Showing papers in "Psychiatric Services in 2008"

Disparity in depression treatment among racial and ethnic minority populations in the United States.

Abstract: Objective: Prior work on racial/ethnic disparities in depression treatment has been limited by the scarcity of national samples that include an array of diagnostic and quality indicators and substantial non-English speaking minorities. Using nationally representative data (n=8762), we evaluate differences in access to and quality of depression treatments between ethnic/racial minority patients and non-Latino whites.

Pathways between internalized stigma and outcomes related to recovery in schizophrenia spectrum disorders.

Abstract: Objective: The mechanisms by which internalized stigma affects outcomes related to recovery among people with severe mental illness have yet to be explicitly studied. This study empirically evaluated a model for how internalized stigma affects important outcomes related to recovery. Methods: A total of 102 persons with schizophrenia spectrum disorders completed measures of internalized stigma, awareness of mental illness, psychiatric symptoms, self-esteem, hopefulness, and coping. Path analyses tested a predicted model and an alternative model for the relationships between the variables. Results: Results from model 1 supported the view that internalized stigma increases avoidant coping, active social avoidance, and depressive symptoms and that these relationships are mediated by the impact of internalized stigma on hope and self-esteem. Results from model 2 replicated significant relationships from model 1 but also supported the hypothesis that positive symptoms may influence hope and self-esteem. Conclusions: Findings from two models supported the hypothesis that internalized stigma affects hope and selfesteem, leading to negative outcomes related to recovery. It is recommended that interventions be developed and tested to address the important effects of internalized stigma on recovery. (Psychiatric Services 59:1437–1442, 2008)

Jail Incarceration, Homelessness, and Mental Health: A National Study

Abstract: Objective: This study sought to investigate the rates and correlates of homelessness, especially mental illness, among adult jail inmates. Methods: Data from a national survey of jail inmates (N=6,953) were used to compare the proportion of jail inmates who had been homeless in the previous year with the proportion of persons in the general population who had been homeless in the previous year, after standardization to the age, race and ethnicity, and gender distribution of the jail sample. Logistic regression was then used to examine the extent to which homelessness among jail inmates was associated with factors such as symptoms or treatment of mental illness, previous criminal justice involvement, specific recent crimes, and demographic characteristics. Results: Inmates who had been homeless (that is, those who reported an episode of homelessness anytime in the year before incarceration) made up 15.3% of the U.S. jail population, or 7.5 to 11.3 times the standardized estimate of 1.36% to 2.03% in the general U.S. adult population. In comparison with other inmates, those who had been homeless were more likely to be currently incarcerated for a property crime, but they were also more likely to have past criminal justice system involvement for both nonviolent and violent offenses, to have mental health and substance abuse problems, to be less educated, and to be unemployed. Conclusions: Recent homelessness was 7.5 to 11.3 times more common among jail inmates than in the general population. Homelessness and incarceration appear to increase the risk of each other, and these factors seem to be mediated by mental illness and substance abuse, as well as by disadvantageous sociodemographic characteristics. (Psychiatric Services 59:170–177, 2008)

Perpetration of Violence, Violent Victimization, and Severe Mental Illness : Balancing Public Health Concerns

Abstract: Objective: This review examined U.S. empirical studies published since 1990 of the perpetration of violence and of violent victimization among persons with severe mental illness and their relative importance as public health concerns. Methods: MEDLINE, PsycINFO, and Web of Science were searched for published empirical investigations of recent prevalence or incidence of perpetration or victimization among persons with severe mental illness. Studies of special populations were included if separate rates were reported for persons with and without severe mental illness. Results: The search yielded 31 studies of violence perpetration and ten studies of violent victimization. Few examined perpetration and victimization in the same sample. Prevalence rates varied by sample type and time frame (recall period). Half of the studies of perpetration examined inpatients; of these, about half sampled only committed inpatients, whose rates of perpetration (17%–50%) were higher than those of other samples. Among outpatients, 2% to 13% had perpetrated violence in the past six months to three years, compared with 20% to 34% who had been violently victimized. Studies combining outpatients and inpatients reported that 12% to 22% had perpetrated violence in the past six to 18 months, compared with 35% who had been a victim in the past year. Conclusions: Perpetration of violence and violent victimization are more common among persons with severe mental illness than in the general population. Victimization is a greater public health concern than perpetration. Ironically, the discipline’s focus on perpetration among inpatients may contribute to negative stereotypes. (Psychiatric Services 59:153–164, 2008)

Depression and anxiety in the United States: findings from the 2006 Behavioral Risk Factor Surveillance System.

Abstract: Objective: This study examined the unadjusted and adjusted prevalence estimates of depression and anxiety at the state level and examined the odds ratios of depression and anxiety for selected risk behaviors, obesity, and chronic diseases. Methods: The 2006 Behavioral Risk Factor Surveillance Survey, a random-digit-dialed telephone survey, collected depression and anxiety data from 217,379 participants in 38 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. Current depressive symptoms were assessed with the standardized and validated eight-item Patient Health Questionnaire, and lifetime diagnosis of depression and anxiety was assessed by two additional questions (one question for each diagnosis). Results: The overall prevalence of current depressive symptoms was 8.7% (range by state and territory, 5.3%–13.7%); of a lifetime diagnosis of depression, 15.7% (range, 6.8%–21.3%); and of a lifetime diagnosis of anxiety, 11.3% (range, 5.4%–17.2%). After sociodemographic characteristics, adverse health behaviors, and chronic illnesses were adjusted for, cardiovascular disease, diabetes, asthma, smoking, and obesity were all significantly associated with current depressive symptoms, a lifetime diagnosis of anxiety, and a lifetime diagnosis of depression. Physically inactive adults were significantly more likely than those who were physically active to have current depressive symptoms or a lifetime diagnosis of depression, whereas those who drank heavily were significantly more likely than those who did not to have current depressive symptoms or a lifetime diagnosis of anxiety. Conclusions: Depression and anxiety were strongly associated with common chronic medical disorders and adverse health behaviors. Examination of mental health should therefore be an integral component of overall health care. (Psychiatric Services 59:1383–1390, 2008)

Prevalence of Psychiatric Disorders Among Toronto Hospital Workers One to Two Years After the SARS Outbreak

Abstract: Objective: This study aimed to determine the incidence of psychiatric disorders among health care workers in Toronto in the one- to two-year period after the 2003 outbreak of severe acute respiratory syndrome (SARS) and to test predicted risk factors. Methods: New-onset episodes of psychiatric disorders were assessed among 139 health care workers by using the Structured Clinical Interview for DSM-IV and the Clinician-Administered PTSD Scale. Past history of psychiatric illness, years of health care experience, and the perception of adequate training and support were tested as predictors of the incidence of new-onset episodes of psychiatric disorders after the SARS outbreak. Results: The lifetime prevalence of any depressive, anxiety, or substance use diagnosis was 30%. Only one health care worker who identified the SARS experience as a traumatic event was diagnosed as having PTSD. New episodes of psychiatric disorders occurred among seven health care workers (5%). New episodes of psychiatric disorders were directly associated with a history of having a psychiatric disorder before the SARS outbreak (p=.02) and inversely associated with years of health care experience (p=.03) and the perceived adequacy of training and support (p=.03). Conclusions: Incidence of new episodes of psychiatric disorders after the SARS outbreak were similar to or lower than community incidence rates, which may indicate the resilience of health care workers who continued to work in hospitals one to two years after the SARS outbreak. In preparation for future events, such as pandemic influenza, training and support may bolster the resilience of health care workers who are at higher risk by virtue of their psychiatric history and fewer years of health care experience. (Psychiatric Services 59:91–95, 2008)

Perceived Stigma and Mental Health Care Seeking

Abstract: Objective: There is limited empirical evidence on the extent to which perceived public stigma prevents individuals from using mental health services, despite substantial recent policy interest in this issue. This study investigated associations between perceived public stigma and mental health care seeking. Methods: This study used cross-sectional survey data from a representative sample of undergraduate and graduate students (N=2,782) at one university. A five-item scale was used to assess perceived public stigma toward mental health service use. Perceived need for help in the past 12 months and current presence of depressive and anxiety disorders were also assessed. Results: Perceived stigma was higher among males, older students, Asian and Pacific Islanders, international students, students with lower socioeconomic status backgrounds, and students with current mental health problems. Perceived stigma was also higher among those without any family members or friends who had used mental health services and among those who believed that therapy or medication is not very helpful. Perceived stigma was negatively associated with the likelihood of perceiving a need for mental health services, but only among younger students. Among those with probable depressive or anxiety disorders, there was no evidence that perceived stigma was associated with service use. Conclusions: These results suggest that, at least in this population, perceived stigma may not be as important a barrier to mental health care as the mental health policy discourse currently assumes. (Psychiatric Services 59:392–399, 2008)

Mental Health Care Institutions in Nine European Countries, 2002 to 2006

Abstract: Objective: Although mental health reforms in the 20th century were characterized by deinstitutionalization, previous research suggested a new era of reinstitutionalization in six European countries between 1990 and 2002. This study aimed to establish whether there has been a trend in Europe toward more institutionalized care since 2002. Methods: Primary data sources were used to collect data on conventional inpatient beds, involuntary hospital admissions, forensic beds, places in residential care and supervised and supported housing, and the prison population in nine countries: Austria, Denmark, England, Germany, Republic of Ireland, Italy, the Netherlands, Spain, and Switzerland. Results: Between 2002 and 2006 the number of conventional psychiatric inpatient beds tended to fall and changes in involuntary admissions were inconsistent. The number of forensic beds, places in supervised and supported housing, and the prison population increased in most, but not all, of the countries studied. Conclusions: The findings suggest an ongoing although not consistent trend toward increasing provision of institutionalized mental health care across Europe.

The role of staff turnover in the implementation of evidence-based practices in mental health care

Abstract: Objectives: This study examined turnover rates of teams implementing psychosocial evidence-based practices in public-sector mental health settings. It also explored the relationship between turnover and implementation outcomes in an effort to understand whether practitioner perspectives on turnover are related to implementation outcomes. Methods: Team turnover was measured for 42 implementing teams participating in a national demonstration project examining implementation of five evidence-based practices between 2002 and 2005. Regression techniques were used to analyze the effects of team turnover on penetration and fidelity. Qualitative data collected throughout the project were blended with the quantitative data to examine the significance of team turnover to those attempting to implement the practices. Results: High team turnover was common (M±SD=81%±46%) and did not vary by practice. The 24-month turnover rate was inversely related to fidelity scores at 24 months (N=40, beta=–.005, p=.01). A negative trend was observed for penetration. Further analysis indicated that 71% of teams noted that turnover was a relevant factor in implementation. Conclusions: The behavioral health workforce remains in flux. High turnover most often had a negative impact on implementation, although some teams were able to use strategies to improve implementation through turnover. Implementation models must consider turbulent behavioral health workforce conditions. (Psychiatric Services 59:732–737, 2008)

Correlates of Adverse Childhood Experiences Among Adults With Severe Mood Disorders

Abstract: OBJECTIVES: Adverse childhood experiences have been found to be associated with poor physical and poor mental health, impaired functioning, and increased substance abuse in the general adult population. The purpose of this study was to examine the clinical correlates of these experiences among adults with severe mood disorders. METHODS: Adverse childhood experiences (including physical abuse, sexual abuse, parental mental illness, loss of parent, parental separation or divorce, witnessing domestic violence, and placement in foster or kinship care) were assessed retrospectively in a sample of 254 adults with major mood disorders. The relationships between cumulative exposure to these experiences and psychiatric problems, health, substance use disorders, community functioning, trauma exposure in adulthood, and high-risk behaviors were examined. RESULTS: Increased exposure to childhood adverse experiences was related to high-risk behaviors, diagnosis of a substance use disorder, exposure to trauma in adulthood, psychiatric problems (younger age at first hospitalization, number of suicide attempts, and diagnosis of posttraumatic stress disorder), medical service utilization, and homelessness. CONCLUSIONS: The findings extend research in the general population by suggesting that adverse childhood experiences contribute to worse mental and physical health and functional outcomes among adults with severe mood disorders. Language: en

Using computerized adaptive testing to reduce the burden of mental health assessment.

Abstract: Objective: This study investigated the combination of item response theory and computerized adaptive testing (CAT) for psychiatric measurement as a means of reducing the burden of research and clinical assessments. Methods: Data were from 800 participants in outpatient treatment for a mood or anxiety disorder; they completed 616 items of the 626-item Mood and Anxiety Spectrum Scales (MASS) at two times. The first administration was used to design and evaluate a CAT version of the MASS by using post hoc simulation. The second confirmed the functioning of CAT in live testing. Results: Tests of competing models based on item response theory supported the scale’s bifactor structure, consisting of a primary dimension and four group factors (mood, panic-agoraphobia, obsessive-compulsive, and social phobia). Both simulated and live CAT showed a 95% average reduction (585 items) in items administered (24 and 30 items, respectively) compared with administration of the full MASS. The correlation between scores on the full MASS and the CAT version was .93. For the mood disorder subscale, differences in scores between two groups of depressed patients—one with bipolar disorder and one without—on the full scale and on the CAT showed effect sizes of .63 (p<.003) and 1.19 (p<.001) standard deviation units, respectively, indicating better discriminant validity for CAT. Conclusions: Instead of using small fixed-length tests, clinicians can create item banks with a large item pool, and a small set of the items most relevant for a given individual can be administered with no loss of information, yielding a dramatic reduction in administration time and patient and clinician burden. (Psychiatric Services 59:361–368, 2008)

Best Practices: A Program to Support Shared Decision Making in an Outpatient Psychiatric Medication Clinic

Abstract: This column presents preliminary findings of an intervention to support shared decision making in psychopharmacology consultation. The waiting area in an urban psychiatric medication clinic was transformed into a peer-run Decision Support Center featuring a user-friendly, Internet-based software program with which clients could create a one-page computer-generated report for use in the medication consultation. The Decision Support Center was used 662 times by 189 unique users from a young-adult and general adult case management team from October 2006 to September 2007. All clients had severe mental disorders. Only ten clients refused to use the intervention at some point during the pilot study. Focus groups with medical staff (N=4), clients (N=16), case managers (N=14), and peer-specialist staff (N=3) reported that the intervention helped to create efficiencies in the consultation and empower clients to become more involved in treatment-related decision making. A randomized controlled trial is currently in process. (Psychiatric Services 59: 603–605, 2008)

Science and recovery in schizophrenia.

Abstract: Mental health advocates and policy makers are increasingly attuned to the importance of the recovery concept, and psychiatrists and neuroscientists increasingly emphasize the medical model and neurobiological mechanisms in relation to schizophrenia. Studies have shown that people with schizophrenia are tremendously heterogeneous in each domain of recovery, and the various domains of recovery are themselves relatively independent from one another. Studies have also shown that current interventions are effective for specific dimensions of the illness and functions, are usually ameliorative rather than curative, and are effective only for a proportion of patients. Hence, the authors suggest defining recovery in terms of improvements in specific domains rather than globally -- for example, "recovery of cognitive functioning" or "recovery of vocational functioning" -- to signify improvements in specific areas. This definition realistically emphasizes states of relative and partial recovery that patients can achieve in response to treatment. The emphasis on a range of improvements in specific areas should allow clinicians to communicate more clearly regarding the current findings and goals of treatment. The article also examines current research on various aspects of recovery, including the effects of treatment on pathophysiology, symptoms, cognitive impairments, quality of life, and self-agency. An operational definition of recovery allows for bridging hope and recovery with important advances in the science of the brain. Future clinical and neuroscience research and service development should emphasize measures of recovery as outcomes for people with schizophrenia.

Psychotropic medications for patients with bipolar disorder in the United States: polytherapy and adherence.

Abstract: Objective: Because treatments for bipolar disorder include a growing number of psychotropic agents, the authors evaluated psychotropic polytherapy and adherence to treatment among U.S. patients with bipolar disorder. Methods: National health plan claims data (2000–2004) were used to identify patients diagnosed as having bipolar disorder who had continuous benefits and had not been prescribed medication for bipolar disorder for six months or more. The study compared drugs dispensed to these patients initially and at one year and characterized patients who were adherent to mood-stabilizers. Results: A total of 7,406 patients had a bipolar disorder: bipolar I (55%), bipolar II (15%), or bipolar disorder not otherwise specified (30%). Women represented 57% of the sample; mean±SD age was 35.4±12.4 years. Initial prescription fills involved one psychotropic agent in 67% of patients, and two or more psychotropics (polytherapy) in 33%. Initial prescription drug selections involved: antidepressants > anticonvulsants ≥ antipsychotics > sedatives > lithium; initial mood stabilizer use ranked: valproate > lithium > carbamazepine or oxcarbazepine > lamotrigine; antipsychotics ranked: olanzapine > quetiapine ≥ risperidone > ziprasidone > aripiprazole > clozapine. Rankings were similar at one year, when only 31% of patients received monotherapy (a 2.2-fold decline), 32% received polytherapy, and 37% received no psychotropics. Initially patients received 1.42 psychotropic drugs per person; at one year, patients received 175, and at both times polytherapy was less likely with lithium than with anticonvulsants. In multivariate modeling, one-year mood stabilizer use was greater with the following: older age, type of mood stabilizer (lamotrigine > valproate > carbamazepine or oxcarbazepine > lithium) and was associated with more psychiatric office and emergency visits, clinician type (more common with psychiatrists than with primary care physicians), and nonuse of off-label anticonvulsants. Conclusions: Polytherapy was used by one-third of patients initially and at one year, antidepressant use was highly prevalent initially and later, but lack of treatment was prevalent at one year. Plausible clinical and treatment factors were associated with sustained mood stabilizer adherence. (Psychiatric Services 59:1175–1183, 2008)

Treatment Seeking Among Ontario Problem Gamblers: Results of a Population Survey

Abstract: Objective: This study examined help seeking for gambling concerns among people with different levels of gambling problems. Methods: Ontario adults who had gambled more than $100 (N=4,217) and who screened positive for a possible gambling problem (N= 1,205) were classified according to gambling problem severity and asked about their experiences with gambling treatment. Results: Only 6% of gamblers had ever accessed a service, including a self-help group or self-help materials. With self-help materials excluded, only 3% of gamblers (from 1% of those who met only the initial CLiP screening criteria to 53% of those with pathological gambling) had sought treatment for gambling. Conclusions: Few gamblers sought treatment for gambling problems; greater problem severity was associated with greater likelihood of using treatment, with self-help materials used most often. Further research is needed on why treatment seeking is low and on the effectiveness of self-help resources in reaching gamblers with problems in earlier stages. (Psychiatric Services 59:1343–1346, 2008)

Integrating Peer-Provided Services: A Quasi-experimental Study of Recovery Orientation, Confidence, and Empowerment

Abstract: Objective: Peer-provided mental health services have become increasingly prominent in recent years, despite a lack of evidence of beneficial impact. The study presented here compared the effectiveness of the Vet-toVet program, a peer education and support program, and standard care without peer support on measures of recovery orientation, confidence, and empowerment. Methods: Participants were recruited in two consecutive cohorts between 2002 and 2006, one before the implementation of the Vet-to-Vet program in June 2002 (cohort 1; N=78) and one after (cohort 2; N=218). Follow-up interviews were conducted at one, three, and nine months. There were few baseline differences between the cohorts. Intention-to-treat analyses compared cohorts on changes over time on measures of recovery orientation, confidence, and empowerment. A third cohort (cohort 2–V) was constructed that consisted of the subset of participants from the second cohort who directly participated in more than ten Vet-to-Vet sessions since the last research interview (N=102). Comparisons between this cohort and the first cohort constitute as-treated analyses. Results: In the intention-to-treat analyses, the Vet-to-Vet cohort scored significantly higher on measures of empowerment. In the as-treated analyses, significant differences favoring the Vet-to-Vet cohort were observed on both empowerment and confidence. Secondary analyses of clinical measures showed significant differences favoring the cohorts 2 and 2–V on measures of functioning and on alcohol use. Conclusions: These data suggest that participation in peer support may enhance personal well-being, as measured by both recovery-oriented and more traditional clinical measures. (Psychiatric Services 59:1307–1314, 2008)

Access to Medical Care Among Persons With Psychotic and Major Affective Disorders

Abstract: Objective People with serious mental illness have higher mortality rates than the general population, and this difference is not explained by such causes as suicide or accidents. This study therefore examined access and barriers to medical care among persons with serious mental illness. Methods Using a nationally representative sample, the authors examined access and barriers to medical care among individuals reporting psychotic and mood disorders. The National Health Interview Survey (NHIS) and NHIS-Disability Component for 1994 and 1995 were merged to provide a sample of 156,475 people over age 18. Individuals with psychotic disorders, bipolar disorder, or major depression were compared with persons without mental disorders on the following outcomes: having a primary care physician, being unable to get needed medical care, being unable to get a needed prescription medication, and delaying medical care because of cost. Results Persons with psychotic disorders (odds ratio [OR]=.55, 95% confidence interval [CI]=.44-.69) and bipolar disorder (OR=.74, CI=.56-.98) had significantly reduced odds of having a primary care physician compared with people without mental disorders. For any barriers to care, persons with psychotic disorders, bipolar disorder, or major depressive disorder had greatly increased odds (ORs=2.5-7.0) of reporting difficulties in accessing care. Conclusions Persons with psychotic disorders and bipolar disorder reported markedly more difficulty in obtaining a primary care physician and greater barriers to care than the general population. Interventions are needed to improve provision of primary medical care to this population.

A Typology of Advance Statements in Mental Health Care

Abstract: Advance statements documenting mental health service consumers’ preferences for treatment during a future mental health crisis or period of incapacity have gained currency in recent years in the United States and some European countries. Several kinds of advance statements have emerged—some as legal instruments, others as treatment planning methods—but no formal comparison has been made among them. This article reviews the literature in English and German to develop a comparative typology of advance statements: joint crisis plans, crisis cards, treatment plans, wellness recovery action plans, and psychiatric advance directives (with and without formal facilitation). The features that distinguish them are the extent to which they are legally binding, whether health care providers are involved in their production, and whether an independent facilitator assists in their production. The differing nature of advance statements is related to the diverse models of care upon which they are based and the legislative and service contexts in which they have been developed. However, there is recent convergence between the United Kingdom and the United States with respect to research interventions that facilitate the production of advance statements, as evidence emerges for the effectiveness of facilitated psychiatric advance directives and joint crisis plans. Different types of advance statements can coexist and in some cases may interact in complementary ways. However, the relationship of advance statements to involuntary treatment is more problematic, as is their effective implementation in many mental health service settings. (Psychiatric Services 59:63–71, 2008)

Rates and Risk Factors for Homelessness After Successful Housing in a Sample of Formerly Homeless Veterans

Abstract: Objective: Research suggests that subsidized housing combined with mental health services may be an effective intervention for successfully placing individuals who have a mental illness and a history of homelessness into community housing. However, there is limited longitudinal information available about the risk of loss of housing after a successful exit from homelessness. Methods: The study presented here examined the risk and predictors of returning to homelessness after successful housing in a sample of 392 formerly homeless veterans involved in an experimental trial of case management plus rent subsidy vouchers, case management only, or standard care. Results: Over the course of a fiveyear period, 44% of all participants experienced a period of homelessness for at least one day after successful placement into housing. Cox regression analysis found that participants in the case management plus voucher condition had significantly longer periods of continuous housing, compared with participants in the other two groups. Other predictors of decreased housing tenure were drug use and a diagnosis of posttraumatic stress disorder. Conclusions: Subsidized housing vouchers, combined with intensive case management, are advantageous both for facilitating the initial transition from homelessness to being housed and for reducing the risk of discontinuous housing, even among individuals with more severe substance abuse problems. (Psychiatric Services 59: 268–275, 2008)

Improving medical and psychiatric outcomes among individuals with bipolar disorder: a randomized controlled trial.

Abstract: Objectives: Comorbid medical conditions, notably cardiovascular disease, occur disproportionately among persons with bipolar disorder; yet the quality and outcomes of medical care for these individuals are suboptimal. This pilot study examined a bipolar disorder medical care model (BCM) and determined whether, compared with usual care, individuals randomly assigned to receive BCM care had improved medical and psychiatric outcomes. Methods: Persons with bipolar disorder and cardiovascular disease–related risk factors were recruited from a large Department of Veterans Affairs mental health facility and randomly assigned to receive BCM or usual care. BCM care consisted of four self-management sessions on bipolar disorder symptom control strategies, education and behavioral change related to cardiovascular disease risk factors, and promotion of provider engagement. Primary outcomes were physical and mental health–related quality of life; secondary outcomes included functioning and bipolar symptoms. Results: Fifty-eight persons participated. Twentyseven received BCM care, and 31 received usual care. The mean±SD age was 55±8 years, 9% were female, 90% were white, and 10% were African American. Repeated-measures analysis was used, and significant differences were observed between the two groups in change in scores from baseline to six months for the 12-Item Short-Form Health Survey (SF-12) subscale for physical health (t=2.01, df=173, p=.04), indicating that the usual care group experienced a decline in physical health over the study period. Change in SF-12 scores also indicated that compared with the usual care group, the BCM group showed improvements in mental health–related quality of life over the six-month study period; however, this finding was not significant. Conclusions: Compared with usual care, BCM care may have slowed the decline in physical health–related quality of life. Further studies are needed to determine whether BCM care leads to longterm positive changes in physical and mental health–related quality of life and reduced risk of cardiovascular disease among persons with bipolar disorder. (Psychiatric Services 59:760–768, 2008)

What CATIE found: results from the schizophrenia trial.

Abstract: The authors provide an overview of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) sponsored by the National Institute of Mental Health. CATIE was designed to compare a proxy first-generation antipsychotic, perphenazine, to several newer drugs. In phase 1 of the trial, consenting patients were randomly assigned to receive olanzapine, perphenazine, quetiapine, risperidone, or ziprasidone for up to 18 months on a double-blind basis. Patients with tardive dyskinesia were excluded from being randomly assigned to perphenazine and were assigned to one of the four second-generation antipsychotics in phase 1A. Clozapine was included in phase 2 of the study. Overall, olanzapine had the longest time to discontinuation in phase 1, but it was associated with significant weight and metabolic concerns. Perphenazine was not significantly different in overall effectiveness, compared with quetiapine, risperidone, and ziprasidone. Also, perphenazine was found to be the most cost-effective drug. Clozapine was confirmed as the most effective drug for individuals with a poor symptom response to previous antipsychotic drug trials, although clozapine was also associated with troublesome adverse effects. There were no differences in neurocognitive or psychosocial functioning in response to medications. Subsequent randomizations suggest that a poor response to an initial medication may mean that a different medication will be more effective or better tolerated. Although the CATIE results are controversial, they are broadly consistent with most previous antipsychotic drug trials and meta-analyses; however, the results may not generalize well to patients at high risk of tardive dyskinesia. Patient characteristics and clinical circumstances affected drug effectiveness; these patient factors are important in making treatment choices.