than true score theory (TST) in determining the usefulness of reverse-scored items in the Mississippi Scale for Posttraumatic Stress Disorder (M-PTSD). Subjects were 803 individuals in inpatient PTSD units at 10 VA sites. TST indicated that the M-PTSD performed well and could be improved slightly by deleting one item. Factor analysis using raw scores indicated that the reverse-scored items formed the second factor and had poor relationships with normally scored items. However, since item-total correlations supported their usefulness, they were kept. The subsequent Rasch analysis indicated that five of the seven worst fitting items were reverse-scored items. We concluded that using reversed items with disturbed patients can cause confusion that reduces reliability. Deleting them improved validity without loss of reliability. The study supports the use of Rasch analysis over TST in health research since it indicated ways to reduce respondent burden while maintaining reliability and improving validity.
TL;DR: Quality of pharmacotherapy for depression in the nation's largest mental health system, at least by one standard measure, is relatively good and the specific antidepressant drug used has little impact on quality.
Abstract: Objectives:This article examines the use of antidepressant medication in the treatment of major depression in the Department of Veterans Affairs (VA) during the 2001 fiscal year and considers the relationship of patient, drug, provider, and facility to adherence to medication treatment guidelines.Me
TL;DR: Interaction analyses showed that, for men, greater social support increased the likelihood of both HIV testing and receipt of results, while sexual victimization during follow-up decreased the likelihood that men would return for their HIV results.
Abstract: OBJECTIVE: The purpose of this study was to determine the rates and predictors of HIV testing and receipt of results among homeless adults with serious mental illness in the initial 3-month period after contact with a community-based case management program. METHOD: Baseline and follow-up interview data came from clients (N=5,890) in the Access to Community Care and Effective Services and Supports program, an 18-site, 5-year federally sponsored demonstration designed to evaluate the effect of service system integration on outcomes for homeless persons with serious mental illness. RESULTS: Overall, 38.0% of clients were tested for HIV in the 3 months after program entry; of these, 88.8% returned to receive their test results. Likelihood of being tested was independently associated with having been tested before, more severe psychiatric symptoms and drug problems, level of worry about getting AIDS, younger age, less education, minority status, longer-term homelessness, being sexually assaulted, being arrest...
TL;DR: The relatively small proportion of homeless veterans who attributed homelessness to their military service, coupled with the long 14-year average lag time between discharge and their first episode of homelessness, is consistent with epidemiological data suggesting that military service itself does not substantially increase the risk for becoming homeless among veterans.
Abstract: This study examined the perceived relationship between military service and the risk of homelessness after discharge and identified specific aspects of military service that homeless veterans experience as having increased their risk for becoming homeless. A cross-sectional survey was conducted among 631 homeless veterans enrolled in the VA Therapeutic Employment Placement and Support Program from January 2001 through September 2003. Associations of sociodemographic characteristics, clinical status, and military service characteristics (independent variables) were examined in relation to perceptions of increased risk for homelessness and time to first episode of homelessness after leaving the military (two dependent variables), using analysis of variance, logistic regression, and multiple regression statistical analyses. Fewer than one third (31%) of the homeless veterans in this study reported that military service increased their risk for homelessness--either somewhat (18%) or very much (13%). Among those veterans who perceived military service as increasing their risk for becoming homeless, the three aspects of military service most commonly identified included a) substance abuse problems that began in the military (75%), b) inadequate preparation for civilian employment (68%), and c) loss of a structured lifestyle. The relatively small proportion of homeless veterans who attributed homelessness to their military service, coupled with the long 14-year average lag time between discharge and their first episode of homelessness, is consistent with epidemiological data suggesting that military service itself does not substantially increase the risk for becoming homeless among veterans.
TL;DR: Prior residential treatment appears to have little effect on treatment outcomes among formerly homeless veterans placed into permanent supported housing programs providing indirect support for the direct placement supported housing model.
Abstract: This study examines the effect of previous participation in time limited residential treatment and other factors on treatment outcomes among homeless veterans with serious mental illness placed into permanent supported housing. The sample consisted of 655 veterans placed into supported housing at 18 sites through the VA's Healthcare for Homeless Veterans (HCHV) Supported Housing Program during the period 1993-2000. Data on client and program characteristics, and treatment outcomes, were documented by HCHV case managers staffing these programs. Data on use of VA services, including time limited residential treatment received 6 months prior to entry into supported housing, were extracted from VA administrative files. The relationship of prior residential treatment, as well as other measures of client characteristics, service use, and program characteristics, to outcomes were assessed using both bivariate and multivariate Cox proportional hazards regression and logistic regression. After adjusting for client characteristics, service use, and program characteristics, no differences in outcomes were found between clients who had received prior residential treatment and those placed directly into permanent supported housing. Prior residential treatment appears to have little effect on treatment outcomes among formerly homeless veterans placed into permanent supported housing programs providing indirect support for the direct placement supported housing model.
TL;DR: It was found that the majority (62.1%) of patients were dosed within the PORT-recommended dosing range, and patients treated at facilities with more emphasis on mental health and research and education were more likely to be dosed above the recommendations.
Abstract: Very little is known about patient, provider, and facility characteristics that may affect the likelihood that a schizophrenia patient who receives an antipsychotic medication is dosed according to treatment recommendations. In this study, prescription drug records for schizophrenia patients were collected from the Department of Veterans Affairs, and indicators were constructed describing whether the average daily dose was outside of the range recommended by the schizophrenia Patient Outcomes Research Team (PORT). Generalized estimation equations were used to identify patient, facility, and provider characteristics that are associated with adherence to PORT recommendations. We found that the majority (62.1%) of patients were dosed within the PORT-recommended dosing range. Patients who were older, were female, had comorbid psychiatric disorders, or were prescribed conventional antipsychotics were less likely to adhere to PORT recommendations. Provider and facility characteristics were generally not significantly associated with adherence. When patients were dosed outside of the recommendations, patients treated at facilities with more emphasis on mental health and research and education were more likely to be dosed above the recommendations.
TL;DR: The haplotype -1725G/-25T at the NotCH4 locus, which results from SNPs of NOTCH4 that are in LD, may increase susceptibility to schizophrenia in AAs.
TL;DR: Vet-to-Vet is described, a consumer-professional partnership model in which consumer services are embedded in a mental health system and has potential for minimizing implementation barriers and for maximizing long-term sustainability.
Abstract: Recently, there has been increased interest in consumer-provided mental health services. Two models have been proposed: One emphasizing full independence from professional services, and one in which consumers work within the mental health system. In this paper we describe Vet-to-Vet, a consumer-professional partnership model in which consumer services are embedded in a mental health system. We describe the advantages of this approach and barriers to implementation of other models. Vet-to-Vet has several unique elements, developed and implemented by consumers with professional consultation and supervision. We believe that consumer-partnership models of consumer-provided mental health services have potential for minimizing implementation barriers and for maximizing long-term sustainability.
TL;DR: Although the populations had different demographic and clinical characteristics, differences in the quality measures between the two systems were few, with the VA slightly outperforming the private sector in the prescription of antidepressants during the acute phase of treatment, the first 84 days (84.7 compared with 81 percent) and during the maintenance phase of Treatment, thefirst 181 days (53.9 compared with 50.9 percent).
Abstract: OBJECTIVE: Comparing quality of care between large health care systems is important for health systems management. This study compared measures of the quality of pharmacotherapy for patients with major depression across a sample of patients from the Department of Veterans Affairs (VA) and the private sector. METHODS: In this observational study, all patients who were given a new prescription for an antidepressant and a diagnosis of major depression in the VA during fiscal year 2000 were identified by using administrative data (N=27,713). In the private sector, a similar sample of patients were identified by using Medstat's MarketScan database (N=4,852). For both groups, measures of the quality of antidepressant pharmacotherapy were constructed. These measures were compared across the two groups by using logistic regression models. Controls for age, gender, comorbid disorders, and initial antidepressant drug prescribed were included in some models. RESULTS: Although the populations had different demographi...
TL;DR: Clients with less severe mental health and addiction problems at baseline and those in communities that had higher social capital and more affordable housing were more likely to become independently housed, to show greater clinical improvement, and to have greater access to housing services.
Abstract: Objective: This study examined the various living arrangements among formerly homeless adults with mental illness 12 months after they entered case management. Methods: The study surveyed 5,325 clients who received intensive case management services in the Access to Community Care and Effective Services and Supports (ACCESS) program. Living arrangements 12 months after program entry were classified into six types on the basis of residential setting, the presence of others in the home, and stability (living in the same place for 60 days). Differences in perceived housing quality, unmet housing needs, and overall satisfaction were compared across living arrangements by using analysis of covariance. Results: One year after entering case management, 37 percent of clients had been independently housed during the previous 60 days (29 percent lived alone in their own place and 8 percent lived with others in their own place), 52 percent had been dependently housed during the previous 60 days (11 percent lived in someone else’s place, 10 percent lived in an institution, and 31 percent lived in multiple places), and 11 percent had literally been homeless during the previous 60 days. Clients with less severe mental health and addiction problems at baseline and those in communities that had higher social capital and more affordable housing were more likely to become independently housed, to show greater clinical improvement, and to have greater access to housing services. After the analysis adjusted for potentially confounding factors, independently housed clients were more satisfied with life overall. However, no significant association was found between specific living arrangements and either perceived housing quality or perceived unmet needs for housing. Conclusions: Living independently was positively associated with satisfaction of life overall, but it was not associated with the perception that the quality of housing was better or that there was less of a need for permanent housing. (Psychiatric Services 55:566–574, 2004)
TL;DR: The apparent contrast between the diversity of VA participant goals and the growing focus by VA rehabilitation professionals on competitive employment suggests that greater dialogue is needed between providers and consumers.
Abstract: Research into vocational rehabilitation (VR) consumer service preferences has been limited. The current study describes the self-reported goals of 228 applicants to a VR program sponsored by the Veterans Administration (VA) and documents the relationship of those goals to participant background variables and outcomes. Participants endorsed a wide variety of goals for participation, including clinical and practical goals. Competitive employment was a goal of only 53% and was the primary goal of only 5%. The apparent contrast between the diversity of VA participant goals and the growing focus by VA rehabilitation professionals on competitive employment suggests that greater dialogue is needed between providers and consumers.
TL;DR: Although clozapine generates substantially fewer side effects than haloperidol, its impact on psychiatric aspects of schizophrenia is less robust and primarily involves positive symptoms.
Abstract: Objective The objective of this study was to demonstrate a multivariate health state approach to analyzing complex disease data that allows projection of long-term outcomes using clustering, Markov modeling, and preference weights. Subjects We studied patients hospitalized 30 to 364 days with refractory schizophrenia at 15 Veterans Affairs medical centers. Study design We conducted a randomized clinical trial comparing clozapine, an atypical antipsychotic, and haloperidol, a conventional antipsychotic. Methods Health status instruments measuring disease-related symptoms and drug side effects were administered in face-to-face interviews at baseline, 6 weeks, and quarterly follow-up intervals for 1 year. Cost data were derived from Veterans Affairs records supplemented by interviews. K-means clustering was used to identify a small number of health states for each instrument. Markov modeling was used to estimate long-term outcomes. Results Multivariate models with 7 and 6 states, respectively, were required to describe patterns of psychiatric symptoms and side effects (movement disorders). Clozapine increased the proportion of clients in states characterized by mild psychiatric symptoms and decreased the proportion with severe positive symptoms but showed no long-term benefit for negative symptoms. Clozapine dramatically increased the proportion of patients with no movement side effects and decreased incidences of mild akathisia. Effects on extrapyramidal symptoms and tardive dyskinesia were far less pronounced and slower to develop. Markov modeling confirms the consistency of these findings. Conclusions Analyzing complex disease data using multivariate health state models allows a richer understanding of trial effects and projection of long-term outcomes. Although clozapine generates substantially fewer side effects than haloperidol, its impact on psychiatric aspects of schizophrenia is less robust and primarily involves positive symptoms.
TL;DR: Clients exposed to limit-setting interventions had poorer outcomes than others on many measures, suggesting that within the limits of a nonexperimental study, such interventions do not appear to prevent adverse outcomes.
Abstract: OBJECTIVE: This study examined the relationship of limit-setting interventions and six-month outcomes in assertive community treatment. METHODS: Case managers from 40 Veterans Affairs assertive community treatment teams at 40 different sites documented their use of 25 limit-setting activities with 1,564 clients during the first six months of treatment. Five scales were constructed representing different types of limit-setting activities: withholding certain types of assistance until the client curtailed certain behaviors; behavioral contracting in which specific goals were identified and linked to reinforcers if the goals were achieved; invocation of external authorities, such as a probation officer; seeking a declaration of incompetence to manage funds or initiation of a request for a payee; and forced hospitalization through civil commitment. Structured interviews conducted at baseline and six months documented changes in clinical status and community adjustment. Multiple regression analysis was used to...
TL;DR: The results suggest that these two genetic variants in the CALCYON gene do not play a major role in predisposition to either schizophrenia or cocaine dependence in AA or EA subjects.
Abstract: Calcyon is a brain-specific D1 dopamine receptor-interacting protein, with a potential role in D1-mediated physiological processes, including motor control, reward mechanisms, and cognitive processes. Our objective was to investigate the relationship between polymorphism of the CALCYON gene and (1) schizophrenia and (2) cocaine dependence in African-American (AA) and European-American (EA) subjects. Two single nucleotide polymorphisms (SNPs) at the CALCYON locus were genotyped in 70 AA and 206 EA individuals with schizophrenia and 90 AA and 118 EA individuals with cocaine dependence. The control group was comprised of 46 AA and 207 EA subjects screened to exclude those with psychiatric or substance use disorders. The specific polymorphisms studied were markers +295214G/A and +297151T/G. Comparisons of allele and haplotype frequencies between cases and controls were performed with the Fisher's Exact Test. Linkage disequilibrium (LD) between these two SNPs was calculated with the 3LOCUS program. No alleles or haplotypes were found to be associated with schizophrenia or cocaine dependence either in AA or EA subjects. The markers +295214G/A and +297151T/G are in the same haplotype block in all subgroups. Allele and haplotype frequencies differed significantly between EA and AA subjects. These results suggest that these two genetic variants in the CALCYON gene do not play a major role in predisposition to either schizophrenia or cocaine dependence in AA or EA subjects. Furthermore, these findings begin to establish a haplotype map for this gene in the AA and EA populations.
TL;DR: This study used standard regression models to examine the strength of the association between continuity of care measures and health outcomes for a sample of female veterans newly entering outpatient treatment for PTSD, finding only weak and inconsistent evidence of the clinical benefits of continuity of Care.
Abstract: Continuity of care (COC) is often used as an indicator of treatment quality for patients with severe psychiatric or addictive disorders. However, few studies have examined the relationship between measures of COC and treatment outcomes. This study used standard regression models to examine the strength of the association between continuity of care measures and health outcomes for a sample of female veterans newly entering outpatient treatment for PTSD. There were few consistently significant associations between COC and outcome measures. Four months following program entry only one measure of treatment process, commitment to treatment, was positively associated with one or more continuity of care measures and several COC measures were associated with poor outcomes. Eight months following program entry patients with greater COC during the first four months of treatment had greater declines in violent behavior and PTSD measurements and larger increases in global functioning. However, when a Bonferonni corrected alpha of P <.001 was used to adjust for multiple comparisons, none of the relationships remained statistically significant. Thus, this study provides only weak and inconsistent evidence of the clinical benefits of continuity of care.
TL;DR: Black veterans were found to have higher satisfaction levels on most measures over the period of study while the satisfaction of whites and Hispanics were not significantly different.
Abstract: This paper presents an analysis of changes in satisfaction of minorities with inpatient mental health services provided by the Veterans Health Administration (VHA) during a period of major system change (1995–2001). Post discharge data from 16,223 veterans who received inpatient VHA mental health services at 87 medical centers during this period was examined using hierarchical linear models. Blacks were found to have higher satisfaction levels on most measures over the period of study while the satisfaction of whites and Hispanics were not significantly different. There was little change over the study period in the relative satisfaction of minorities and whites. Changes in patterns of VHA mental health care have not adversely affected the satisfaction of minority veterans.