Showing papers by "Robert A. Rosenheck published in 2015"

Risk Factors for Homelessness Among US Veterans

Abstract: Homelessness among US veterans has been a focus of research for over 3 decades. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, this is the first systematic review to summarize research on risk factors for homelessness among US veterans and to evaluate the evidence for these risk factors. Thirty-one studies published from 1987 to 2014 were divided into 3 categories: more rigorous studies, less rigorous studies, and studies comparing homeless veterans with homeless nonveterans. The strongest and most consistent risk factors were substance use disorders and mental illness, followed by low income and other income-related factors. There was some evidence that social isolation, adverse childhood experiences, and past incarceration were also important risk factors. Veterans, especially those who served since the advent of the all-volunteer force, were at greater risk for homelessness than other adults. Homeless veterans were generally older, better educated, and more likely to be male, married/have been married, and to have health insurance coverage than other homeless adults. More studies simultaneously addressing premilitary, military, and postmilitary risk factors for veteran homelessness are needed. This review identifies substance use disorders, mental illness, and low income as targets for policies and programs in efforts to end homelessness among veterans.

The NAVIGATE Program for First-Episode Psychosis: Rationale, Overview, and Description of Psychosocial Components

Abstract: Comprehensive coordinated specialty care programs for first-episode psychosis have been widely implemented in other countries but not in the United States. The National Institute of Mental Health’s Recovery After an Initial Schizophrenia Episode (RAISE) initiative focused on the development and evaluation of first-episode treatment programs designed for the U.S. health care system. This article describes the background, rationale, and nature of the intervention developed by the RAISE Early Treatment Program project—known as the NAVIGATE program—with a particular focus on its psychosocial components. NAVIGATE is a team-based, multicomponent treatment program designed to be implemented in routine mental health treatment settings and aimed at guiding people with a first episode of psychosis (and their families) toward psychological and functional health. The core services provided in the NAVIGATE program include the family education program (FEP), individual resiliency training (IRT), supported employment an...

Marijuana use is associated with worse outcomes in symptom severity and violent behavior in patients with posttraumatic stress disorder.

Abstract: OBJECTIVE: An increasing number of states have approved posttraumatic stress disorder (PTSD) as a qualifying condition for medical marijuana, although little evidence exists evaluating the effect of marijuana use in PTSD. We examined the association between marijuana use and PTSD symptom severity in a longitudinal, observational study. METHOD: From 1992 to 2011, veterans with DSM-III/-IV PTSD (N = 2,276) were admitted to specialized Veterans Affairs treatment programs, with assessments conducted at intake and 4 months after discharge. Subjects were classified into 4 groups according to marijuana use: those with no use at admission or after discharge ("never-users"), those who used at admission but not after discharge ("stoppers"), those who used at admission and after discharge ("continuing users"), and those using after discharge but not at admission ("starters"). Analyses of variance compared baseline characteristics and identified relevant covariates. Analyses of covariance then compared groups on follow-up measures of PTSD symptoms, drug and alcohol use, violent behavior, and employment. RESULTS: After we adjusted for relevant baseline covariates, marijuana use was significantly associated with worse outcomes in PTSD symptom severity (P CONCLUSIONS: In this observational study, initiating marijuana use after treatment was associated with worse PTSD symptoms, more violent behavior, and alcohol use. Marijuana may actually worsen PTSD symptoms or nullify the benefits of specialized, intensive treatment. Cessation or prevention of use may be an important goal of treatment. Language: en

Duration of Untreated Psychosis in Community Treatment Settings in the United States

Abstract: Objective:This study is the first to examine duration of untreated psychosis (DUP) among persons receiving care in community mental health centers in the United States.Methods:Participants were 404 individuals (ages 15–40) who presented for treatment for first-episode psychosis at 34 nonacademic clinics in 21 states. DUP and individual- and site-level variables were measured.Results:Median DUP was 74 weeks (mean=193.5±262.2 weeks; 68% of participants had DUP of greater than six months). Correlates of longer DUP included earlier age at first psychotic symptoms, substance use disorder, positive and general symptom severity, poorer functioning, and referral from outpatient treatment settings.Conclusions:This study reported longer DUP than studies conducted in academic settings but found similar correlates of DUP. Reducing DUP in the United States will require examination of factors in treatment delay in local service settings and targeted strategies for closing gaps in pathways to specialty FEP care.

Prescription Practices in the Treatment of First-Episode Schizophrenia Spectrum Disorders: Data From the National RAISE-ETP Study

Abstract: Objective:Treatment guidelines suggest distinctive medication strategies for first-episode and multiepisode patients with schizophrenia. To assess the extent to which community clinicians adjust their usual treatment regimens for first-episode patients, the authors examined prescription patterns and factors associated with prescription choice in a national cohort of early-phase patients.Method:Prescription data at study entry were obtained from 404 participants in the Recovery After an Initial Schizophrenia Episode Project’s Early Treatment Program (RAISE-ETP), a nationwide multisite effectiveness study for patients with first-episode schizophrenia spectrum disorders. Treatment with antipsychotics did not exceed 6 months at study entry.Results:The authors identified 159 patients (39.4% of the sample) who might benefit from changes in their psychotropic prescriptions. Of these, 8.8% received prescriptions for recommended antipsychotics at higher than recommended dosages; 32.1% received prescriptions for ol...

PTSD and Substance Use Disorder Among Veterans: Characteristics, Service Utilization and Pharmacotherapy

Abstract: Objective: While there has been considerable concern about veterans with dually diagnosed posttraumatic stress disorder (PTSD) and comorbid substance use disorders, a national study of clinical characteristics, service utilization, and psychotropic medication use of such veterans in Veterans Affairs (VA) has yet to be conducted. We hypothesized that veterans having both PTSD and substance use disorder would have lower socioeconomic status, greater medical and psychiatric comorbidity, higher medical service utilization, and more psychotropic pharmacotherapy fills. Methods: National VA data from fiscal year 2012 were used to compare veterans with dually diagnosed PTSD and substance use disorder to veterans with PTSD without substance use disorder on sociodemographic characteristics, psychiatric and medical comorbidities, mental health and medical service utilization, and psychotropic pharmacotherapy. Comparisons were based on bivariate and Poisson regression analyses. Results: The sample included all 638,45...

An assessment of attitudes towards people with mental illness among medical students and physicians in Ibadan, Nigeria.

Abstract: The authors surveyed attitudes towards mental illness among Nigerian medical personnel at three different levels of training and experience: medical students who had not completed their psychiatry rotation, medical students who had competed their psychiatry rotation, and graduate physicians. Six questions addressed beliefs about the effectiveness of treatments for four specific mental illnesses (schizophrenia, bipolar disorder, depression, and anxiety) and two medical illnesses (diabetes and hypertension) among the three groups. A self-report questionnaire including 56 dichotomous items was used to compare beliefs about and attitudes towards people with mental illness. Factor analysis was used to identify key attitudes and analysis of covariance (ANCOVA) was used to compare the groups adjusting for age and personal experience with people with mental illness. There were no significant trends in attitudes towards the effectiveness of medication. Exploratory factor analysis of the beliefs and attitudes items identified four factors: (1) comfort socializing with people with mental, illness; (2) non-superstitious beliefs about the causes of mental illness; (3) neighborly feelings towards people with mental illness; and (4) belief that stress and abuse are part of the etiology of mental illness. ANCOVA comparing attitudes among the three groups showed that on three (1, 2, and 4) of the four factors medical students who had completed a rotation in psychiatry had significantly higher scores than the medical students who had not completed a rotation in psychiatry. Graduate physicians showed a similar pattern scoring higher than the medical students who had not completed a rotation in psychiatry in two factors (1 and 4) but showed no differences from students who had completed their psychiatry rotation. While beliefs about medication effectiveness do not differ between medical trainees and graduate professionals, stigmatizing attitudes towards people with mental illness seem to be most strongly affected by clinical training. Psychiatric education and especially clinical experience result in more progressive attitudes towards people with mental illness.

Prevalence and correlates of co-prescribing psychotropic medications with long-term opioid use nationally in the Veterans Health Administration.

Abstract: We used national data for fiscal year 2012 to examine demographic, psychiatric and medical diagnoses, indications for psychotropics, and service use correlates of psychotropic medication fills in Veterans with at least 10 opioid prescriptions during the year (the highest 29% of opioid users); and whether the Veteran was treated in a specialty mental health clinic. Of the 328,398 Veterans who filled at least 10 opioid prescriptions, 77% also received psychotropics, of whom: 74% received antidepressants, 55% anxiolytics/sedatives/hypnotics, and 26% three or more classes of psychotropic medications. Altogether, 87% had a psychiatric or medical indication; and 54% received mental health treatment. Veterans treated in a mental health clinic were prescribed more psychotropics and were more likely to have a documented psychiatric or medical indication than those treated solely in other settings. Indicated psychiatric diagnoses were the strongest predictors of specific class of psychotropics prescribed; anxiety disorder and insomnia were most strongly associated with anxioloytics/sedatives/hypnotics receipt. Since psychotropics and opioids can produce harmful side effects, especially when combined, and since they are likely prescribed by separate providers in different settings, coordinated consideration of the risks and benefits of co-prescribing these medications may be needed, along with further study of related adverse events.

Concomitant cannabis abuse/dependence in patients treated with opioids for non-cancer pain.

Abstract: Background and Objectives Cannabis use is common among patients taking prescription opioids, although rates of concomitant cannabis use disorder (CUD) have been largely unexamined. CUD may increase safety risks in those taking opioid pain medications but it is unknown whether cannabis and opioids function as substitutes (cannabis use is associated with less prescription opioid use), or rather as complements (cannabis is associated with increased use of prescription opioids). Methods We examined rates of CUD in a national sample of Veterans Health Administration (VHA) patients (n = 1,316,464) with non-cancer pain diagnoses receiving opioid medications in fiscal year 2012. Using bivariate analysis to identify potentially confounding variables associated with CUD (eg, psychotropic medication, other substance use disorders) in this population, we then utilized logistic regression to examine rates of cannabis use disorder among individuals receiving different numbers of opioid prescriptions (0, 1–2, 3–10, 11–19, 20+). Results Descriptive analysis, largely confirmed by logistic regression, demonstrated that greater numbers of prescription opioid fills were associated with greater likelihood of CUD. This relationship was reduced somewhat for those receiving the most opioid prescriptions (20+) in the logistic regression, which controlled for potentially confounding variables. Discussion and Conclusions These results warrant increased attention to CUDs among patients receiving numerous opioid prescriptions. Increasing legalization of cannabis is likely to further increase use and abuse of cannabis in patients prescribed opioids. Scientific Significance These findings suggest that clinicians should be alert to concomitant CUD and prescription opioid use, as these substances appear to complement each other. (Am J Addict 2015;24:538–545)

Correlates of major depressive disorder with and without comorbid alcohol use disorder nationally in the veterans health administration

Abstract: Background and Objectives This study assesses medical and psychiatric comorbidities, service utilization, and psychotropic medication prescriptions in veterans with comorbid major depressive disorder (MDD) and alcohol use disorder (AUD) relative to veterans with MDD alone. Methods Using cross-sectional administrative data (fiscal year [FY]2012: October 1, 2011–September 30, 2012) from the Veterans Health Administration (VHA), we identified veterans with a diagnosis of current (12-month) MDD nationally (N = 309,374), 18.8% of whom were also diagnosed with current (12-month) AUD. Veterans with both MDD and AUD were compared to those with MDD alone on sociodemographic characteristics, current (12-month) medical and psychiatric disorders, service utilization, and psychotropic prescriptions. We then used logistic regression analyses to calculate odds ratio and 95% confidence interval of characteristics that were independently different between the groups. Results Dually diagnosed veterans with MDD and AUD, relative to veterans with MDD alone, had a greater number of comorbid health conditions, such as liver disease, drug use disorders, and bipolar disorder as well as greater likelihood of homelessness and higher service utilization. Conclusions and Scientific Significance Dually diagnosed veterans with MDD and AUD had more frequent medical and psychiatric comorbidities and more frequently had been homeless. These data suggest the importance of assessing the presence of comorbid medical/psychiatric disorders and potential homelessness in order to provide appropriately comprehensive treatment to dually diagnosed veterans with MDD and AUD and indicate a need to develop more effective treatments for combined disorders. (Am J Addict 2015;24:419 –426)

Randomized Trial of the Effect of Four Second-Generation Antipsychotics and One First-Generation Antipsychotic on Cigarette Smoking, Alcohol, and Drug Use in Chronic Schizophrenia.

Abstract: No large-scale randomized trial has compared the effect of different second-generation antipsychotic drugs and any first-generation drug on alcohol, drug and nicotine use in patients with schizophrenia. The Clinical Antipsychotic Trial of Intervention Effectiveness study randomly assigned 1432 patients formally diagnosed with schizophrenia to four second-generation antipsychotic drugs (olanzapine, risperidone quetiapine, and ziprasidone) and one first-generation antipsychotic (perphenazine) and followed them for up to 18 months. Secondary outcome data documented cigarettes smoked in the past week and alcohol and drug use severity ratings. At baseline, 61% of patients smoked, 35% used alcohol, and 23% used illicit drugs. Although there were significant effects of time showing reduction in substance use over the 18 months (all p < 0.0001), this study found no evidence that any antipsychotic was robustly superior to any other in a secondary analysis of data on substance use outcomes from a large 18-month randomized schizophrenia trial.

A Comparison of Homeless Male Veterans in Metropolitan and Micropolitan Areas in Nebraska: A Methodological Caveat

Abstract: This study explored differences between homeless male veterans in metropolitan and micropolitan cities in Nebraska on sociodemographic, housing, clinical, and psychosocial characteristics as well as health service use A convenience sample of 151 homeless male veterans (112 metropolitan, 39 micropolitan) were recruited from Veterans Affairs facilities and area shelters in Omaha, Lincoln, Grand Island, and Hastings in Nebraska Research staff conducted structured interviews with homeless veterans Results showed that compared to homeless veterans in metropolitans, those in micropolitans were more likely to be White, unmarried, living in transitional settings, and were far more transient but reported greater social support and housing satisfaction Veterans in micropolitans also reported more medical problems, diagnoses of anxiety and personality disorders, and unexpectedly, were more likely to report using various health services and less travel time for services Together, these findings suggest access to homeless and health services for veterans in micropolitan areas may be facilitated through Veterans Affairs facilities and community providers that work in close proximity to one another Many homeless veterans in these areas are transient, making them a difficult population to study and serve Innovative ways to provide outreach to homeless veterans in micropolitan and more rural areas are needed

Implementing Computer-Based Psychotherapy Among Veterans in Outpatient Treatment for Substance Use Disorders

Abstract: Objective:Computer-based psychotherapy interventions (CBPIs) are increasingly offered as first-level access to evidence-based mental health treatment. However, their implementation has not been evaluated in public-sector outpatient settings.Methods:An evidence-based CBPI for insomnia was implemented with provider and patient education sessions, on-site Internet access, and clinician telephone support. Persons receiving care at a Veterans Health Administration substance abuse treatment clinic were screened for chronic insomnia and offered CBPI access. The feasibility of this strategy was evaluated in a pre-post design, which assessed engagement and completion rates, participant-reported acceptability, and clinical outcomes.Results:Of 100 veterans referred, 51 enrolled in the program, of whom 22 (43%) completed all sessions, 13 (26%) partially completed the program, and 16 (31%) did not engage. There were no statistically significant differences between these three groups in baseline characteristics. In the...

Characteristics and Use of Services Among Literally Homeless and Unstably Housed U.S. Veterans With Custody of Minor Children.

Abstract: Objective:The study examined the number of homeless veterans with minor children in their custody (“children in custody”), compared sociodemographic and clinical characteristics among homeless veterans with and without children in custody, and observed differences in referral and admission patterns among veterans with and without children in custody for a variety of U.S. Department of Veterans Affairs (VA) programs for homeless veterans.Methods:Data were obtained from the VA Homeless Operations Management and Evaluation System for 89,142 literally homeless and unstably housed veterans. Sociodemographic, housing, health, and psychosocial characteristics of veterans were analyzed.Results:Among literally homeless veterans, 9% of men and 30% of women had children in custody; among unstably housed veterans, 18% of men and 45% of women had children in custody. Both male and female veterans with children in custody were younger and less likely to have chronic general medical conditions and psychiatric disorders ...

Development of a checklist of short-term and long-term psychological symptoms associated with ketamine use.

Abstract: BACKGROUND: Ketamine is an increasingly popular drug of abuse in China but there is currently no method for classifying the psychological effects of ketamine in individuals with ketamine dependence. AIM: Develop a scale that characterizes the acute and long-term psychological effects of ketamine use among persons with ketamine dependence. METHODS: We developed a preliminary symptom checklist with 35 dichotomous ('yes' or 'no') items about subjective feelings immediately after ketamine use and about perceived long-term effects of ketamine use that was administered to 187 inpatients with ketamine dependence recruited from two large hospitals in Guangzhou, China. Exploratory factor analysis (EFA) was conducted on a randomly selected half of thesample to reduce the items and to identify underlying constructs. Confirmatory factor analysis (CFA) was conducted on the second half of the sample to assess the robustness of the identified factor structure. RESULTS: Among the 35 symptoms, the most-reported acute effects were 'floating or circling' (94%), 'euphoric when listening to rousing music' (86%), and 'feeling excited, talkative, and full of energy' (67%). The mostreported long-term symptoms were 'memory impairment' (93%), 'personality changes' (86%), and 'slowed reactions' (81%). EFA resulted in a final 22-item scale best modelled by a four-factor model: two factors representing chronic symptoms (social withdrawal and sleep disturbances), one about acute psychoticlike symptoms, and one that combined acute drug-related euphoria and longer-term decreased libido. CFA showed that these 4 factors accounted for 50% of the total variance of the final 22-item scale and that the model fit was fair (Goodness of Fit Index, GIF=83.3%; Root Mean Square Error of Approximation, RMSEA=0.072). CONCLUSION: A four-factor model including social withdrawal, sleep disturbance, psychotic-like symptoms, and euphoria at the time of drug use provides a fair description of the short-term and long-term psychological symptoms associated with ketamine use. Future work on the 22-item version of the scale with larger samples is needed to confirm the validity of this 4-factor structure, to assess the scale's test-retest reliability, and to determine whether or not it can be useful in the differential diagnosis and monitoring of treatment of individuals with ketamine dependence.

Is severity of family burden a correlate of length of stay

Abstract: It has been difficult to identify relevant correlates of inpatient psychiatric length of stay (LOS), but few have examined family burden as a potential factor. The present study investigated the association of several dimensions of family burden with LOS net of other factors. Dimensions of burden experienced by primary caregivers were evaluated in a sample of 602 psychiatric inpatients in a large hospital in Guangzhou, China within 1 week of admission. Factor analysis reduced the burden data to five factors. Bivariate association and multiple linear regression analyzes were used to investigate burden and other factors associated with LOS (average LOS=58.8 days, SD=44.3). Multiple regression analysis showed that in addition to having health insurance coverage, being diagnosed with schizophrenia, being unmarried, and not being employed; being perceived by family members as showing more violent behavior and causing higher levels of caregiver distress were independently associated with longer LOS.

Major depressive disorder in hemodialysis patients in China.

Abstract: Introduction Major depressive disorder (MDD) has been regarded as the most common psychiatric disorder among hemodialysis (HD) patients. However, few studies have investigated MDD in HD patients in Mainland China. This study sought to investigate the prevalence and treatment of MDD, as well as the sociodemographic and clinical characteristics in this population. Methods Two hundred sixty HD patients were screened with the nine-item Patient Health Questionnaire, and the formal diagnosis of MDD was further assessed using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Severity of depressive symptoms was assessed with Hamilton Rating Scale for Depression. Finally, patients meeting diagnostic criteria were compared with those who did not on demographic and clinical characteristics. Results Among the 260 subjects, 26.2% screened positively and 10% were confirmed to have a diagnosis of MDD. Among HD patients with MDD, 69.2% had severe or very severe depressive symptoms. There was no evidence of a clinical diagnosis or of treatment for MDD in any of the patients' medical records. Those with shorter duration of HD, lower monthly income, and lower levels of blood urea nitrogen were significantly more likely to have a diagnosis of MDD. Discussion MDD is frequent in HD patients. Regular screening and professional diagnosis should be undertaken to increase the detection and treatment of MDD in HD patients. The effectiveness of interventions for MDD in HD patients deserves further research.

VA Patients With High Numbers of Opioid Prescriptions: A National Study of Sociodemographic and Diagnostic Characteristics, Health Service, and Psychotropic Medication Use

Abstract: Background and Objectives:Prescription opioid use is a major public health concern, particularly among military personnel and veterans. This study used administrative data on Veterans Health Administration users to identify characteristics associated with high numbers of opioid prescriptions. Methods:Veterans Health Administration patients (n=5,300,000) who attended ≥1 outpatient visit during fiscal year 2010 were classified into 5 groups: no opioid prescriptions, 1 to 2, 3 to 10, 10 to 19, and >20 opioid prescriptions filled during the year. Bivariate comparisons and logistic regression were used to identify sociodemographic, diagnostic characteristics, health service, and psychotropic medication usage that differentiated the high opioid group (>20) from those who used none. Results:On bivariate analysis, the patients in the high opioid group (1% of sample) were more likely to be diagnosed with metastatic cancer, other medical illnesses, and various forms of pain, drug abuse, alcohol abuse, mood disorders, and anxiety. Psychotropic prescriptions were also associated with high opioid use. Logistic regression showed that drug abuse, depressive disorders, and dual diagnosis were independently associated with high prescription opioid use. Medical outpatient visits but not mental health or emergency room visits, and antidepressant prescriptions but not other psychotropics, were more independently associated with high opioid use. Service during the recent Middle East conflicts was associated with lower risk of high opioid use. Discussion and Conclusions:Drug use disorders, depression, and antidepressant medication prescriptions were independently associated with extensive opioid use. Providers should be attuned to high rates of comorbid drug use and depression and concomitant antidepressants among patients with high opioid prescription use.

Psychiatric Services and Prescription Fills Among Veterans With Serious Mental Illness in Methadone Maintenance Treatment

Abstract: Objective: Comorbidity and co-prescription patterns of people with serious mental illness in methadone maintenance may complicate their treatment and have not been studied The goal of this study was to examine the care and characteristics of people with serious mental illness in methadone maintenance treatment nationally in the Veterans Health Administration (VHA) Methods: Using national VHA data from FY2012, bivariate and multiple logistic regression analyses were used to compare veterans in methadone maintenance treatment wo had a serious mental illness (schizophrenia, bipolar disorder, or major affective disorder) to patients in methadone maintenance treatment without serious mental illness and patients with serious mental illness who were not in methadone maintenance treatment Results: Only a small fraction of patients with serious mental illness were receiving methadone maintenance treatment (065%), but a relatively large proportion in methadone maintenance treatment had a serious mental illness

Vietnam Veteran Perceptions of Delayed Onset and Awareness of Posttraumatic Stress Disorder

Abstract: Although 40 years have passed since the Vietnam War, demand for treatment of posttraumatic stress disorder (PTSD) among veterans from this conflict has increased steadily. This study investigates the extent to which two factors, delayed onset or awareness of PTSD symptoms, may influence this demand. Using data from two studies of Vietnam Veterans in outpatient (n = 353) and inpatient (n = 721) PTSD treatment, this analysis examines retrospective perceptions of the time of symptom onset and awareness of the connection between symptoms and war-zone stress. The association of these two constructs with pre-war, wartime, and post-war clinical variables are analyzed. Delay in onset of symptoms was reported by 50% of outpatients and 35% of inpatients. Delay in awareness was reported by 60% of outpatients and 65% of inpatients. Onset of symptoms occurred within six years and onset of awareness within 20 years in 90% of individuals. Reported delays in onset and awareness were associated with more numerous negative life events after military service and before the onset of symptoms. Findings suggest that providers, administrators, and policy makers should be aware of the potential for protracted treatment demand among veterans from current conflicts, due in part by delay in onset and awareness of symptoms.

Homeless Veterans Eligible for Medicaid Under the Affordable Care Act

Abstract: Objective:Among homeless veterans and those at risk of homelessness currently enrolled in Veterans Affairs (VA) health care, this study examined the proportion likely to become eligible for Medicaid in 2014 and their health needs.Methods:A total of 114,497 homeless and at-risk veterans were categorized into three groups: currently covered by Medicaid, likely to become eligible for Medicaid, and not likely.Results:Seventy-eight percent of the sample was determined to be likely to become eligible for Medicaid in states that expand Medicaid. Compared with veterans not likely to become eligible for Medicaid, those likely to become eligible were less likely to have general medical and psychiatric conditions and to have a VA service-connected disability but more likely to have substance use disorders.Conclusions:Programs serving homeless and at-risk veterans should anticipate the potential interplay between VA health care and the expansion of Medicaid in states that implement the expansion.

Brief Chinese version of the Family Experience Interview Schedule to assess caregiver burden of family members of individuals with mental disorders.

Abstract: BACKGROUND Caregiver burden is an important issue that needs to be addressed when developing management programs for persons with chronic mental illnesses, but there is, as yet, no reliable way for assessing this in China. AIM Assess the validity and reliability of a brief adapted Chinese version of the Family Experience Interview Schedule (FEIS) among caregivers of inpatients with mental disorders in China. METHODS We first translated and back-translated the original 114-item FEIS and administered it to 606 primary caregivers of psychiatric inpatients. After excluding 9 items about sociodemographic variables and 9 items that over 15% of respondents were unable to answer, we conducted an exploratory factor analysis using a random half of the sample on the remaining 96 items and, based on the results of the factor analysis, selected the items to be included in the final shortened scale. Correlation analysis, confirmatory factor analysis, and internal consistency measures were used to assess the reliability and validity of the final scale using data from the second half of the sample. RESULTS The final scale included 28 items that loaded on five dimensions: (a) patients' violent behavior; (b) patients' suicidal tendency; (c) caregivers' depression and anxiety; (d) disruption of caregivers' daily routines; and (e) caregivers' satisfaction with health services. These five dimensions explained 50.5% of the total variance. Confirmatory factor analysis found reasonable fit of this 5-factor model (χ (2) /df=2.94, p<0.001, goodness-of-fit index [GFI]=0.85, comparative fit index [CFI]=0.85, root-mean-square error of approximation [RMSEA]=0.08). The correlation coefficients between each item and the corresponding factor were all above 0.5. The Cronbach α coefficient of the entire scale was 0.76 and that for the five dimensions varied between 0.71 and 0.84. CONCLUSION The five dimensions of family burden assessed by the 28-item brief Chinese version of FEIS have good internal consistency and, thus, appear to assess valid dimensions of family burden in Chinese caregivers of persons with serious mental illnesses. Further work is needed to assess the test-retest reliability of this scale and its sensitivity to change over time.

The impact of missing data on the results of a schizophrenia study.

Abstract: Missing data pose a serious challenge to the integrity of randomized clinical trials, especially of treatments for prolonged illnesses such as schizophrenia, in which long-term impact assessment is of great importance, but the follow-up rates are often no more than 50%. Sensitivity analysis using Bayesian modeling for missing data offers a systematic approach to assessing the sensitivity of the inferences made on the basis of observed data. This paper uses data from an 18-month study of veterans with schizophrenia to demonstrate this approach. Data were obtained from a randomized clinical trial involving 369 patients diagnosed with schizophrenia that compared long-acting injectable risperidone with a psychiatrist's choice of oral treatment. Bayesian analysis utilizing a pattern-mixture modeling approach was used to validate the reported results by detecting bias due to non-random patterns of missing data. The analysis was applied to several outcomes including standard measures of schizophrenia symptoms, quality of life, alcohol use, and global mental status. The original study results for several measures were confirmed against a wide range of patterns of non-random missingness. Robustness of the conclusions was assessed using sensitivity parameters. The missing data in the trial did not likely threaten the validity of previously reported results. Copyright © 2014 John Wiley & Sons, Ltd.

Comparing Antipsychotic Treatments for Schizophrenia: A Health State Approach

Abstract: The overall impact of first and second generation antipsychotics on quality of life and symptoms of people with schizophrenia remains controversial. We applied health state modeling to data from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Schizophrenia study, a randomized trial of antipsychotic medications, and evaluated the likelihood of patients moving to more favorable health states over time. We applied K-means clustering to the data to create discrete groupings of patients with symptom and side effect characteristics that were then validated using quality of life measures. We compared cluster distributions across medications at baseline and 6 months after randomization. 1,049 patients were included in the initial cluster analysis. Five health states were identified: (1) low symptoms and low side effects (LS + LSE) (2) low symptoms and obesity (LS + Ob) (3) high symptoms and low side effects (HS + LSE) (4) high symptoms with depression and akathisia (HS + Dp + Ak) and (5) moderate symptoms and high side effects (MS + HSE). Six-month outcomes among patients randomly assigned to perphenazine, olanzapine, risperidone and quetiapine were compared. At baseline, almost 20% of patients were in the worst health state (HS + Dp + Ak), with greater decreases at 6 months in this health state for perphenazine (9.2% decrease) and olanzapine (11.1%) groups compared to risperidone (4.7%) and quetiapine (6.7%). This study demonstrated that health state analysis can provide insight into the overall clinical state of patients beyond the mere comparison of average scores and largely confirmed original CATIE findings.

VA Disability Compensation and Money Spent on Substance Use Among Homeless Veterans: A Controversial Association

Abstract: Objective:There has long been concern that public support payments are used to support addictive behaviors. This study examined the amount of money homeless veterans spend on alcohol and drugs and the association between public support income, including VA disability compensation, and expenditures on alcohol and drugs.Methods:Data were from 1,160 veterans from 19 sites on entry into the Housing and Urban Development–Veterans Affairs Supportive Housing program. Descriptive statistics and nonparametric analyses were conducted.Results:About 33% of veterans reported spending money on alcohol and 22% reported spending money on drugs in the past month. No significant association was found between public support income, VA disability compensation, and money spent on alcohol and drugs.Conclusions:A substantial proportion of homeless veterans spend some income on alcohol and drugs, but disability income, including VA compensation, does not seem to be related to substance use or money spent on addictive substances.