Showing papers by "Robert A. Rosenheck published in 2009"

Posttraumatic stress disorder as a risk factor for suicidal ideation in Iraq and Afghanistan War veterans.

Abstract: Posttraumatic stress disorder (PTSD) was examined as a risk factor for suicidal ideation in Iraq and Afghanistan War veterans (N = 407) referred to Veterans Affairs mental health care. The authors also examined if risk for suicidal ideation was increased by the presence of comorbid mental disorders in veterans with PTSD. Veterans who screened positive for PTSD were more than 4 times as likely to endorse suicidal ideation relative to non-PTSD veterans. Among veterans who screened positive for PTSD (n = 202), the risk for suicidal ideation was 5.7 times greater in veterans who screened positive for two or more comorbid disorders relative to veterans with PTSD only. Findings are relevant to identifying risk for suicide behaviors in Iraq and Afghanistan War veterans.

A Qualitative Study of Determinants of PTSD Treatment Initiation in Veterans

Abstract: Although there are effective treatments for Posttraumatic Stress Disorder (PTSD), many PTSD sufferers wait years to decades before seeking professional help, if they seek it at all. An understanding of factors affecting treatment initiation for PTSD can inform strategies to promote help-seeking. We conducted a qualitative study to identify determinants of PTSD treatment initiation among 44 U.S. military veterans from the Vietnam and Afghanistan/Iraq wars; half were and half were not receiving treatment. Participants described barriers to and facilitators of treatment initiation within themselves, the post-trauma socio-cultural environment, the health care and disability systems, and their social networks. Lack of knowledge about PTSD was a barrier that occurred at both the societal and individual levels. Another important barrier theme was the enduring effect of experiencing an invalidating socio-cultural environment following trauma exposure. In some cases, system and social network facilitation led to treatment initiation despite individual-level barriers, such as beliefs and values that conflicted with help-seeking. Our findings expand the dominant model of service utilization by explicit incorporation of factors outside the individual into a conceptual framework of PTSD treatment initiation. Finally, we offer suggestions regarding the direction of future research and the development of interventions to promote timely help-seeking for PTSD.

Cross-sectional and Longitudinal Relationships Between Insight and Attitudes Toward Medication and Clinical Outcomes in Chronic Schizophrenia

Abstract: Background: We evaluated the cross-sectional and longitudinal association of measures of both insight and attitudes toward medication to outcomes that included psychopathology and community functioning. Methods: Clinical Antipsychotic Trial of Intervention Effectiveness (CATIE) was a large 18-month follow-up study pharmacotherapy of people with schizophrenia. Insight was measured using the Insight and Treatment Attitudes Questionnaire and attitudes toward medication by the Drug Attitude Inventory. Widely known scales were used to assess symptoms of schizophrenia and depression and community functioning. Medication adherence was globally assessed by the treating psychiatrist using several sources of information. Bivariate correlations and mixed model regression analyses were used to test the relationship of insight and medication attitudes to outcomes at baseline and during the follow-up period. Regression models were used to evaluate the relationship between change in insight and medication attitudes and changes outcomes. Results: There was a significant relationship at baseline between insight and drug attitudes and symptoms of schizophrenia and depression, as well as with community functioning. Higher levels of insight at baseline were significantly associated with lower levels of schizophrenia symptoms at follow-up while more positive medication attitudes were significantly associated with both lower symptom levels and better community functioning. Change in insight scores over time was associated with declining schizophrenia symptoms but increasing levels of depression. Change toward more positive medication attitudes was associated, independently of changes in insight, with significant decreases in psychopathology, improvement in community functioning, and greater medication compliance. Conclusion: Greater patient understanding of their illness and more positive attitudes toward medication may improve outcomes. Educational interventions that affect these attitudes may be an important part of psychosocial rehabilitation and/or recovery-oriented services.

Off-Label Use of Antipsychotic Medications in the Department of Veterans Affairs Health Care System

Abstract: Objective: This study aimed to determine the prevalence of prescribing antipsychotics to adults without schizophrenia or bipolar disorder and to identify factors associated with such off-label use. Methods: Patients with at least one prescription for an antipsychotic medication from the Department of Veterans Affairs (VA) during fiscal year (FY) 2007 were identified in national VA administrative databases. Rates of off-label antipsychotic use were determined along with average doses. Multivariate logistic regression models identified sociodemographic and clinical characteristics associated with off-label use. Results: Of the 279,778 individuals in FY 2007 who received an antipsychotic medication, 168,442 (60.2%) had no record of a diagnosis for which these drugs are approved. The most common mental illness diagnoses among patients given prescriptions for antipsychotics off label were posttraumatic stress disorder (PTSD, 41.8%), minor depression (39.5%), major depression (23.4%), and anxiety disorder (20.0%). Among VA patients with mental illness other than schizophrenia or bipolar disorder, the proportion who received prescriptions for antipsychotic medications ranged from a low of 9.1% among patients with adjustment reaction; to about 20% for those with depression, dementia, or PTSD; and to a high of 40.7% among patients with other psychoses. Doses were low, with over half of patients who received off-label quetiapine, risperidone, or first-generation antipsychotics receiving doses below those recommended for schizophrenia. In logistic regression models, patients diagnosed as having other psychosis or dementia had the highest odds of receiving an antipsychotic medication off label. Conclusions: Off-label use of antipsychotic medications was common. Given that these drugs are expensive, have potentially severe side effects, and have limited evidence supporting their effectiveness for off-label usage, they should be used with greater caution. (Psychiatric Services 60:1175–1181, 2009)

Depression Screening of Perinatal Women: An Evaluation of the Healthy Start Depression Initiative

Abstract: Objective: To address problems with low rates of detection and treatment of depression of pregnant and postpartum women, many advocate depression screening in obstetrical settings. This study evaluated the Healthy Start depression initiative to assess whether it resulted in diminished rates of depressive symptoms and increased rates of detection, referral, and treatment among pregnant and postpartum women. Methods: Three cohorts were used to examine the program impact: a pre–Healthy Start depression initiative cohort, a post–Healthy Start depression initiative cohort that was enrolled in New Haven Healthy Start, and a post–Healthy Start depression initiative cohort not enrolled in the New Haven program. Participants included 1,336 pregnant and postpartum women receiving obstetrical care at publicly funded health care clinics. Measures included the Primary Care Evaluation of Mental Disorders Brief Patient Health Questionnaire; the PTSD Symptom Scale; a five-item modification of the Conflict Tactics Scale; and questions regarding alcohol, illicit substances, and general medical and obstetrical history. Results: The Healthy Start depression initiative changed neither levels of depressive symptoms nor use of depression treatment in unselected populations. The initiative may have decreased the rate of referral for depression in the cohort under study. Conclusions: Universal screening and support for treatment referral by paraprofessionals did not reduce the overall rates of depressive symptoms of perinatal women who received care at publicly funded obstetrical clinics. Future work on depression screening should consider strategies to engage women who are more severely affected by a depressive disorder in behavioral health treatment. (Psychiatric Services 60:322–328, 2009)

Access to primary care for homeless veterans with serious mental illness or substance abuse: a follow-up evaluation of co-located primary care and homeless social services.

Abstract: To examine the hypothesis that a demonstration clinic integrating homeless, primary care, and mental health services for homeless veterans with serious mental illness or substance abuse would improve medical health care access and physical health status. A quasi-experimental design comparing a ‘usual VA care’ group before the demonstration clinic opened (N = 130) and the ‘integrated care’ group (N = 130). Regression models indicated that the integrated care group was more rapidly enrolled in primary care, received more prevention services and primary care visits, and fewer emergency department visits, and was not different in inpatient utilization or in physical health status over 18 months. The demonstration clinic improved access to primary care services and reduced emergency services but did not improve perceived physical health status over 18 months. Further research is needed to determine generalizability and longer term effects.

Mental Health and Other Risk Factors for Jail Incarceration Among Male Veterans

Abstract: Data derived from the 2002 Survey of Inmates in Local Jails and the 2000 National Survey of Veterans show that having mental health problems in addition to such sociodemographic characteristics as being a member of a minority group, not being married, having less education, and being younger are risk factors for incarceration among veterans, as they are for the general population. As in previous studies veterans who served during the Vietnam Era and to an even greater extent, those who served in the early years of the All Volunteer Force were at greater risk of incarceration than veterans from the most recent period of the AVF, after controlling for age and other factors.

Influence of PTSD symptom clusters on smoking status among help-seeking Iraq and Afghanistan veterans

Abstract: Introduction Despite the strong association between smoking and posttraumatic stress disorder (PTSD), mechanisms influencing smoking in this population remain unclear. Previous smoking research has largely examined PTSD as a homogenous syndrome despite the fact that PTSD is composed of four distinct symptom clusters (i.e., reexperiencing, effortful avoidance, emotional numbing, and hyperarousal). Examination of the relationship between smoking and PTSD symptom clusters may increase understanding of mechanisms influencing comorbidity between smoking and PTSD. The goals of the present study were to (a) examine the influence of overall PTSD symptom severity on likelihood of smoking and smoking heaviness and (b) examine the influence of each PTSD symptom cluster on smoking. Methods Participants (N = 439) were Operation Iraqi Freedom/Operation Enduring Freedom combat veterans referred to VA mental health services. Results Multinomial logistic regression was chosen to accommodate a three-level outcome, in which the likelihood of being a nonsmoker was compared with (a) light smoking (1-9 cigarettes/day), (b) moderate smoking (10-19 cigarettes/day), and (c) heavy smoking (> or =20 cigarettes/day). Results showed that veterans with higher levels of overall PTSD symptomatology were more likely to endorse heavy smoking (Wald = 4.56, p = .03, odds ratio [OR] = 1.65). Veterans endorsing high levels of emotional numbing were also more likely to endorse heavy smoking (Wald = 6.49, p = .01, OR = 1.81); all other PTSD symptom clusters were unrelated to smoking. Discussion The association between emotional numbing and heavy daily smoking suggests that veterans with PTSD may smoke to overcome emotional blunting following trauma exposure.

Tracing the Flow of Knowledge Geographic Variability in the Diffusion of Prazosin Use for the Treatment of Posttraumatic Stress Disorder Nationally in the Department of Veterans Affairs

Abstract: Context Passive diffusion of new medical innovations is an important mechanism by which knowledge transitions from research to clinical practice. Preliminary evidence has emerged about the effectiveness of the α 1 -adrenergic blocker prazosin hydrochloride in the treatment of nightmares and hyperarousal among patients with posttraumatic stress disorder (PTSD). This treatment has been neither widely accepted nor the subject of active dissemination efforts, and its efficacy was discovered in a discrete geographic location. Objectives To evaluate the pace and reach of the passive dissemination of a promising technology within a national health care system. Design Geographic surveillance data study. Setting Academic research. Patients We tracked the use of prazosin in the treatment of patients diagnosed as having PTSD in the Department of Veterans Affairs during fiscal years 2004 (n = 203 414) and 2006 (n = 319 670). Main Outcome Measure The percentage of patients diagnosed as having PTSD who received a prescription for prazosin. Results Whereas 37.6% of patients with PTSD treated within the Veterans Affairs Puget Sound Health Care System, Tacoma, Washington, in 2004 were prescribed prazosin, only 18.2% were treated with prazosin at medical centers up to 499 miles (to convert miles to kilometers, multiply by 1.6) away, 6.7% at centers 500 to 999 miles away, 4.0% at centers 1000 to 2499 miles away, and 1.9% at centers 2500 miles away or farther. Adjusting for patient characteristics, patients with PTSD treated up to 499 miles from Puget Sound were about 49% less likely in 2006 and about 63% less likely in 2004 to be prescribed prazosin than their counterparts treated within Puget Sound, while those who were treated 2500 miles away or farther were about 94% less likely in 2006 and about 97% less likely in 2004 to be treated with prazosin than patients within Puget Sound. Conclusion Passive diffusion of a new treatment can be rapid in the immediate area in which it is developed, but the geographic gradient of use seems to be steep and enduring even when cost and organizational barriers are minimal.

VA Intensive Mental Health Case Management in Urban and Rural Areas: Veteran Characteristics and Service Delivery

Abstract: Objective: The availability of mental health services in rural areas— particularly intensive services such as assertive community treatment (ACT)—has been of increasing concern and was the focus of this study. In recent decades the U.S. Department of Veterans Affairs (VA) has developed a national network of ACT-like programs called mental health intensive case management (MHICM), which have served veterans from diverse locations across the country, including urban and rural areas. Methods: This study used rural-urban commuting area codes and national VA administrative data to compare characteristics of veterans and patterns of MHICM service delivery among veterans with mental illness living in large urban, large rural, small rural, and isolated rural communities. Results: Among veterans enrolled in MHICM from FY 2000 to FY 2005 (N=5,221), 84% (N=4,373) resided in urban areas, 8% (N=421) in large cities, 6% (N=291) in small rural towns, and 3% (N=136) in isolated rural areas. MHICM participants who lived in rural areas had clinical problems broadly similar to those in urban areas, although more rural veterans were unemployed, disabled, received VA disability compensation, and had a payee or fiduciary. MHICM clients in smaller or isolated rural areas received slightly less frequent and less intensive contacts and less recovery-oriented services than those in large urban locations. Conclusions: These data highlight the need for intensive case management services in rural areas and note some challenges in providing them at the intensity and frequency observed in urban areas where travel distances and times are shorter. (Psychiatric Services 60: 914–921, 2009)

A Randomized Controlled Trial of a Money Management-Based Substance Use Intervention

Abstract: Objective—Money management has been implemented, often in bundled interventions, as a strategy to counteract spending of public support checks and other funds on drugs and alcohol. The authors conducted a randomized controlled trial of a voluntary money management program as an adjunctive treatment for patients in treatment for mental illness, substance use disorders, or both. In the advisor-teller money manager (ATM) intervention, a money manager stores patients’ checkbooks and automated bank cards, trains patients to manage their own funds, and links spending to activities related to their treatment goals. Methods—Eighty-five veterans with recent use of alcohol or cocaine were randomly assigned to 36 weeks of the ATM intervention or a control intervention (completion of a simple financial workbook). Results—With ATM, 75% of veterans gave their checkbook to their money manager to hold, and participants attended significantly more therapy sessions than those assigned to the control therapy (mean of 20.6 versus 8.1 sessions). Although participants assigned to ATM did not show significantly greater improvement over time on the primary outcomes (self-reported abstinence from alcohol and cocaine and negative urine tests for cocaine metabolite), they reduced their Addiction Severity Index drug and alcohol use composite scale scores more rapidly than the control group. High rates of abstinence in both groups created a ceiling effect, limiting the power to detect improved abstinence rates. Conclusions—In this relatively small trial, ATM, a money management intervention, showed promise in engaging patients, improving their money management, and improving some substance abuse outcomes.

Developing A Policy For Second-Generation Antipsychotic Drugs

Abstract: Second-generation antipsychotics (SGAs) have replaced older drugs in the treatment of schizophrenia; their costs in the United States have reached $13 billion a year. Recent research, however, shows that their net risk/benefit profiles are no better than some older, cheaper drugs. Stepped therapy, allowing exceptions with prior authorization and giving preference to generic drugs with low risk of both neurologic and metabolic side effects, could increase the cost-effectiveness and safety of antipsychotic drugs. Educational preparation and monitoring of adverse events would foster better acceptance of such procedures among providers, patients, and families. Research to evaluate these interventions would ideally precede their widespread implementation.

Scaling up the dissemination of evidence-based mental health practice to large systems and long-term time frames.

Abstract: This Open Forum raises issues related to large-scale dissemination of sustainable evidence-based practices. Current dissemination efforts have been time limited and primarily conducted at volunteer sites with the skills of external expert trainers. The authors describe an effort to implement supported employment at 166 veterans programs in what is hoped to be a permanent addition to mental health services offered by the Department of Veterans Affairs. A two-stage process is described for developing a cadre of internal trainers who can realize the goals of this large-scale dissemination effort. Such strategies appear necessary to fully realize the broad national changes envisioned in the New Freedom Commission report.

Use of antipsychotics in the treatment of major depressive disorder in the U.S. Department of Veterans Affairs.

Abstract: Background Despite the recent U.S. Food and Drug Administration approval of aripiprazole as the first antipsychotic to be used as an adjunct to antidepressant medications in the treatment of major depressive disorder (MDD), information on the current use of antipsychotics in the treatment of MDD has not been available. Method Records of antipsychotic prescriptions for all U.S. Department of Veterans Affairs patients diagnosed with MDD (ICD-9 criteria), excluding those with comorbid schizophrenia, schizoaffective disorder, or bipolar disorder, in the fiscal year 2007 (N = 191,522) were examined. Descriptive statistics and generalized estimating equations (GEEs) were used to identify veterans' characteristics, measures of service use, and medical center characteristics that were associated with receipt of these medications and, among such users, with use of the lower doses suggested for MDD. Results Altogether, 20.6% of veterans with MDD received antipsychotic medications, and 43% of those who did received them at the higher doses recommended for schizophrenia. GEE models showed that younger age, male gender, psychiatric comorbidities, duration of diagnosed MDD, and more intensive mental health service use were all associated with greater likelihood of receiving antipsychotics and with less likelihood of receiving them at conventional antipsychotic doses. Conclusion Antipsychotic medications were commonly used in the treatment of MDD prior to FDA approval, especially in the presence of comorbid mental illness and longer term MDD. Further research is needed to evaluate the long-term safety and efficacy of these medications in combination with antidepressants.

Investigation of Racial and Ethnic Disparities in Service Utilization Among Homeless Adults With Severe Mental Illnesses

Abstract: Objective: This study examined whether there are service disparities among homeless adults with severe mental illnesses, a vulnerable population with a high level of unmet need. Methods: Data were collected at baseline for 6,829 black, Latino, and non-Latino white participants in the Access to Community Care and Effective Services and Support study. Outcome variables were measures of utilization of psychiatric outpatient, housing, and case management services in the previous 60 days. The sample was divided into white-black and white-Latino cohorts. Within each cohort, participants were stratified into comparable groups by propensity scores that estimated log-odds of being black or Latino as a function of several confounding variables. White-black and white-Latino differences in mean number of visits (a measure of intensity) and in the mean probability of at least one visit (a measure of access) were subsequently estimated for each of the three services. Results: The composition of the sample was 50% black, 6% Latino, and 44% white. Service utilization was low for the three services regardless of race-ethnicity. On multivariate analyses of service utilization in the previous 60 days, blacks made fewer psychiatric outpatient visits than whites (mean difference=.46, 95% confidence interval [CI]=.10 to .81]), yet Latinos had more case management visits than whites (mean difference=–.51, CI=–1.03 to –.05]). Analyses of access did not reveal racial-ethnic disparities. Conclusions: Whereas blacks used psychiatric outpatient services less frequently than whites, hence experiencing a service disparity, Latinos used case management services more than whites did. Possible contributors and clinical and methodological implications of these results are discussed. (Psychiatric Services 60:1032–1038, 2009)

Duration of pharmacotherapy with long-acting injectable risperidone in the treatment of schizophrenia.

Abstract: Although long-acting injectable risperidone (LAIR) has been hypothesized to improve medication adherence compared to oral medications, data from real-world practice have yet to be presented on time to treatment discontinuation. Records of all new prescriptions for antipsychotic medication during the first 2 months of FY 2006 for VA patients diagnosed with schizophrenia (N = 11,821) were examined and duration of treatment with LAIR and oral antipsychotics were calculated for the next 2 years. Multivariable logistic regression was used to identify patient characteristics independently associated with receipt of LAIR. Proportional hazards models were used to compare the likelihood of discontinuing each of the medications as compared to LAIR. Altogether, 2.4% of the 11,821 new starts were prescribed LAIR, 44.6% of whom continued therapy for 540-720 days (18-24 months), less than the 77.1% of those on clozapine, 57.9% on oral conventional antipsychotics, 55.0% on olanzapine, and 49.5% on risperidone, but more than the 27.7% on aripiprazole. After adjusting for potentially confounding factors, patients who were initiated on LAIR were more likely to discontinue their medication than those who were initiated on oral first- or second-generation antipsychotics (SGAs) with the exception ziprasidone and aripiprazole. Less than half of patients on LAIR continued treatment for 18 months, a smaller proportion than of those started on most oral first- or second-generation antipsychotics, suggesting that for many patients with schizophrenia improved adherence from this treatment may not be sustained.

Association study of DTNBP1 with schizophrenia in a US sample.

Abstract: Background Straub et al. (2002b) located a susceptibility region for schizophrenia at the DTNBP1 locus. At least 40 studies (including one study in US populations) attempted to replicate this original finding, but the reported findings are highly diverse and at least five pathways by which dysbindin protein might be involved in schizophrenia have been proposed. This study aimed to test the association in two common US populations by using powerful analytic methods. Methods Six markers at DTNBP1 were genotyped by mass spectroscopy (‘MassARRAY’ technique) in a sample of 663 individuals, including 346 healthy individuals European--Americans (EAs) and 48 African--Americans (AAs), and 317 individuals with schizophrenia (235 EAs and 82 AAs). Thirty-eight ancestry-informative markers were genotyped in this sample to infer the ancestry proportions. Diplotype, haplotype, genotype, and allele frequency distributions were compared between the cases and controls, controlling for possible population stratification, admixture, and sex-specific effects, and taking interaction effects into account, using a logistic regression analysis (an extended structured association method). Results Conventional case-control comparisons showed that genotypes of the markers P1578 (rs1018381) and P1583 (rs909706) were nominally associated with schizophrenia in EAs and in AAs, respectively. These associations became less or nonsignificant after controlling for population stratification and admixture effects (using structured association or regression analysis), and became nonsignificant after correction for multiple testing. However, regression analysis showed that the common diplotypes (ACCCTT/GCCGCC or GCCGCC/GCCGCC) and the interaction effects of haplotypes GCCGCC×GCCGCC significantly affected risk for schizophrenia in EAs, effects that were modified by sex. Fine-mapping using δ or J statistics located the specific markers (δ: P1328; J: P1333) closest to the putative risk sites in EAs. Conclusion This study shows that DTNBP1 is a risk gene for schizophrenia in EAs. Variation at DTNBP1 may modify risk for schizophrenia in this population.

Assessing the Effects of Maternal Symptoms and Homelessness on the Mental Health Problems in their Children

Abstract: Objective: This study examines the longitudinal association between measures of child well being and maternal posttraumatic stress disorder symptoms, homelessness, substance abuse, and other psychiatric conditions. Method: A sample of 142 mothers who were veterans of the US armed forces were assessed at program entry and every three months thereafter for one year. A repeated-measures with mixed-effects analytic strategy was used to assess the association of children’s mental health, school enrolment and attendance with measures of maternal psychiatric symptoms and homelessness. Results: Significant associations between mothers’ psychiatric symptoms and child well-being were identified. However, the multivariable mixed-models suggest that increased depression and anxiety symptoms among children were associated primarily with mothers’ PTSD, and not depression, symptoms. Conclusions: These findings provide evidence of an association between maternal and child mental health and may suggest that treating maternal PTSD symptoms may also benefit children, regardless of whether the child was also exposed to the traumatic experience.

Seeking safety therapy: clarification of results.

Abstract: LETTERS Letters from readers are welcome. They will be published at the editor's discretion as space permits and will be subject to editing. They should not exceed 500 words with no more than three authors and five references and should include the writer's e-mail address. Letters related to material published in Psychiatric Services, which will be sent to the authors for possible reply, should be sent to To the Editor: Our study of Seeking Safety therapy was published in the September issue (1). We would like to correct two omissions, which may help clarify outcomes for Seeking Safety and the comparison condition (enhanced residential services). In the article we addressed outcomes over a one-year time frame. However, we did not present outcomes at six months, which was the end of the Seeking Safety intervention. Second, we failed to identify the full extent and asymmetry of the data loss that characterized the study after the end of treatment. At six months, two significant differences favored Seeking Safety over the comparison condition after Bonfer-roni correction: avoidant behavior and social support. Two additional variables that favored Seeking Safety were not significant after Bonferroni correction: the PTSD Checklist and days worked. On eight variables, both Seeking Safety and the comparison condition showed significant improvements over baseline, with no difference between conditions: days of drug use, days of alcohol use, the 30-item Symptom Checklist Revised, self-esteem , the psychiatric composite of the Addiction Severity Index (ASI), the medical measure on the 12-Item Short-Form Survey (SF-12), hyper-vigilant behavior, and days homeless. Two additional variables (ASI drug and alcohol subscales) had a similar pattern; although the difference from baseline was a non-significant trend for the Seeking Safety condition, this likely reflects the greater statistical power in the much larger comparison condition. Finally, only two variables, intrusive thoughts and the medical measure of the SF-12, did not show significant improvements from base-line for either condition. Sample sizes decreased substantially over time. At three months, about 80% of participants in both conditions completed the assessment, and at six months the rate for both was about 63%. However, at nine months only 40% of Seeking Safety participants and 56% of comparison participants were available, and at 12 months the proportions dropped to 27% and 53%, respectively. It is thus difficult to draw conclusions about the later time points, and we suggest caution in interpreting the one-year outcomes reported in the …

A Psychometric Study of Empowerment and Confidence among Veterans with Psychiatric Disabilities

Abstract: The word "recovery" as used in every day language is taken by most people to mean a cure, or the complete absence of illness. In the mental health field, the term has increasingly been given a broader meaning that addresses the multi-faceted process of living a full and meaningful life with a mental illness (Resnick, Fontana, Lehman, & Rosenheck, 2005). With the release of prominent commission reports such as the President's New Freedom Commission report (President's New Freedom Commission on Mental Health, 2003) and SAMHSA's National Consensus Statement on Recovery (e.g., SAMHSA, 2004), as well as the growing recognition of the importance of broader conceptualizations of living with mental illness, identifying tools for reliably and validly measuring recovery has become increasingly necessary. As Mancini (2008) has mused, based on the high level of interest in the recovery concept, one might expect the field to have developed empirically-supported definitions of the term and to have identified well-defined recovery-oriented practices supported by scientific data. Yet there is little consistency or consensus across recovery definitions (Resnick et al., 2005; Silverstein & Bellack, 2008), with the same terms sometimes used to describe different constructs, and different terms used to describe similar constructs, making it difficult to generalize across studies. For example, Figure 1 is an illustration of some potential recovery domains. In this figure self-esteem and optimism are included twice, representing different theoretical perspectives on their placement in a recovery definition. Empowerment is an often cited recovery domain that has been linked empirically with participation in peer support (Burti et al., 2005; Dumont & Jones, 2002; Resnick & Rosenheck, 2008; Rogers et al., 2007), working for pay, and participation in family psycho-education (Resnick, Rosenheck, & Lehman, 2004). Rogers et al. (1997) using a mixed-methods approach, created a tool to measure empowerment, and identified five subordinate factors: self-esteem/self-efficacy, power-powerlessness, community activism and autonomy, optimism and control over the future, and righteous anger. Carpinello et al. (2000) identified a related concept, confidence, with similar components to those identified by Rogers et al.: optimism, coping, and advocacy, suggesting overlap between the operationalization of empowerment by Rogers et al. and that of confidence by Carpinello. The current study is an evaluation of the psychometric properties of these two measures and their interrelationships. We examine the internal consistency and test-retest reliability for each measure and examine convergent and discriminant validity of both the total scale and subscales in a sample of veterans receiving community-based outpatient mental health services. [FIGURE 1 OMITTED] Method Subjects Participants consisted of 296 veterans with severe mental illness who were admitted to the Community Reintegration Program, a community-based outpatient program at the Errera Community Care Center of the V.A. Connecticut Healthcare System between 2002 and 2006, and who agreed to participate in a quasi-experimental efficacy study of a peer education program for veterans. In the parent study, participants were recruited in two cohorts, but are pooled into a single sample for the present study, and thus represent both control and experimental groups (Resnick & Rosenheck, 2008). As summarized in Table 1, respondents were predominantly male (95%) and white (66%), averaging 48.5 years of age and 12.6 years of education. One-third (36%) indicated regular full- or part-time employment. Although a comparable number (34%) reported unemployment due to disability, only one in five (19%) were receiving service-connected disability payments from the Veterans Administration for either medical or psychiatric reasons. PTSD symptom severity was high (mean [+ or -] SD = 46. …

An evaluation of an initiative to improve Veterans Health Administration mental health services: broad impacts of the VHA's Mental Health Strategic Plan.

Abstract: In federal fiscal year (FY) 2005 the Department of Veterans Affairs (VA) implemented the comprehensive Mental Health Strategic Plan (MHSP). This study used performance measures from six broad domains to examine changes in the overall delivery of mental health services in the VA since the implementation of the MHSP. Performance measures from fiscal year 2004, the year before implementation of the MHSP, were compared with measures from fiscal years 2005, 2006, and 2007, the first 3 years of MHSP implementation. We combined heterogeneous performance measures within domains through the use of standardized scores or "z-scores." An overall improvement of 0.32 standardized units was observed from FY 2004 to FY 2007, representing moderate to large changes by conventional standards. The domains with the greatest improvement (>1.0 standard deviation units) from FY 2004 to FY 2007 were population coverage/access, outpatient care quality, economic performance (primarily efficiency), and global functioning. There was a 0.3 standard deviation decline in inpatient satisfaction and a slight increase in reliance on inpatient care. Overall improvement in VA mental health care was thus substantial and continuing.

Assessing the relationship between health utilities, quality of life, and health services use in Alzheimer's disease.

Abstract: Objectives To examine the relationship between use of multiple health services and health utilities, quality of life and other factors in Alzheimer's disease (AD). Design Data were obtained via caregiver proxy at baseline and 3- 6- and 9-months post-random assignment among 421 community-dwelling AD patients participating in the CATIE-AD trial of anti-psychotic medications. Service use includes both institutional and outpatient services. Correlates include the AD-Related Quality of Life Scale (ADRQoL), Health Utilities Index (HUI)-III, Neuropsychiatric Inventory, Mini Mental Status Examination, and AD-Cooperative Study Activities of Daily Living Scale. Chi squared tests, t-tests and logistic regression (using general estimating equations) were used to examine the correlates of service use. Results Three quarters (74.2%) used at least one service each month. Average monthly utilization rates for specific service types were: 4.5%, inpatient hospital; 5.6%, nursing home; 3.9%, residential care; 44.0%, AD-related outpatient; 9.4%, mental health outpatient; and 45.5%, medical-surgical outpatient. The likelihood of using any service was higher among older patients [Odds Ratio (OR) = 1.03] and non-Hispanic Whites (OR = 1.61). Each 0.10 increment on the Health Utilities Index (HUI)-III was associated with a 7.0% decrease in the odds of using one or more service (OR = 0.93). The odds of using outpatient and institutional services were 6.0% and 10.0% lower, respectively, for each 0.10 increment on the HUI-III (OR = 0.94, OR = 0.90). The AD-Related Quality of Life Scale proved significantly related to outpatient medical-surgical services only (OR = 1.01). Conclusion Findings suggest that the HUI-III could be combined with other known correlates of service use to inform population planning associated with AD. Copyright © 2008 John Wiley & Sons, Ltd.

Veterans Affairs Intensive Case Management for Older Veterans

Abstract: Background: There is a growing need for information on evidence-based practices that may potentially address needs of elderly people with severe mental illness (SMI), and more specifically on community-based services such as assertive community treatment (ACT). Methods: This study examines national evaluation data from fiscal year 2001–2005 from Veterans Affairs Mental Health Intensive Case Management (MHICM) program (N = 5,222), an ACT-based service model, to characterize the age distribution of participants and the distinctive needs, patterns of service delivery, and treatment outcomes for elderly veterans. Results: Altogether, 24.8% of participants were 55–64 years; 7.4% 65–74 years; and 2.8% were older than 75. Veterans over 75 formed a distinct subgroup that had a later age of onset of primarily nonpsychotic illnesses without comorbid substance abuse and had experienced more limited lifetime hospital treatment than younger participants. Older veterans were less symptomatic and more satisfied with their social relationships than younger clients. They mostly live independently or in minimally restrictive housing, but they received less recovery-focused services and more crisis intervention and medical services. They thus do not appear to be young patients with SMI who have aged but rather constitute a distinct group with serious late-onset problems. It is possible that MHICM services keep them in the community and avoid costly nursing home placement while providing a respite service that reduces family burden. Conclusion: These data highlight the unique characteristics of older veterans receiving ACT-like services and the need to focus greater attention on recovery-oriented services as well as community support for this subgroup.

Home Ownership and Housing Cost Burden: A Comparison of Veterans and Non-Veterans

Abstract: Past research has found that veterans are at modestly greater risk than non-veterans for homelessness. Most attempts to explain these findings have focused on sociodemographic risk factors such as age, race, and prevalent mental illness. Less attention has been given to a potential proximate explanation of homelessness, housing status (i.e., home ownership and housing cost burden). We used data from the 2006 American Community Survey to examine whether male veterans in age-race/ethnic groups at greatest risk of homelessness are also less likely to own a home than matched male non-veterans, and whether they have a greater likelihood of experiencing housing cost burdens that could put them at risk of homelessness. Compared to non-veterans, recently discharged veterans and veterans from the immediate post-Vietnam era, veteran cohorts at greatest relative risk of homelessness were significantly less likely than their non-veteran peers to own their home while other cohorts of veterans were significantl...