Showing papers by "Robert A. Rosenheck published in 2007"
Duke University1, University of California, Los Angeles2, Icahn School of Medicine at Mount Sinai3, University of California, San Diego4, University of Maryland, Baltimore5, Vanderbilt University6, University of North Carolina at Chapel Hill7, Yale University8, National Institutes of Health9, Columbia University10
TL;DR: After 2 months of antipsychotic treatment, all groups had a small but significant improvement in neurocognition, and after 18 months of treatment, neurocognitive improvement was greater in the perphenazine group than in the olanzapine and risperidone groups.
Abstract: change in a neurocognitive composite score after 2 months of treatment. Secondary outcomes included neurocognitive composite score change at 6 months and 18 months after continued treatment and changes in neurocognitive domains. Results: At 2 months, treatment resulted in small neurocognitive improvements of z= 0.13 for olanzapine (P.002), 0.25 for perphenazine (P.001), 0.18 for quetiapine (P.001), 0.26 for risperidone (P.001), and 0.12 for ziprasidone (P.06), with no significant differences between groups. Results at 6 months were similar. After 18 months of treatment, neurocognitive improvement was greater in the perphenazine group than in the olanzapine and risperidone groups. Neurocognitive improvement predicted longer time to treatment discontinuation, independently from symptom improvement, in patients treated with quetiapine or ziprasidone. Conclusions: After 2 months of antipsychotic treatment, all groups had a small but significant improvement in neurocognition. There were no differences between any pair of agents, including the typical drug perphenazine. These results differ from the majority of previous studies, and the possible reasons are discussed.
966 citations
TL;DR: All antipsychotic treatment groups in all phases made modest improvements in psychosocial functioning, and more substantial improvements would likely require more intensive adjunctive psychossocial rehabilitation interventions.
Abstract: Objective: This study examined the relative effects of the second-generation antipsychotic drugs and an older representative agent on psychosocial functioning in patients with chronic schizophrenia. Method: Consenting patients were enrolled in the NIMH Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) project. In phase 1, patients were randomly assigned to receive olanzapine, perphenazine, quetiapine, risperidone, or ziprasidone for up to 18 months. Clozapine was included for patients who chose this pathway after discontinuing phase 1 due to inefficacy; all other patients received another second-generation antipsychotic. Psychosocial functioning was assessed using the Quality of Life Scale. Results: Psychosocial functioning modestly improved for the one-third of phase 1 patients who reached the primary Quality of Life Scale analysis endpoint of 12 months (average effect size 0.19 SD units). Although for several of the drugs individually there were significant changes from baseline, overa...
278 citations
TL;DR: The results do not support association of the OPRM1 Asn40Asp polymorphism with NTX treatment response for AD, and polymorphic variants at each of the 3 opioid receptor genes are studied.
Abstract: Background: Pharmacotherapy of alcohol dependence (AD) is at an early stage of development; currently available medications have limited efficacy. It would be clinically valuable to identify, before initiation of a course of treatment, those patients who, based on genetic markers, are most likely to respond to a specific pharmacotherapy. A previous report suggested that a functional variant at the genetic locus encoding the μ opioid receptor (Asn40Asp) is such a marker, in short-term (3-month) treatment with the opioid-blocking drug naltrexone (NTX).
Methods: We studied polymorphic variants at each of the 3 opioid receptor genes—OPRM1, OPRD1, and OPRK1, which encode the μ, δ, and κ opioid receptors, respectively—including the OPRM1 Asn40Asp variant—as predictors of response to NTX or placebo in 215 alcohol-dependent male subjects who participated in Veterans Affairs Cooperative Study 425, “Naltrexone in the Treatment of Alcohol Dependence.”
Results: At the 3-month time point, treatment condition, age, and the pretreatment number of drinks per drinking day were all significant (p<0.05) predictors of the rate of relapse and time to relapse. Although NTX had no significant effect on relapse to heavy drinking in the overall sample in CSP 425, it significantly reduced relapse in the subgroup that provided DNA for analysis (i.e., the present study sample). There were no significant interactions between any individual single nucleotide polymorphisms studied and NTX treatment response.
Conclusions: These results do not support association of the OPRM1 Asn40Asp polymorphism with NTX treatment response for AD.
200 citations
TL;DR: It is suggested that caregivers' perceptions of stigma may negatively affect their mental health by reducing their coping effectiveness and this study investigates the associations between perceived stigma, depressive symptoms and coping among caregivers of people with bipolar disorder.
Abstract: This study investigates the associations between perceived stigma, depressive symptoms and coping among caregivers of people with bipolar disorder. Caregivers of 500 people with DSM-IV bipolar disorder responded to measures of these constructs at study entry. Patients' clinical and functional status were evaluated within 30 days of the caregiver assessment. Perceived stigma was positively associated with caregiver depressive symptoms, controlling for patient status and socio-demographic factors. Social support and avoidance coping accounted for 63% of the relationship between caregiver stigma and depression. Results suggest that caregivers' perceptions of stigma may negatively affect their mental health by reducing their coping effectiveness.
175 citations
TL;DR: Burdens experienced by family caregivers of people with bipolar disorder are associated with problems in health, mental health, and cost and Psychosocial interventions targeting the strains of caregiving for a patient with bipolar Disorder are needed.
Abstract: Objectives: Caring for a relative with schizophrenia or dementia is associated with reports of high caregiver burden, symptoms of depression, poor physical health, negligence of the caregiver's own health needs, elevated health service use, low use of social supports, and financial strain. This study presents the design and preliminary data on the costs and consequences of caring for a relative or friend with bipolar disorder from the Family Experience Study, a longitudinal study of the primary caregivers to 500 patients enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder.
Methods: Subjects were primary caregivers of 500 patients with bipolar disorder diagnosed by the Mini International Neuropsychiatric Interview and the Affective Disorder Evaluation. Caregivers were evaluated within 1 month after patients entered Systematic Treatment Enhancement Program using measures of burden, coping, health/mental health, and use of resources and costs.
Results: Eighty-nine percent, 52%, and 61% of caregivers, respectively, experienced moderate or higher burden in relation to patient problem behaviors, role dysfunction, or disruption of household routine. High burden caregivers reported more physical health problems, depressive symptoms, health risk behavior and health service use, and less social support than less burden caregivers. They also provided more financial support to their bipolar relative.
Conclusions: Burdens experienced by family caregivers of people with bipolar disorder are associated with problems in health, mental health, and cost. Psychosocial interventions targeting the strains of caregiving for a patient with bipolar disorder are needed.
156 citations
TL;DR: Since 1997, the average annual growth in all users of VA specialty mental health services has averaged 37,000 veterans per year, including 22,000 per year with PTSD, which was associated with a 37 percent reduction in mental health visits per veteran per year.
Abstract: Treating post-traumatic stress disorder (PTSD) among returning Iraq/Afghanistan veterans is a high priority for the U.S. Department of Veterans Affairs (VA). The number of Persian Gulf–era veterans diagnosed with PTSD grew by 8,000 veterans per year from 2003 to 2005. Since 1997, however, the average annual growth in all users of VA specialty mental health services has averaged 37,000 veterans per year, including 22,000 per year with PTSD. This expansion was associated with a 37 percent reduction in mental health visits per veteran per year. The VA has substantially increased funding for PTSD services. Nevertheless, the observed growth in demand requires continued monitoring to assure that the needs of returning veterans are met.
136 citations
TL;DR: Among this group of patients with chronic schizophrenia who had just discontinued the older antipsychotic perphenazine, quetiapine and olanzapine were more effective than risperidone, as reflected by longer time to discontinuation for any reason.
Abstract: Objective: The relative effectiveness of newly started antipsychotic drugs for individuals with schizophrenia may depend on multiple factors, including each patient’s previous treatment response and the reason for a new medication trial. This randomized, double-blind study compared olanzapine, quetiapine, and risperidone in patients who had just discontinued the older antipsychotic perphenazine. Method: Subjects with schizophrenia (N=114) who had been randomly assigned to and then discontinued perphenazine in phase 1 of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia study were reassigned randomly to double-blinded treatment with olanzapine, 7.5–30.0 mg/day (N=38); quetiapine, 200–800 mg/day (N=38); or risperidone, 1.5–6.0 mg/day (N=38). The primary aim was to determine whether there were differences among these three treatments in effectiveness, as measured by time to treatment discontinuation for any reason. Secondary outcomes included reasons for treatment disconti...
131 citations
TL;DR: A national study of persons with schizophrenia-related disorders examined clinical factors and labormarket conditions related to employment outcomes, finding work attachment and earnings were substantially lower than in previous survey data, not very sensitive to labor market conditions, and strongly related to clinical status.
Abstract: Objective: Data from a national study of persons with schizophrenia-related disorders were examined to determine clinical factors and labormarket conditions related to employment outcomes. Methods: Data were obtained from the U.S. Schizophrenia Care and Assessment Program, a naturalistic study of more than 2,300 persons from organized care systems in six U.S. regions. Data were collected via surveys and from medical records and clinical assessments at baseline and for three years. Outcome measures included any community-based (nonsheltered) employment, 40 or more hours of work in the past month, employment at or above the federal minimum wage, days and hours of work, and earnings. Bivariate and multiple regression analyses of data from more than 7,000 assessments tested relationships between outcomes and sociodemographic, clinical, and local labor market characteristics. Results: The employment rate was 17.2%; only 57.1% of participants who worked reported 40 or more hours of past-month employment. The mean hourly wage was $7.05, and mean monthly earnings were $494.20. Employment rates and number of hours worked were substantially below those found in household surveys or in baseline data from trials of employment programs but substantially higher than those found in a recent large clinical trial. Strong positive relationships were found between clinical factors and work outcomes, but evidence of a relationship between local unemployment rates and outcomes was weak. Conclusions: Work attachment and earnings were substantially lower than in previous survey data, not very sensitive to labor market conditions, and strongly related to clinical status. (Psychiatric Services 58:315–324, 2007
112 citations
TL;DR: A previous publication found HUD-VASH resulted in superior housing outcomes but yielded no benefits on clinical outcomes but reanalyzed data using multiple imputation statistical methods to account for the missing observations.
Abstract: In 1992, the US Department of Housing and Urban Development (HUD) and the US Department of Veterans Affairs (VA) established the HUD-VA Supported Housing (HUD-VASH) Program to provide integrated clinical and housing services to homeless veterans with psychiatric and/or substance abuse disorders at 19 sites. At four sites, 460 subjects were randomly assigned to one of the three groups: (1) HUD-VASH, with both Section 8 vouchers and intensive case management; (2) case management only; and (3) standard VA care. A previous publication found HUD-VASH resulted in superior housing outcomes but yielded no benefits on clinical outcomes. Since many participants missed prescheduled visits during the follow-up period and follow-up rates were quite different across the groups, we reanalyzed these data using multiple imputation statistical methods to account for the missing observations. Significant benefits were found for HUD-VASH in drug and alcohol abuse outcomes that had not previously been identified.
88 citations
TL;DR: A sustained training program can be used to implement IPS in systems that have had little past experience with this approach and this effort was associated with improved employment outcomes and more rapid housing placement.
Abstract: Objective: There has been growing interest in the dissemination of supported employment, but few studies have used a control group to examine the benefits of multisite dissemination efforts for clients or have addressed the needs of homeless persons with psychiatric disorders, addiction disorders, or both. This study examined a low-intensity training approach for implementing the individual placement and support (IPS) model at nine Department of Veterans Affairs (VA) programs and compared client outcomes before (phase 1) and after (phase 2) the program was implemented (phase 1). Methods: Special funds and sustained training, which was based primarily on teleconferencing, were used to support implementation of the IPS model of supported employment at nine VA programs for homeless veterans. A comparison cohort (phase 1) (N=308) was recruited from the nine sites before IPS was implemented. A postimplementation cohort (phase 2) (N=321) was recruited at the same sites and offered IPS. Mixed models were used to compare quarterly employment outcomes over two years in phase 1 and phase 2, adjusting for significant baseline differences (N=629). Results: Measures of both client-level service delivery and site-level fidelity to IPS suggest that implementation was successful at most, but not all, sites. Overall, compared with veterans in the phase 1 group, those in the phase 2 group had a better long-term work history at the time of program entry. When the analyses controlled for baseline differences, the mean number of competitive employment days per month over the two-year follow-up period was 15% higher for veterans in phase 2 (8.4 days compared with 7.3 days; p<.001) and the mean number of days housed during follow-up was also higher in phase 2 (34.1 days compared with 29.8 days; p=.04), but there were no differences for other outcome measures. Conclusions: A sustained training program can be used to implement IPS in systems that have had little past experience with this approach. This effort was associated with improved employment outcomes and more rapid housing placement.
82 citations
TL;DR: Mental illness stigma was found to be prevalent among caregivers of persons with bipolar disorder who have active symptoms as well as for caregivers of those who have remitted symptoms.
Abstract: Objective: Little is known about the factors contributing to mental illness stigma among caregivers of people with bipolar disorder. Methods: A total of 500 caregivers of patients participating in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study were interviewed in a cross-sectional design on measures of stigma, mood, burden, and coping. Relatives and friends with bipolar disorder were assessed on measures of diagnosis and clinical status, determined by a days-well measure derived from psychiatrist ratings of DSM-IV episode status. Because patients’ clinical status varied widely, separate models were run for patients who were euthymic for at least threefourths of the past year (well group) and for those who met criteria for an affective episode for at least one-fourth of the previous year (unwell group). Stepwise multiple regression was used to identify patient, illness, and caregiver characteristics associated with caregiver stigma. Results: In the unwell group, greater mental illness stigma was associated with bipolar I (versus II) disorder, less social support for the caregiver, fewer caregiver social interactions, and being a caregiver of Hispanic descent. In the well group, greater stigma was associated with being a caregiver who is the adult child of a parent with bipolar disorder, who has a college education, who has fewer social interactions, and who cares for a female bipolar patient. Conclusions: Mental illness stigma was found to be prevalent among caregivers of persons with bipolar disorder who have active symptoms as well as for caregivers of those who have remitted symptoms. Stigma is typically associated with factors identifying patients as “different” during symptomatic periods. Research is needed to understand how the stigma experienced by caregivers during stable phases of illness differs from the stigma experienced during patients’ illness states. (Psychiatric Services 58:41–48, 2007)
TL;DR: A sustained training program can be used to implement CTI in systems that have little past experience with this approach and can yield improved housing and mental health outcomes.
Abstract: Objective: This study evaluated a modification of the critical time intervention (CTI) community case management model for homeless veterans with mental illness who were leaving Department of Veterans Affairs (VA) inpatient care. CTI offers time-limited intensive case management designed to negotiate transitions from institutional settings to community living. Methods: CTI was implemented at eight VA medical centers through a training program that used primarily teleconference-based case review. A comparison cohort (phase 1) of 278 participants was recruited before CTI was implemented, and a treatment cohort (phase 2) of 206 participants was recruited after implementation and offered CTI. Mixed-regression models were used to compare outcomes in phase 1 and phase 2 and controlled for baseline differences between participants in the two phases. Results: Measures of client service delivery show that CTI was successfully implemented at most sites. Phase 1 veterans had a better work history and more drug use at baseline than phase 2 clients had. Controlling for these differences, veterans in phase 2 on average had 19% more days housed in each 90-day reporting period over the one-year follow-up (p<.002) and 14% fewer days in institutional settings (p=.041). Veterans in phase 2 also had 19% lower Addiction Severity Index (ASI) alcohol use scores (p<.001), 14% lower ASI drug use scores (p=.003), and 8% lower ASI psychiatric problem scores (p=.001). Conclusions: A sustained training program can be used to implement CTI in systems that have little past experience with this approach and can yield improved housing and mental health outcomes.
TL;DR: There were no differences in measures of effectiveness between initiation of active treatments or placebo (which represented watchful waiting) but the placebo group had significantly lower health care costs.
Abstract: Context Second-generation antipsychotics (SGAs) are prescribed for psychosis, aggression, and agitation in Alzheimer disease (AD). Objective To conduct a cost-benefit analysis of SGAs and placebo (taken to represent a “watchful waiting” treatment strategy) for psychosis and aggression in outpatients with AD. Design Randomized placebo-controlled trial of alternative SGA initiation strategies. Setting Forty-two outpatient clinics. Participants Outpatients with AD and psychosis, aggression, or agitation (N = 421). Intervention Participants were randomly assigned to treatment with olanzapine, quetiapine fumarate, risperidone, or placebo with the option of double-blind rerandomization to another antipsychotic or citalopram hydrobromide or open treatment over 9 months. Main Outcome Measures Monthly interviews documented health service use and costs. The economic perspective addressed total health care and medication costs. Costs of study drugs were estimated from wholesale prices with adjustment for discounts and rebates. Quality-adjusted life-years (QALYs) were assessed with the Health Utilities Index Mark 3 and were supplemented with measures of functioning, activities of daily living, and quality of life. Primary analyses were conducted using all available data. Secondary analyses excluded observations after the first medication change (ie, phase 1 only). Cost-benefit analysis was conducted using the net health benefits approach in a sensitivity analysis in which QALYs were valued at $50 000 per year and $100 000 per year. Results Average total health costs, including medications, were significantly lower for placebo than for SGAs, by $50 to $100 per month. There were no differences between treatments in QALYs or other measures of function. Phase 1–only analyses were broadly similar. Net-benefit analysis showed greater net health benefits for placebo as compared with other treatments, with probabilities ranging from 50% to 90%. Conclusions There were no differences in measures of effectiveness between initiation of active treatments or placebo (which represented watchful waiting) but the placebo group had significantly lower health care costs. Trial Registration clinicaltrials.gov Identifier: LOCATOR="http://clinicaltrials.gov/ct/show/NCT00015548?order=1">NCT00015548.
TL;DR: For all racial/ethnic groups, the risk of incarceration among veterans compared to nonveterans declined among those who served in the later years of the implementation of the All Volunteer Force, from 1973 to 1980, and the improved quality of personnel recruited after 1980.
Abstract: In this study, we used data from national surveys of U.S. veterans and nonveterans to investigate whether military service increased risk for incarceration compared to non-veteran peers. White veterans aged thirty-five to fifty-four (early years of the All Volunteer Force and the Vietnam era) were at higher risk for incarceration than white nonveterans. Black and Hispanic veterans of these eras were generally at lower risk of incarceration than age-and race-matched nonveterans. For all racial/ethnic groups, the risk of incarceration among veterans compared to nonveterans declined among those who served in the later years of the implementation of the All Volunteer Force. These findings may reflect the disadvantaged backgrounds of recruits during the early implementation of the All Volunteer Force, from 1973 to 1980, and the improved quality of personnel recruited after 1980. Among all males, the risk of incarceration was not elevated among Vietnam-era and World War II veterans.
TL;DR: Naltrexone may have a clinically meaningful effect for alcohol-dependent patients with a high chance of consistent drinking, even in studies where it failed to show efficacy in planned analyses.
TL;DR: It is suggested that homeless people have either a more rapid disease course, leading to earlier morbidity, or lower admission threshholds sufficient to generate hospital admission, among all diagnostic groups.
Abstract: Background Homelessness is associated with high rates of hospitalizations and age-adjusted mortality. Few studies have examined whether homeless people are admitted to the hospital at an earlier age than the general population or for different diagnoses. Methods We compared the age at admission and the primary discharge diagnoses in a national sample of 43,868 hospitalized veterans. Results The difference in median age between homeless and housed inpatients ranged from 10-18 years for medical-surgical diagnoses and 3-4 years for psychiatric and substance abuse diagnoses (p#.005 for all diagnoses). Homeless veterans were more likely to have been admitted for psychiatric and substance abuse diagnoses (79.9%), compared with housed veterans (29.1%). Conclusions Substance abuse and psychiatric illness account for the majority of admissions among homeless veterans. Among all diagnostic groups, homeless people were admitted at younger ages. Our findings suggest that homeless people have either a more rapid disease course, leading to earlier morbidity, or lower admission threshholds sufficient to generate hospital admission.
TL;DR: This initiative represents the largest dissemination effort of any psychosocial rehabilitation model to date in any single healthcare system in the United States, and development of a mentor-trainer system at two intensity levels is reviewed.
Abstract: The dissemination of complex innovative practices is one of the major challenges of mental health service organi- zations. Although substantial progress has been made in the development of evidence-based practices for people with severe mental illness, development of approaches for the large-scale dissemination of such practices has lagged. In 2004, the Veter- ans Health Administration began a national dissemination effort of supported employment (SE). Concomitant with the clinical initiative, a research project was funded to study the factors that promote successful program implementation through an evalu- ation of the effectiveness and cost-effectiveness of two levels of training in the evidence-based practice of SE. This article reviews the dissemination effort and associated research project. This initiative represents the largest dissemination effort of any psychosocial rehabilitation model to date in any single healthcare system in the United States. We review the dissemination plan, including development of a mentor-trainer system at two intensity levels, regular on-site and telephone training and supervision, ongoing fidelity evaluation, and national outcomes monitoring with a Web-based data collection system.
TL;DR: The CATIE trial was designed to evaluate the cost-effectiveness of atypical antipsychotics and examined the benefits and costs of treatments and attempted to determine whether one treatment would result in better outcomes and lower costs than another one.
Abstract: Sales of atypical antipsychotics have expanded rapidly as their use for treatment of schizophrenia and other illnesses has increased. The CATIE trial was designed to evaluate the cost-effectiveness of these medications. Cost-effectiveness analysis in CATIE examined the benefits and costs of treatments and attempted to determine whether one treatment would result in better outcomes and lower costs than another one. While the data from CATIE on cost-effectiveness have not been analyzed yet, it is still possible to consider the potential implications of the analysis, including how the roles of researchers and stakeholders should be considered in deciding optimal clinical practices and public policies.
TL;DR: Reduction of tardive dyskinesia with second-generation antipsychotics appears unlikely to meet standards for cost-effectiveness.
Abstract: Background Second-generation antipsychotics may have few advantages over older, cheaper drugs, except for possibly reduced risk of tardive dyskinesia.
Aims To evaluate the cost-effectiveness of second-generation antipsychotics with regard to reducing tardive dyskinesia.
Method Literature was reviewed on riskof tardive dyskinesia with second-generation antipsychotics; on severity, duration and impairment of tardive dyskinesia; and on the relationship of this disorder to quality of life and quality-adjusted life-years (QALYs). Diverse cost and benefit assumptions and of 1-year and 5-year planning horizons were examined in a deterministic sensitivity analysis.
Results Estimating 0.143 QALYs lost per case of severe tardive dyskinesia, 1-year cost-effectiveness estimates for second-generation antipsychotics ranged from £185 000 ($370 000) to £850 000 ($1.7 million) per QALY, and 5-year cumulative estimates ranged from £74 000 ($149 000) to £342 000 ($683 0000) per QALY, all above the conventional policy threshold of £25 000 ($50 000).
Conclusions Reduction of tardive dyskinesia with second-generation antipsychotics appears unlikely to meet standards for cost-effectiveness.
TL;DR: It is suggested that rehabilitation outcomes may be enhanced by adding CM to current programming or by restructuring traditional work-for-pay contingencies to include direct financial rewards for achievement of clinical goals.
Abstract: In this random-assignment trial, we evaluated the efficacy of using a contingency management (CM) intervention to enhance job acquisition and tenure among participants of a vocational rehabilitation (VR) program. The CM intervention offered participants cash incentives up to $1,170 for completing tasks related to sobriety and job search and maintenance. Participants were 100 veterans with comorbid psychiatric disorders and substance dependence who were randomly assigned either to VR only or VR + CM. Relative to participants in the VR-only group, those in the VR + CM group showed more intense job searches and transitioned to competitive employment faster and at higher rates. No significant difference was found in job tenure, though this may be due to the limited follow-up period. Abstinence rates were significantly better in the VR + CM group during the first 16 weeks of follow-up but not significantly different in subsequent follow-ups. No relationship was found between relapse and employment. These results suggest that rehabilitation outcomes may be enhanced by adding CM to current programming or by restructuring traditional work-for-pay contingencies to include direct financial rewards for achievement of clinical goals.
TL;DR: The authors examined the relationship between disability income and employment, adjusting for health status and other factors, and found that disability income payments had no globally detrimental effect on labor force participation, in that the likelihood of employment was reduced only at payment levels of more than $800 per month.
Abstract: Using a national sample of veterans, we examined the relationship between disability income and employment, adjusting for health status and other factors. Veterans Affairs disability income payments had no globally detrimental effect on labor force participation, in that the likelihood of employment was reduced only at payment levels of more than $800 per month. Although unearned income from other sources also did not have a substantial negative effect on labor force participation, veterans who received benefits from the Social Security Administration or welfare payments were less likely to be employed, mostly likely because employment earnings above a certain level in some programs may result in the loss of monetary benefits and health insurance.
TL;DR: In this paper, a secondary analysis of the first 13 weeks of VA CSP #425, a study that evaluated the efficacy of naltrexone 50 mg/d in 627 alcohol dependent military veterans receiving Twelve Step Facilitation therapy at 20 VA Medical Centers.
Abstract: Background: It is not clear whether naltrexone is effective in reducing alcohol consumption among patients with clinically significant mood symptoms and whether naltrexone favorably interacts with antidepressant medications when they are co-prescribed.
Methods: This study reflects a secondary analysis of the first 13 weeks of VA CSP #425, a study that evaluated the efficacy of naltrexone 50 mg/d in 627 alcohol dependent military veterans receiving Twelve Step Facilitation therapy at 20 VA Medical Centers. This study included patients with comorbid mood and anxiety disorders, providing they did not need treatment for these comorbid conditions at the time of study entry. Sixty patients developed sufficiently severe mood symptoms while on study medication that they required antidepressant treatment. This analysis evaluated whether the efficacy of naltrexone and placebo was influenced by the prescription of antidepressant medications to some study patients for their mood and anxiety symptoms.
Results: In patients randomized to placebo (n = 209), prescription of antidepressants was associated with a significantly higher percentage of drinking days (lsmean = 24.4, se = 4.85 vs. lsmean = 12.9, se = 1.69, p = 0.02). Although the group of patients receiving naltrexone (n = 418) was larger than the group assigned to placebo, there were no significant differences in drinking-related outcomes in the groups who did or did not receive antidepressants (lsmean = 11.5, se = 1.18 vs. lsmean = 12.9, se = 1.69, p = 0.47). Among the group of patients receiving antidepressants, naltrexone prescription was associated with a reduction in the percent drinking days compared to placebo [lsmean = 10.1, se = 3.47 vs. lsmean = 24.4, se = 4.85, F(1,556) = 5.84, p = 0.02].
Conclusions: Further investigation will be needed to determine whether naltrexone is efficacious among depressed alcohol dependent patients and whether naltrexone and antidepressant medications show interactive efficacy for treating alcohol dependence.
TL;DR: Although many veterans were able to obtain care after Hurricane Katrina, there was a substantial disruption in delivery of Veterans Administration services, with disproportionate declines in mental health and substance use care.
Abstract: Objective: This study examined national patterns of outpatient service use by veterans from regions affected by Hurricane Katrina. Methods Analyses tracked use of general medical and mental/substance use services in September and October through December 2005 in New Orleans and Biloxi-Gulfport compared to a cohort receiving care during the same months in the previous 2 years. Results: In adjusted models, veterans from New Orleans and Biloxi-Gulfport were, respectively, 73% and 41% less likely in September 2005 to use any outpatient services as were cohorts from 2003–2004. Particularly in New Orleans, the relative decline in service use was substantially greater for specialty mental health and substance use services than for general medical services. Conclusions: Although many veterans were able to obtain care after Hurricane Katrina, there was a substantial disruption in delivery of Veterans Administration services, with disproportionate declines in mental health and substance use care.
TL;DR: Results of CATIE are robust to potential methodological limitations and perphenazine seems to have been a more representative choice for first-generation antipsychotic comparison treatment than haloperidol.
Abstract: The cost–effectiveness component of the 18-month CATIE trial of schizophrenia pharmacotherapy (n = 1460) showed that the first-generation antipsychotic perphenazine was US$300–600 per month less expensive than each of four second-generation antipsychotics, and no less effective across multiple measures. We consider whether or not each of eight potential methodological limitations could weaken this conclusion: follow-up rates, study duration, sample characteristics, the choice of outcome measures, exclusion of patients with tardive dyskinesia from assignment to perphenazine, choice of study drugs and doses, reliance on intention-to-treat analysis, and differences in prestudy treatment. We conclude that results of CATIE are robust to these limitations. Perphenazine seems to have been a more representative choice for first-generation antipsychotic comparison treatment than haloperidol.
TL;DR: Comparing assertions reportedly made to VA psychiatrists with package insert information suggests that many assertions made by drug company representatives are inconsistent with prescribing information approved by the U.S. Food and Drug Administration, although assertions consistent with package Insert information were more common than inconsistent ones.
Abstract: Objective: The interaction between physicians and the pharmaceutical industry has become a subject of increased interest and concern. This study surveyed a national sample of psychiatrists practicing within Department of Veterans Affairs (VA) medical centers in 2005. It specifically focused on the experiences of these physicians with representatives of the manufacturers of second-generation antipsychotics. Methods: VA psychiatrists were invited by e-mail to complete a Web-based questionnaire about their contact with representatives of each of the relevant pharmaceutical companies. Respondents were then questioned about several potential assertions about treatment effectiveness, side effects, and costs of these drugs. Results: Of the 1,833 potential participants, 639 (35%) visited the Web site and completed the questionnaire. Among the responders, 558 (87%) reported at least one contact with company representatives. In the year before the survey the percentage of respondents reporting contact with representatives of each individual company varied from 58% to 70%. The three most commonly reported assertions made at any time in the past through direct speech during those meetings were that the representative’s second-generation antipsychotic resulted in “a decreased risk of extrapyramidal symptoms” (79%), “greater symptom reduction than placebo” (78%), or “better negative symptom control than conventional antipsychotics” (77%). Statements least likely to be reported included that drugs resulted in “better positive symptom control than conventional antipsychotics” (36%), “better positive or negative symptom control than another atypical antipsychotic” (38%), and “increased risk of the development of diabetes mellitus” (39%). Conclusions: Comparing assertions reportedly made to VA psychiatrists with package insert information suggests that many assertions made by drug company representatives are inconsistent with prescribing information approved by the U.S. Food and Drug Administration, although assertions consistent with package insert information were more common than inconsistent ones. (Psychiatric Services 58:1292–1296, 2007)
TL;DR: Although substance use is associated with being assigned a payee, substance use does not decline substantially following payee assignment and participants assigned payees made greater subsequent use of psychiatric services, suggesting the potential for benefit from payees assignment.
TL;DR: Greater efforts are needed to increase HIV testing and counseling among persons with serious mental illness to better identify and care for HIV-positive individuals and potentially reduce future transmission of the virus in this vulnerable, at-risk population.
Abstract: This study examined the prevalence and correlates of receipt of human immunodeficiency virus (HIV) testing, test results, and posttest counseling among outpatients with serious mental illness at 3 public-sector facilities in Connecticut (N = 487). A substantial proportion (41.9%) reported never having been tested for HIV, including fully one-third of those who were "very afraid" of getting acquired immune deficiency syndrome. Independent correlates of HIV testing included younger age, felony criminal history, stronger therapeutic alliance with one's primary clinician, and increased drug problems and psychological distress. Of those tested, nearly all (96.5%) reported receiving the test results; however, only half (50.5%) reported receiving any posttest counseling. Independent correlates of posttest counseling included higher educational level, felony criminal history, and receipt of community-based case management services. Greater efforts are needed to increase HIV testing and counseling among persons with serious mental illness to better identify and care for HIV-positive individuals and potentially reduce future transmission of the virus in this vulnerable, at-risk population.
TL;DR: This commentary reviews recent research and proposes a new algorithm for maintenance antipsychotic therapy that relies on standardized documentation and feedback, without a restrictive formulary that would limit physician choice.
Abstract: In this commentary, we review recent research suggesting that (a) second-generation antipsychotics (SGAs) may be no more effective than first-generation antipsychotics (FGAs), (b) the reduced risk of EPS and tardive dyskinesia with SGAs is more weakly supported by the research literature than has been appreciated, and (c) benefits may be offset by greater metabolic risks of some SGAs and their substantially greater cost. Bearing in mind, as well, that risperidone, currently the least expensive SGA, will soon be available as an even less expensive generic drug, we propose a new algorithm for maintenance antipsychotic therapy. We further outline a cautious implementation procedure that relies on standardized documentation and feedback, without a restrictive formulary that would limit physician choice. The algorithm outlined here and the process for its implementation are intended as a stimulus for discussion of potential policy responses, not as a finalized proposition.
TL;DR: Adolescents were at a higher risk than children of being: (a) victimized, (b) involved in incidents outside their home, (c) experiencing a threat to their lives, and (d) suffering physical injuries.
Abstract: This study explores the clinical epidemiology of children's exposure to violence as addressed by a program in which mental health clinicians work with law-enforcement agents in 10 U.S. cities. Data were collected on all participants contacted by the Child Development Community Policing Program (N = 7,313 individuals involved in 2,466 community incidents). Multivariate regression was used to examine sociodemographic and clinical correlates of the role of participants (victim, offender, or witness), location, and type of incident. The majority of incidents occurred in participants' homes. Adolescents were at a higher risk than children of being: (a) victimized, (b) involved in incidents outside their home, (c) experiencing a threat to their lives, and (d) suffering physical injuries. Males were more likely to be offenders than females, and to be subjected to physical injuries or involved in incidents that imposed a threat to their life. Females were significantly more likely to be victimized.
TL;DR: This program achieved only modest success and was most successful with veterans who were already receiving VA services and who might have received benefits even without the outreach effort.
Abstract: Public support payments may facilitate exit from homelessness for persons with mental illness. We examined data from 10,641 homeless veterans contacted from October 1, 1995 to September 30, 2002 in a collaborative outreach program designed to facilitate access to Department of Veterans Affairs (VA) disability benefits. Those who were awarded benefits (22% of contacted veterans) were more likely to report disability, poor to fair self-rated health, and were more likely to have used VA services in the past. Thus, this program achieved only modest success and was most successful with veterans who were already receiving VA services and who might have received benefits even without the outreach effort.