Showing papers by "Robert A. Rosenheck published in 2014"

Cardiometabolic Risk in Patients With First-Episode Schizophrenia Spectrum Disorders Baseline Results From the RAISE-ETP Study

Abstract: Importance The fact that individuals with schizophrenia have high cardiovascular morbidity and mortality is well established. However, risk status and moderators or mediators in the earliest stages of illness are less clear. Objective To assess cardiometabolic risk in first-episode schizophrenia spectrum disorders (FES) and its relationship to illness duration, antipsychotic treatment duration and type, sex, and race/ethnicity. Design, Setting, and Participants Baseline results of the Recovery After an Initial Schizophrenia Episode (RAISE) study, collected between July 22, 2010, and July 5, 2012, from 34 community mental health facilities without major research, teaching, or clinical FES programs. Patients were aged 15 to 40 years, had research-confirmed diagnoses of FES, and had less than 6 months of lifetime antipsychotic treatment. Exposure Prebaseline antipsychotic treatment was based on the community clinician’s and/or patient’s decision. Main Outcomes and Measures Body composition and fasting lipid, glucose, and insulin parameters. Results In 394 of 404 patients with cardiometabolic data (mean [SD] age, 23.6 [5.0] years; mean [SD] lifetime antipsychotic treatment, 47.3 [46.1] days), 48.3% were obese or overweight, 50.8% smoked, 56.5% had dyslipidemia, 39.9% had prehypertension, 10.0% had hypertension, and 13.2% had metabolic syndrome. Prediabetes (glucose based, 4.0%; hemoglobin A 1c based, 15.4%) and diabetes (glucose based, 3.0%; hemoglobin A 1c based, 2.9%) were less frequent. Total psychiatric illness duration correlated significantly with higher body mass index, fat mass, fat percentage, and waist circumference (all P P = .04]). Conversely, antipsychotic treatment duration correlated significantly with higher non–HDL-C, triglycerides, and triglycerides to HDL-C ratio and lower HDL-C and systolic blood pressure (all P ≤ .01). In multivariable analyses, olanzapine was significantly associated with higher triglycerides, insulin, and insulin resistance, whereas quetiapine fumarate was associated with significantly higher triglycerides to HDL-C ratio (all P ≤ .02). Conclusions and Relevance In patients with FES, cardiometabolic risk factors and abnormalities are present early in the illness and likely related to the underlying illness, unhealthy lifestyle, and antipsychotic medications, which interact with each other. Prevention of and early interventions for psychiatric illness and treatment with lower-risk agents, routine antipsychotic adverse effect monitoring, and smoking cessation interventions are needed from the earliest illness phases.

Effectiveness of paliperidone palmitate vs haloperidol decanoate for maintenance treatment of schizophrenia: a randomized clinical trial.

Abstract: Importance Long-acting injectable antipsychotics are used to reduce medication nonadherence and relapse in schizophrenia-spectrum disorders. The relative effectiveness of long-acting injectable versions of second-generation and older antipsychotics has not been assessed. Objective To compare the effectiveness of the second-generation long-acting injectable antipsychotic paliperidone palmitate with the older long-acting injectable antipsychotic haloperidol decanoate. Design, Setting, and Participants Multisite, double-blind, randomized clinical trial conducted from March 2011 to July 2013 at 22 US clinical research sites. Randomized patients (n = 311) were adults diagnosed with schizophrenia or schizoaffective disorder who were clinically assessed to be at risk of relapse and likely to benefit from a long-acting injectable antipsychotic. Interventions Intramuscular injections of haloperidol decanoate 25 to 200 mg or paliperidone palmitate 39 to 234 mg every month for as long as 24 months. Main Outcome Measures Efficacy failure, defined as a psychiatric hospitalization, a need for crisis stabilization, a substantial increase in frequency of outpatient visits, a clinician’s decision that oral antipsychotic could not be discontinued within 8 weeks after starting the long-acting injectable antipsychotics, or a clinician’s decision to discontinue the assigned long-acting injectable due to inadequate therapeutic benefit. Key secondary outcomes were common adverse effects of antipsychotic medications. Results There was no statistically significant difference in the rate of efficacy failure for paliperidone palmitate compared with haloperidol decanoate (adjusted hazard ratio, 0.98; 95% CI, 0.65-1.47). The number of participants who experienced efficacy failure was 49 (33.8%) in the paliperidone palmitate group and 47 (32.4%) in the haloperidol decanoate group. On average, participants in the paliperidone palmitate group gained weight and those in the haloperidol decanoate group lost weight; after 6 months, the least-squares mean weight change for those taking paliperidone palmitate was increased by 2.17 kg (95% CI, 1.25-3.09) and was decreased for those taking haloperidol decanoate (−0.96 kg; 95% CI, −1.88 to −0.04). Patients taking paliperidone palmitate had significantly higher maximum mean levels of serum prolactin (men, 34.56 µg/L [95% CI, 29.75-39.37] vs 15.41 µg/L [95% CI, 10.73-20.08]; P P P =.006). Conclusions and Relevance In adults with schizophrenia or schizoaffective disorder, use of paliperidone palmitate vs haloperidol decanoate did not result in a statistically significant difference in efficacy failure, but was associated with more weight gain and greater increases in serum prolactin, whereas haloperidol decanoate was associated with more akathisia. However, the CIs do not rule out the possibility of a clinically meaningful advantage with paliperidone palmitate. Trial Registration clinicaltrials.gov Identifier:NCT01136772

Homelessness in a national sample of incarcerated veterans in state and federal prisons.

Abstract: The Veterans Health Administration (VHA) has been increasing efforts to reach out to assist incarcerated veterans. While previous studies have shown strong associations between incarceration and homelessness, few studies have examined distinctive characteristics of incarcerated homeless and non-homeless veterans. National administrative data on 30,348 incarcerated veterans served by the Health Care for Re-entry Veterans (HCRV) program were analyzed. Incarcerated veterans were classified into four groups based on their history of past homelessness: not homeless, transiently homeless, episodically homeless, and chronically homeless. Multinomial logistic regression was used to compare groups on sociodemographic characteristics, criminal justice status, clinical status, and their interest in using VHA services. Of the sample, 70 % were classified as not homeless, 8 % as transiently homeless, 11 % as episodically homeless, and 11 % as chronically homeless. Thus, 30 % of the sample had a homeless history, which is five times the 6 % rate of past homelessness among adult men in the general population. Compared to non-homeless incarcerated veterans, all three homeless groups reported significantly more mental health problems, more substance abuse, more times arrested in their lifetime, more likely to be incarcerated for a non-violent offense, and were more interested in receiving VHA services after release from prison. Together, these findings suggest re-entry programs, like HCRV, can address relevant mental health-related service needs, especially among formerly homeless veterans and veterans in need of services are receptive to the offer of assistance.

Determinants of prospective engagement in mental health treatment among symptomatic Iraq/Afghanistan veterans.

Abstract: There is considerable public and professional concern about the mental health status of veterans deployed to Iraq and Afghanistan as well as how to engage and retain symptomatic veterans in treatment. This study examined demographic, psychiatric, and psychosocial determinants of prospective

Attitudes Toward Mental Illness and Changes Associated with a Brief Educational Intervention for Medical and Nursing Students in Nigeria

Abstract: This study assessed beliefs about mental disorders and changes in those beliefs following an educational intervention for a convenience sample of Nigerian medical and nursing students. A 43-item questionnaire was used to assess perceptions regarding mental disorders and attitudes toward people with mental illness before and after a 4-day educational intervention. Factor analysis identified four domains: (1) socializing with people with mental illness, (2) belief in witchcraft or curses as causes of mental illness, (3) favorable attitudes toward normalization of the lives of people with mental illness, and (4) biopsychosocial approaches to mental illness. The greatest changes were in attitudes favoring normalization of the lives of people with mental illness (p = 0.0002), socializing with the mentally ill (p = 0.01), and biopsychosocial perspectives on mental illness (p = 0.01). Brief educational interventions may alter some stigmatizing negative attitudes toward mental illness in healthcare trainees in low- and middle-income countries.

A cross-national factor analytic comparison of three models of PANSS symptoms in schizophrenia.

Abstract: The 30-item Positive and Negative Syndrome Scale (PANSS) is used worldwide in the assessment of symptom severity in schizophrenia. The present study uses confirmatory factor analysis (CFA) to compare three different factorial models and to evaluate the best-fitting representation of schizophrenia symptom structure on the PANSS across four samples of patients diagnosed with schizophrenia from the US (the CATIE schizophrenia trial), Sao Paulo, Brazil, and from Beijing and Changsha, China. We examine the goodness of fit of several previously proposed models. The traditional trifactorial model for the PANSS and two five-factor models were evaluated using absolute and incremental indices. Single group CFA found that the five-factor model proposed by NIMH researchers based on an extensive literature review demonstrates the best fit in each of the four samples. This model used 20 of the 30 PANSS items grouped into five factors: positive, negative, disorganized, excited, and depressed symptoms. Subgroups defined by age, gender, nationality, hospitalization status, and severity of illness also did not differ in overall symptom structure as assessed by several standard indices. Our findings suggest that the five factor NIMH model showed the best representation among all four samples from different countries and potentially contrasting cultures.

Attitudes towards people with mental illness among psychiatrists, psychiatric nurses, involved family members and the general population in a large city in Guangzhou, China

Abstract: Stigma towards people with mental illness is believed to be widespread in low and middle income countries. This study assessed the attitudes towards people with mental illness among psychiatrists, psychiatric nurses, involved family members of patients in a psychiatric facility and the general public using a standard 43-item survey (N = 535). Exploratory factor analysis identified four distinctive attitudes which were then compared using Analysis of Covariance (ANCOVA) among the four groups, all with ties to the largest psychiatric facility in Guangzhou, China, adjusting for sociodemographic differences. Four uncorrelated factors expressed preferences for 1) community-based treatment, social integration and a biopsychosocial model of causation, 2) direct personal relationships with people with mental illness, 3) a lack of fear and positive views of personal interactions with people with mental illness, 4) disbelief in superstitious explanations of mental illness. Statistically significant differences favored community-based treatment and biopsychosocial causation (factor 1) among professional groups (psychiatrists and nurses) as compared with family members and the general public (p < 0.001); while family members, unexpectedly, showed far weaker personal preferences for direct personal relationships with people with mental illness than all three other groups (p < 0.001). Both psychiatrists and nurses showed greater support for social integration and biopsychosocial understandings of mental illness than the lay public, most likely because of their training and experience, while family members showed the least positive attitudes towards direct personal relationships with people with mental illness. These findings suggest support for a more extensive, formal system of care that gives family members some distance from the problems of their relatives and support in their care.

Psychiatric correlates of past incarceration in the national co-morbidity study replication

Abstract: Background Mental illness and substance abuse have been increasingly linked to criminal justice system involvement, but this relationship has mostly been by survey of prison populations and inferences of excess rates of disorder made by noting how these rates compare with national population-based surveys of mental disorders. Aims The aim of this study is to examine associations between history of mental disorders, including substance misuse, with incarceration history within a single population-based data set. Methods Data were from the National Comorbidity Survey Replication, a nationally representative household survey of respondents 18 years and older conducted between 5 February 2001 and 7 April 2003. Results Multivariate regression analysis showed the strongest independent risk factors for a history of incarceration were being male [odds ratio (OR) = 6.3; p < 0.001], past receipt of welfare payments (OR = 2.1; p < 0.001), longer than 1 week of past homelessness (OR = 2.1; p < 0.001), not being from the northeast of the USA (OR = 0.31; p < 0.001) and a lifetime substance abuse or dependence diagnosis (OR = 4.9; p < 0.001). With the exception of welfare payments, these measures were also independently associated with longer (27 + days) incarceration. Conclusions The socioeconomic associates of incarceration history were unexpected, and in line with other, differently conducted studies. The fact that only substance misuse disorders of all those assessed were independently associated with incarceration history was a surprise, given the multiplicity of prison surveys, which have shown higher rates of other serious mental disorders. Although we were unable to include measures of schizophrenia or similar psychosis and used impulse control disorders as surrogates for personality disorder, absence of a relationship between depression and incarceration when measured in the same way and over the same time among those previously incarcerated and those not, raises questions about the weight that should be put on the existing epidemiological perspective of mental disorder among prisoners. Published 2013. This article is a U.S. Government work and is in the public domain in the USA. Criminal Behaviour and Mental Health published by John Wiley & Sons Ltd.

Homeless female U.S. veterans in a national supported housing program: comparison of individual characteristics and outcomes with male veterans.

Abstract: As more women serve in the U.S. military, the proportion of females among homeless veterans is increasing. The current study compares the individual characteristics and 1-year outcomes of homeless female and male veterans in the Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program nationally. Administrative data on 43,853 veterans (10.69% females; 89.31% males) referred to HUD-VASH were analyzed for gender differences at baseline and over a 1-year period. Homeless female veterans were younger, had shorter homeless and incarceration histories, and were less likely to have substance use disorders than men. However, despite being less likely to report combat exposure, female veterans were more likely to have posttraumatic stress disorder. Homeless female veterans were also much more likely to have dependent children with them and to plan to live with family members in supported housing. Once admitted to HUD-VASH, there were no gender differences in attrition or main housing outcomes. Case managers were faster to admit female veterans to the program, reported better working alliances, and provided more services related to employment and income than male veterans. These findings suggest homeless female veterans may have certain strengths, including being younger, less involved in the criminal justice system, and more adept at relating to professional and natural supports; but special attention to noncombat trauma and family-oriented services may be needed.

Increased Risk Among Older Veterans of Prescribing Psychotropic Medication in the Absence of Psychiatric Diagnoses

Abstract: Objective This study uses Veterans Health Administration (VHA) pharmacy and encounter claims to evaluate the use of psychotropic medications without a psychiatric diagnosis across age groups. Methods National VHA administrative data for fiscal year 2010 (FY2010) were used to identify all veterans who filled a prescription for at least one psychotropic medication from VHA (N = 1.85 million). Bivariate and multivariate analyses were used to compare the proportion of these veterans without any psychiatric diagnosis, across age groups, adjusting for possible medical indications. Analyses were repeated for six different classes of psychotropic medications and comparing mental health utilizers and non–mental health utilizers. Comparisons were made to prescribing of HIV and diabetes medications without an indicated diagnosis. Results Of all VHA patients prescribed a psychotropic medication in FY2010, 30% had no psychiatric diagnosis, with highest proportions among veterans ages 65–85. This practice was most frequent among nonmental health utilizers and far more prevalent for psychotropic medications than for HIV or diabetes medications. Logistic regression analysis found that age greater than 65 was the strongest predictor of being prescribed a psychotropic without a psychiatric diagnosis. Adjustment for possible medical use of psychotropics and overall medical comorbidity did not substantially alter these trends. Conclusion Older veterans, especially those not using specialty mental healthcare, are more likely to be prescribed psychotropic medications in the absence of a psychiatric diagnosis, perhaps representing unnecessary use, under-diagnosis of mental illness, or incomplete documentation.

National comparison of literally homeless male and female VA service users: entry characteristics, clinical needs, and service patterns.

Abstract: Background Although there are growing numbers of homeless female U.S. veterans, the U.S. Department of Veterans Affairs (VA) has traditionally served a predominantly male population; thus, it is important to examine differences between homeless female and male veterans in their service needs and the current provision of VA homeless services. Methods A national registry of 119,947 users of VA homeless services from 2011 to 2012 was used to 1) estimate the proportion of female veterans among VA homeless service users, 2) examine the proportion of VA homeless service users who are literally homeless by gender, and 3) report differences between female and male VA homeless service users who are literally homeless on sociodemographic and clinical characteristics, as well as on outreach, referral, and admission patterns for an array of specialized VA services. Findings Of VA homeless service users, 8% were female compared with 7% among all homeless veterans, 6% among all VA service users, and 7% among all veterans. Of female VA homeless service users, 54% were literally homeless, slightly fewer than the 59% of male VA homeless service users. Comparing literally homeless VA service users, females were younger, 21% more had dependent children, 8% more were diagnosed with non–military-related posttraumatic stress disorder, and 19% to 20% more were referred and admitted to VA's supported housing program than males. Conclusions Female veterans use VA homeless services at a rate similar to their use of general VA services and they have unique needs, especially for child care, which may require additional specialized resources.

Uninsured veterans who will need to obtain insurance coverage under the patient protection and affordable care act.

Abstract: Objectives. We examined the number and clinical needs of uninsured veterans, including those who will be eligible for the Medicaid expansion and health insurance exchanges in 2014.Methods. We analyzed weighted data for 8710 veterans from the 2010 National Survey of Veterans, classifying it by veterans’ age, income, household size, and insurance status.Results. Of 22 million veterans, about 7%, or more than 1.5 million, were uninsured and will need to obtain coverage by enrolling in US Department of Veterans Affairs (VA) care or the Medicaid expansion or by participating in the health insurance exchanges. Of those uninsured, 55%, or more than 800 000, are likely eligible for the Medicaid expansion if states implement it. Compared with veterans with any health coverage, those who were uninsured were younger and more likely to be single, Black, and low income and to have been deployed to Iraq and Afghanistan.Conclusions. The Patient Protection and Affordable Care Act is likely to have a considerable impact o...

Insight and attitudes towards medication among inpatients with chronic schizophrenia in the US and China.

Abstract: Background The impact of culture on insight on illness and attitudes towards medication among patients with schizophrenia has not been well studied. We compared inpatients in the US and in China (a culture that numerous studies have shown heavily stigmatizes mental illness and psychosis), on measures of insight and acceptance of medication, controlling for overall severity of schizophrenia symptoms.

Street Outreach and Other Forms of Engagement with Literally Homeless Veterans

Abstract: Street outreach is one of the most direct methods of engaging homeless individuals, but the characteristics of those most likely to be engaged this way is not well-understood. Data from the Department of Veterans Affairs (VA) Homeless Operations Management and Evaluation System showed that of the 70,778 literally homeless veterans engaged in VA homeless services in 2011-2012, 12% were through street outreach while the majority was through provider referrals (41%) and self-referrals (28%). Veterans engaged through street outreach had more extensive histories of recent homelessness, were more likely to be chronically homeless, and were more likely to be referred and admitted to the VA's supported housing program than other veterans. These findings suggest street outreach is an especially important approach to engaging chronic street homeless veterans in services and linking them to permanent supported housing.

Sources of the Increasing Number of Vietnam Era Veterans With a Diagnosis of PTSD Using VHA Services

Abstract: ObjectiveCorrelates of the sharp increase in Vietnam era veterans diagnosed as having posttraumatic stress disorder (PTSD) in the Veterans Health Administration (VHA) were examined.MethodsAnalyses compared receipt of a PTSD diagnosis and service-connected disability compensation in 2004–2006 and 2007–2009.ResultsAmong Vietnam era veterans, the percentage with a PTSD diagnosis in 2007–2009 was 22.2% higher than the percentage with PTSD in 2004–2006; the percentage without PTSD was 6.2% higher than in 2004–2006. Of those with PTSD in 2007–2009, 22.6% were previous VHA service users newly diagnosed (“conversions”); only 12.8% were entirely new to VHA (“recents”). Rates of disability compensation among recents and conversions were almost two and three times higher, respectively, than among those without PTSD.ConclusionsThe increase in Vietnam era veterans with PTSD is associated with more frequent “conversion” to PTSD among previous VHA users and receipt of disability compensation.

Incarceration histories of homeless veterans and progression through a national supported housing program

Abstract: There is increasing concern that adults with a past history of incarceration are at particular disadvantage in exiting homelessness. Supported housing with case management has emerged as the leading service model for assisting homeless adults; however there has been limited examination of the success of adults with past history of incarceration in obtaining housing within this paradigm. Data were examined on 14,557 veterans who entered a national supported housing program for homeless veterans, the Housing and Urban Development-Veterans Affairs Supportive Housing program (HUD-VASH) during 2008 and 2009, to identify characteristics associated with a history of incarceration and to evaluate whether those with a history of incarceration are less likely to obtain housing and/or more likely to experience delays in the housing attainment process. Veterans who reported no past incarceration were compared with veterans with short incarceration histories (≤ 1 year) and those with long incarceration histories (>1 year). A majority of participants reported history of incarceration; 43 % reported short incarceration histories and 22 % reported long incarceration histories. After adjusting for baseline characteristics and site, history of incarceration did not appear to impede therapeutic alliance, progression through the housing process or obtaining housing. Within a national supported housing program, veterans with a history of incarceration were just as successful at obtaining housing in similar time frames when compared to veterans without any past incarceration. Supported housing programs, like HUD-VASH, appear to be able to overcome impediments faced by formerly incarcerated homeless veterans and therefore should be considered a a good model for housing assistance programs.

Residential Treatment for Posttraumatic Stress Disorder in the Department of Veterans Affairs: A National Perspective on.

Abstract: Thirty-eight U.S. Department of Veterans Affairs's (VA) residential treatment programs for posttraumatic stress disorder took part in a formative evaluation of their programmatic services, including perceptions of effective treatment. From July 2008 through March 2011, face-to-face qualitative interviews were conducted with over 250 VA residential staff. A wide variety of perceived effective treatment elements were noted. The most frequently mentioned elements were evidence-based treatments, frequency and intensity of milieu, staff cohesion, varied programming, and individualized treatment. Implications for VA managers and policy-makers as well as non-VA health care systems and health care providers are discussed. Language: en

Retrospective assessment of factors associated with readmission in a large psychiatric hospital in Guangzhou, China

Abstract: Conclusion: Shorter length of stay was not associated with increased readmission rates in patients admitted to a large public psychiatric hospital in southern China. This suggests that the expected decrease in the length of psychiatric inpatient admissions that is likely to occur when, based on China’s new regulations, most patients are admitted voluntarily may not lead to increased rates of readmission. Prospective studies with a more comprehensive set of outcome measures (including patient functioning, medication adherence, and family burden) are needed to monitor the effect of the law on patients and on the distribution of mental health services.

Differences in treatment effect among clinical subgroups in a randomized clinical trial of long-acting injectable risperidone and oral antipsychotics in unstable chronic schizophrenia.

Abstract: A long-term randomized trial of unstable patients with schizophrenia found no benefit of long-acting injectable (LAI) risperidone over oral treatment in preventing or delaying time to psychiatric hospitalizations or on clinical outcomes. The initial analyses did not examine whether benefits of LAI emerged in selected subgroups.Patients with schizophrenia or schizoaffective disorder who had been hospitalized within the past 2 years or judged to be at risk for hospitalization because of increasing psychiatric service use were randomly assigned to LAI risperidone 12.5 to 50 mg per injection biweekly or to the psychiatrist's choice of oral antipsychotics and followed for up to 2 years. The primary endpoint was psychiatric rehospitalization. Symptoms, quality of life, and global functioning were assessed through blinded videoconference interviews. Cox's regression and mixed effects models were used to assess difference in treatment effect within 12 subgroups defined by hospitalization at study entry, substance abuse, race, symptom severity, quality of life, body mass index, age, race or sex, or reported medication compliance.Mixed models and Cox's regression using up to 24 months of follow-up data showed no significant differences in treatment effect in 10 of 12 subgroups on psychiatric symptoms, quality of life, or time to hospitalization. With adjustment for multiple comparisons, treatment effect differed by race on substance use outcomes, with white participants showing more benefit from LAI than other groups.LAI risperidone showed no superiority to psychiatrist's choice of oral treatment in most clinically defined subgroups, although the white patients benefited more than the other groups on substance abuse outcomes.

Work outcomes after benefits counseling among veterans applying for service connection for a psychiatric condition.

Abstract: Objective:This study’s objective was to determine the efficacy of benefits counseling in a clinical trial. There has been concern that disability payments for psychiatric disorders reduce incentives for employment and rehabilitation. Benefits counseling, with education about opportunities to work and the financial implications of work on receipt of disability benefits, may counter these disincentives.Methods:This single-blind, six-month randomized clinical trial enrolled 84 veterans who had applied for service-connected compensation for a psychiatric condition. Veterans were randomly assigned to either four sessions of benefits counseling or of a control condition involving orientation to the U.S Department of Veterans Affairs health care system and services. Days of paid work and work-related activities were assessed at follow-up visits by using a timeline follow-back calendar.Results:Veterans assigned to benefits counseling worked for pay for significantly more days than did veterans in the control grou...

Health and well-being of homeless veterans participating in transitional and supported employment: Six-month outcomes.

Abstract: Supported employment, specifically individual placement and support (IPS), improves competitive employment (CE) rates for individuals with serious mental illness, but has not shown greater improvement in non-vocational outcomes than other rehabilitation approaches. The Department of Veterans Affairs offers two types of vocational services, IPS and transitional work experience (TWE), but no study has compared the effectiveness of these approaches. This secondary analysis of data from a study of homeless veterans compared 6 mo improvement in diverse outcomes for five employment patterns: never worked, worked only in TWE, worked in TWE followed by CE, worked in CE without IPS, and worked in CE with IPS referral. Veterans referred to IPS were more likely to be competitively employed. Those who worked in CE (whether following TWE or with or without IPS referral) showed the greatest increase in days worked, employment income, and total income and the greatest decrease in public support income when compared with those who worked only in TWE or not at all. Veterans in TWE showed the greatest increase in residential treatment days, but there were no other differences in non-vocational outcomes between groups. There are multiple paths to CE, but few differences in non-vocational outcomes across employment experiences.

Gender Differences in VA Disability Status for PTSD Over Time

Abstract: ObjectivePosttraumatic stress disorder (PTSD) is the most prevalent psychiatric condition for which veterans receive service-connected disability benefits from the U.S. Department of Veterans Affairs (VA). Historically, women have been less likely than men to obtain PTSD disability benefits. The authors examined whether these gender disparities have been redressed over time and, if not, whether appropriate clinical factors account for persisting differences.MethodsThis longitudinal, observational study was based on a gender-stratified, nationally representative sample of 2,998 U.S. veterans who applied for VA disability benefits for PTSD between 1994 and 1998. The primary outcome was change in PTSD service connection over a ten-year period.ResultsForty-two percent (95% confidence interval [CI]=38%–45%) of the women and 50% (CI=45%–55%) of the men originally denied service connection for PTSD eventually received such benefits. Only 8% (CI=7%–10%) of women and 5% (CI=4%–6%) of men lost PTSD disability statu...

Health insurance in China: variation in co-payments and psychiatric hospital utilization.

Abstract: BACKGROUND Economic reform in China 30 years ago virtually eliminated all public health insurance. In the last 10 years, diverse government insurance programs have been implemented, now covering 95% of the population, primarily for inpatient care. While the development of health care in China is an incomplete work in progress and highly variable, it is unclear whether the depth of insurance coverage affects the accessibility, length of stay (LOS) of inpatient mental health services or not. AIM OF THE STUDY This study aims to examine the relationship between variation in insurance coverage, accessibility to inpatient mental health care and intensity of care as measured by length of stay (LOS). METHODS Using administrative data from the Guangzhou Psychiatric Hospital (GPH), we used regression models to determine the relationship between the depth of insurance coverage and the likelihood of hospital utilization and LOS net of sociodemographic characteristics and diagnosis. RESULTS Between April 1, 2010 and March 31, 2013, 8,478 patients were discharged with ICD-10 psychiatric diagnoses with an average LOS of 75.1 (sd=244.3) days, among which 4,727 (55.8%) patients were first admissions. Logistic regression analysis showed that insurance plans with lower co-payments were significant predictors of multiple psychiatric admissions and longer LOS. IMPLICATIONS FOR HEALTH POLICY These data point to significant variability in the health insurance coverage in China and indicate a clear need for greater equalization in future years. Although the Chinese government has provided at least shallow coverage to virtually all of its citizens at this stage, further efforts are needed to expand and equalize coverage as economic development proceeds, especially in rural areas. IMPLICATIONS FOR FURTHER RESEARCH Although variation in health insurance plans in China are extensive and impact the accessibility and duration of psychiatric hospital care, their impact on outcomes and use of post-discharge outpatient care is unknown and requires further study.

Video Conferencing Technology in Research on Schizophrenia: A Qualitative Study of Site Research Staff

Abstract: The objective of this study was to advance knowledge of the experience of multisite research staff with video conferencing mental health data collection among study participants with schizophrenia. An end-of-study focus group was conducted with all (N = 19) study coordinators of a multisite randomized trial of pharmacotherapy for schizophrenia to characterize the experiences of coordinators overseeing semistructured assessments via video conferencing technology (VCT). Researchers conducted an audiotaped voluntary focus group. Investigators independently coded a transcript of the focus group, followed by discussions to reach consensus on key themes. Three key themes emerged, involving issues associated with (a) the technology itself, (b) the technology in the context of clinical care and research, and (c) the feasibility of using VCT for study assessments, including coordinators' perceptions of participants' experience of VCT. Additional themes were that (a) interviewer skills appeared to moderate the impact of VCT, (b) research participants with serious psychiatric disorders who participated in VCT assessments appeared, overall, to be more amenable to the technology than research coordinators anticipated, and (c) because VCT will be adapted in a wide range of settings, staffing and resource needs should be considered in planning for and adopting VCT for psychiatric research or clinical assessment. This study adds contextual detail and emphasis to the existing literature on the use of VCT in research and factors regarding the effective deployment of the technology in research.

Homeless and nonhomeless VA service users likely eligible for Medicaid expansion.

Abstract: Administrative data on the population of Department of Veterans Affairs (VA) service users in 2010 under the age of 65 (n = 3,841,225) were analyzed to identify the number and characteristics of homeless and nonhomeless VA service users who are likely to be eligible for the Medicaid expansion (LEME) option under the Affordable Care Act. Results showed that, estimating conservatively, about 1.2 million (21%) current VA users are LEME if all states implement the expansion. Homeless service users were twice as likely to be eligible than nonhomeless users (64% vs 30%). VA service users who are LEME, regardless of housing status, were physically healthier than those not LEME but were more likely to have substance use disorders and posttraumatic stress disorder. These findings suggest that many VA service users are LEME, particularly those who are homeless and/or have mental health needs. Cross-system use of VA and Medicaid-funded services may be advantageous for veterans with extensive medical and psychiatric needs but also risks fragmented care. Information and education for VA clinicians and their patients about possible implications of the Affordable Care Act may be important.

Noninferiority of perphenazine vs. three second-generation antipsychotics in chronic schizophrenia.

Abstract: Noninferiority analysis is a statistical method of growing importance in comparative effectiveness research that has rarely been used in psychopharmacology. This method is used here to evaluate whether first-generation antipsychotics are clinically not inferior to second-generation antipsychotics (SGAs) using data from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE). A conservative noninferiority margin (NIM) on the Positive and Negative Syndrome Scale (PANSS) was derived from the smallest published value for the minimal clinically important difference, further reduced by 25%. This NIM was used to assess whether perphenazine is noninferior to olanzapine, risperidone, and quetiapine on the basis of the 95% confidence intervals of differences in mean PANSS outcomes (N = 1049). Perphenazine was noninferior to all three SGAs during 18 months of intention-to-treat analysis and in several subanalyses. Noninferiority can be evaluated from studies designed as superiority trials. Power was available in the CATIE to conduct noninferiority analysis.