Gender related differences in clinical characteristics and hospital based resource utilization among older adults with schizophrenia

OBJECTIVE: This report is an analysis of gender related differences in clinical characteristics and hospital based health resource utilization among older adults with schizophrenia and schizoaffective disorder in an acute care, state hospital over a one-year period. METHODS: This retrospective record review is an analysis of age of illness onset, psychiatric and medical comorbidity, hospital utilization, and psychotropic medication use. RESULTS: There were a total of 66 individuals with either schizophrenia or schizoaffective disorder. Mean age of this group was 55.2 +/- 4.62 years. Women were significantly over-represented among individuals with late onset schizophrenia and schizoaffective disorder. Men with schizophrenia had more comorbid substance abuse compared to women with schizophrenia (p < 0.05). Women and men did not differ significantly in hospital length of stay, amount or type of antipsychotic medication prescribed, or in utilization of seclusion/restraint in hospital. Both genders had substantial utilization of antipsychotic medication. Use of conventional antipsychotic medication monotherapy was always associated with use of anti-extrapyramidal symptom (anti-EPS) medication, while use of atypical antipsychotic medication monotherapy was more rarely associated with use of anti-EPS medication. CONCLUSIONS: In later life, women and men may have some areas of differing health care needs. Women in particular may benefit from psychoeducational approaches that address the experience of psychiatric illness of relatively recent onset (for example, symptom identification and acceptance of illness). Men may benefit from particular emphasis on treatment of comorbid substance abuse disorders.     

Use of PASRR programs to assess serious mental illness and service access in nursing homes

OBJECTIVE: This study assessed the implementation of state Preadmission Screening and Resident Review (PASRR) programs with respect to identification of serious mental illness among nursing facility applicants and residents and access to mental health services. METHODS: A national survey was conducted with representatives from agencies that implement PASRR in all 50 states and the District of Columbia. Also, 44 states sent PASRR data for review. Four states were selected for an in-depth study; six nursing homes per state were selected and one staff member from each facility was interviewed (N=24). Medical records were reviewed for 30 to 40 residents from each facility who met criteria for potentially having a disabling serious mental illness (N=786). RESULTS: Medical records showed that 50 percent of patients at the time of admission and 68 percent of patients at the time of the record review had a psychiatric diagnosis, typically a diagnosis of depressive disorder. At the time of admission, fewer records identified individuals with a serious mental illness (9 to 20 percent) or a primary diagnosis of any psychiatric illness (5 to 12 percent). Many records indicated that in-depth, required PASRR screens were not performed. Ninety percent of the states reported that Medicaid covers only basic psychiatric consultation services, such as medication monitoring, in nursing facilities. Between 30 and 32 percent of national survey respondents also characterized access to facilities that provide mental health services as limited and of variable quality. Although all 24 nursing facilities reported providing psychiatric consultation services, access to other mental health services, such as psychosocial rehabilitation or individual counseling, varied considerably. CONCLUSIONS: Nursing facility compliance with administration and documentation of PASRR screens appears problematic. Nevertheless, there do not appear to be excessively high numbers of residents with serious mental illness, suggesting that state PASRR programs may contribute positively to the identification of people with serious mental illness. However, many nursing facility residents have some type of psychiatric illness, and PASRR legislation does not appear to have enhanced their ability to gain access to mental health services beyond standard psychiatric consultation and medication therapy.     

Homelessness among persons with serious mental illness in an enhanced community-based mental health system

OBJECTIVE: Homelessness and patterns of service use were examined among seriously mentally ill persons in an area with a well-funded community-based mental health system. METHODS: The sample consisted of 438 individuals referred between 1990 and 1992 to an extended acute care psychiatric hospital after a stay in a general hospital. Those experiencing an episode of homelessness, defined as an admission to a public shelter between 1990 and 1993, were compared with those who were residentially stable. Data from a longitudinal integrated database of public mental health and medical services were used to construct service utilization measures to test the mediating effect of outpatient mental health care on preventing homelessness. RESULTS: A homelessness rate of 24 percent was found among the 438 persons with serious mental illness. Those who experienced homelessness were more likely to be African American, receive general assistance, and have a comorbid substance abuse problem. They used significantly more inpatient psychiatric, emergency, and health care services than the subjects who did not become homeless. Forty to 50 percent of the homeless group received outpatient care during the year before and after their shelter episode. The number of persons who received intensive case management services increased after shelter admission. CONCLUSIONS: An enhanced community-based mental health system was not sufficient to prevent homelessness among high-risk persons with serious mental illness. Eleven percent of this group experienced homelessness after referral to an extended acute care facility. Strategies to prevent homelessness should be considered, perhaps at the time of discharge from the referring community hospital or extended acute care facility.     

Treatment of acute schizophrenia in open general medical wards in Jamaica

OBJECTIVE: The study assessed the efficacy of treating acute psychotic illness in open medical wards of general hospitals. METHODS: The sample consisted of 120 patients with schizophrenia whose first contact with a psychiatric service in Jamaica was in 1992 and who were treated as inpatients during the acute phase of their illness. Based on the geographic catchment area where they lived, patients were admitted to open medical wards in general hospitals, to psychiatric units in general hospitals, or to acute care wards in a custodial mental hospital. At first contact, patients' severity of illness was assessed, and sociodemographic variables, pathways to care, and legal status were determined. At discharge and for the subsequent 12 months, patients' outcomes were assessed by blinded observers using variables that included relapse, length of stay, employment status after discharge, and clinical status. RESULTS: More than half (53 percent) of the patients were admitted to the mental hospital, 28 percent to general hospital medical wards, and 19 percent to psychiatric units in general hospitals. The three groups did not differ significantly in geographic incidence rates, patterns of symptoms, and severity of psychosis. The mean length of stay was 90.9 days for patients in the mental hospital, 27.9 days in the general hospital psychiatric units, and 17.3 days in the general hospital medical wards. Clinical outcome variables were significantly better for patients treated in the general hospital medical wards than for those treated in the mental hospital, as were outpatient compliance and gainful employment. CONCLUSIONS: While allowing for possible differences in the three patient groups and the clinical settings, it appears that treatment in general hospital medical wards results in outcome that is at least equivalent to, and for some patients superior to, the outcome of treatment in conventional psychiatric facilities.     

Clinical characteristics and service use of persons with mental illness living in an intermediate care facility.

OBJECTIVE: The study examined the characteristics of residents living in a 450-bed intermediate care facility for persons with severe mental illness in Illinois and sought to determine the factors predicting their utilization of mental health services. METHODS: Data on 100 randomly selected residents with a chart diagnosis of schizophrenia were collected using chart review and interviews. Data for 78 residents whose diagnosis of schizophrenia or schizoaffective disorder was confirmed using the Structured Clinical Interview for DSM-IV were included in the analyses. RESULTS: Fifty-three percent of the residents used facility-based specialty mental health services beyond medication management, such as group therapy or a day program. Persons with the least severe psychiatric illnesses and with higher levels of motivation for overall care used the most mental health services. Thirty-five percent of the residents had been discharged to an inpatient psychiatric unit during the previous year. Residents most likely to be discharged to those settings were young men with a history of homelessness who refused facility-based health services. CONCLUSIONS: Despite recent policy-driven efforts to improve care in this intermediate care facility for persons with mental illness, the facility continues to have problems addressing the mental health needs of the residents.     

Use of inpatient psychiatric care at a VA medical center after implementation of a prospective payment system.

A retrospective audit of patients' utilization of inpatient psychiatric care at a Department of Veterans Affairs medical center before and after implementation of a prospective payment system compared patterns of utilization by chronic and nonchronic patients. It also examined changes over time in the size of the two groups, total number of bed days used, mean number of admissions, mean length of stay, and mean cumulative two-year length of stay. Four years after implementation of the prospective payment system, chronic patients constituted 3 percent of the patient population but used 15.2 percent of all bed days. Both chronic and nonchronic patients had a similar decrease in mean length of stay over the period, but chronic patients' mean number of admissions rose by more than 70 percent. The mean cumulative two-year length of stay of chronic patients remained stable over the period while that of the nonchronic patients decreased by 33.2 percent.     

Association between interruptions in medicaid coverage and use of inpatient psychiatric services

OBJECTIVES: Persons with schizophrenia are heavy and persistent users of Medicaid services. Interruptions in their Medicaid coverage may have serious consequences for the mental health of these individuals and their subsequent use of mental health services. This study sought to determine the impact of interruptions in Medicaid coverage on the use of Medicaid-reimbursed inpatient psychiatric services over a four-year period. METHODS: Inpatient Medicaid claims and eligibility files for 1,830 Medicaid beneficiaries with schizophrenia in Utah from December 1990 to December 1994 were used to identify differences in hospital admissions and total number of days in a hospital associated with interrupted Medicaid coverage. Of the 1,830 Medicaid beneficiaries identified, 1,463 experienced continuous Medicaid eligibility, and 367 had interruptions in their eligibility. RESULTS: Interruptions in Medicaid coverage were associated with an average of.63 more psychiatric hospitalizations per beneficiary over the four-year period, representing an 86 percent higher hospital admission rate. This increase appeared to be largely due to a subset of persons who have much higher hospitalization rates after an interruption in Medicaid coverage. Interruptions in Medicaid coverage were associated with a mean of 8.3 more days of psychiatric hospitalization over the four-year period, representing 61 percent more hospital days. CONCLUSIONS: Medicaid beneficiaries who experience interruptions in coverage have, on average, a significantly greater use of inpatient psychiatric services while participating in Medicaid than beneficiaries with continuous Medicaid coverage. These findings suggest potential benefits of maintaining continuous Medicaid eligibility for beneficiaries with a severe mental illness.     

Involvement in the child welfare system among mothers with serious mental illness

OBJECTIVE: This study sought to determine the association between maternal schizophrenia and major affective disorders (serious mental illness) and child custody arrangements in a sample of Medicaid-eligible mothers. METHODS: Medicaid eligibility and claims data were merged with data from the child welfare system in Philadelphia for 1995 to 2000. The sample comprised 4,827 female residents of Philadelphia between the ages of 15 and 45 as of 1996, who were initially eligible for Medicaid through Aid to Families With Dependent Children between 1995 and 1996 and who had at least one family member younger than 18 years at the beginning of the study period. Logistic regression was used to determine association between maternal mental illness and involvement in the child welfare system. RESULTS: Among the 4,827 mothers, 7.2 percent had a serious mental illness and 4.4 percent had other psychiatric diagnoses. More than 14 percent of mothers with serious mental illness received child welfare services, compared with 10.8 percent of those with other psychiatric diagnoses, and 4.2 percent of those without a diagnosis. After the analyses adjusted for a past inpatient episode, race or ethnicity, and age, mothers with serious mental illness were almost three times as likely to have had involvement in the child welfare system or to have children who had an out-of-home placement. CONCLUSIONS: The results suggest the urgent need for increased planning and coordination between the child welfare and mental health systems, including provision of parenting support as part of mental health treatment for mothers.     

Menopause-related quality of life in chronically mentally ill women

OBJECTIVE: Menopause is an important life event that has not yet been well characterized among women with severe mental illness. Our goal was to evaluate menopause-related quality of life among severely mentally ill women. METHOD: We conducted a cross-sectional assessment of perimenopausal and postmenopausal women, ages 45-55, diagnosed with schizophrenia/schizoaffective disorder, bipolar disorder, or major depression, who were receiving inpatient or outpatient psychiatric care. Women were compared regarding menopausal symptoms and quality of life using the Menopause Specific Quality of Life Scale (MENQOL). RESULTS: Women with severe mental illnesses who were peri- and post-menopausal experienced considerable vasomotor, physical, sexual, and psychosocial symptoms related to menopause. On seven of 29 MENQOL items, women with major depression reported problems significantly more often than women with other serious mental illnesses. CONCLUSIONS: This preliminary study indicates that psychiatrists and other physicians should consider the frequency and overlap of menopausal and psychiatric symptoms among women with serious mental illness in this age group.     

Feasibility,Acceptability, and Preliminary Effectiveness of a Peer-Delivered and Technology Supported Self-Management Intervention for Older Adults with Serious Mental Illness

To assess the feasibility, acceptability, and preliminary effectiveness of a peer-delivered and technology supported integrated medical and psychiatric self-management intervention for older adults with serious mental illness. Ten older adults with serious mental illness (i.e., schizophrenia, schizoaffective disorder, bipolar disorder, or major depressive disorder) and medical comorbidity (i.e., cardiovascular disease, obesity, diabetes, chronic obstructive pulmonary disease, hypertension, and/or high cholesterol) aged 60 years and older received the PeerTECH intervention in their homes. Three certified peer specialists were trained to deliver PeerTECH. Data were collected at baseline, one-month, and three-month. The pilot study demonstrated that a three-month, peer-delivered and technology-supported integrated medical and psychiatric self-management intervention (“PeerTECH”) was experienced by peer specialists and participants as feasible and acceptable. PeerTECH was associated with statistically significant improvements in psychiatric self-management. In addition, pre/post, non-statistically significant improvements were observed in self-efficacy for managing chronic health conditions, hope, quality of life, medical self-management skills, and empowerment. This pre/post pilot study demonstrated it is possible to train peers to use technology to deliver an integrated psychiatric and medical self-management intervention in a home-based setting to older adults with serious mental illness with fidelity. These findings provide preliminary evidence that a peer-delivered and technology-supported intervention designed to improve medical and psychiatric self-management is feasible, acceptable, and is potentially associated with improvements in psychiatric self-management, self-efficacy for managing chronic health conditions, hope, quality of life, medical self-management skills, and empowerment with older adults with serious mental illness and chronic health conditions.     

Utilization of Public Mental Health Services by Adults with Serious Mental Illness

Public mental health (MH) services were examined for non-elderly adults with serious mental illness (SMI) using a database combining information from Medicaid, MH, and substance abuse agencies in three states. These data show that between 23% and 39% of those with SMI received MH services only through Medicaid. Relative use of community versus state hospitals for delivery of psychiatric inpatient care varied across the three states. However, state hospitals accounted for a large proportion of total inpatient days, due to high mean annual days of care. In two states, Medicaid paid for fewer psychiatric inpatient days than expected.     

Co-occurrence of HIV and serious mental illness among Medicaid recipients

OBJECTIVE: The authors estimated the treated period prevalence of HIV infection in the Medicaid population and the rate of HIV infection among persons with serious mental illness in that population. METHODS: This cross-sectional study used Medicaid claims data and welfare recipient files for persons aged 18 years or older for fiscal years 1994 through 1996 in Philadelphia. Claims data were merged with welfare recipient files to calculate the treated period prevalence of serious mental illness, defined as a schizophrenia spectrum disorder or a major affective disorder, and HIV infection in the Medicaid population and the odds of receiving a diagnosis of HIV infection among those who had a diagnosis of serious mental illness. RESULTS: The treated period prevalence of HIV infection was.6 percent among Medicaid recipients who did not have a diagnosis of a serious mental illness and 1.8 percent among those who did. After sex, age, race, and time on welfare during the study period were controlled for, patients with a schizophrenia spectrum disorder were 1.5 times as likely to have a diagnosis of HIV infection, and patients with a diagnosis of a major affective disorder were 3.8 times as likely. CONCLUSIONS: The rate of HIV infection is significantly elevated among persons with serious mental illness. Further studies are needed to determine modes of transmission of HIV, special treatment needs, and effective strategies for reducing the risk of HIV infection.     

The impact of closing a state psychiatric hospital on the county mental health system and its clients.

OBJECTIVE: This three-year study examined the impact of closing a state psychiatric hospital in 1991 on service utilization patterns and related costs for clients with and without serious mental illness. METHODS: The cohort consisted of all individuals discharged from state hospitals and those diverted from inpatient to community services and enrolled in the unified systems project, a state-county initiative to build up the service capacity of the community system. The size of the cohort grew from 1,533 enrollees to 2,240 over the three years. Information on the types, amounts, and cost of all services received by each enrollee was compiled from multiple administrative databases, beginning two years before enrollment and for up to three years after. The data were analyzed to reveal patterns of and changes in service utilization and related costs. RESULTS: Replacement of most inpatient services with residential and ambulatory services resulted in significant cost reduction. For project enrollees, a 94 percent reduction in state hospital services resulted in cost savings of more than $45 million during the three-year evaluation period. These savings more than offset the funds used to expand community services. Overall, the net savings to the system for mental health services for this group was $3.4 million over three years. CONCLUSIONS: The hospital closure and infusion of funds into community services produced desired growth of those services. The project reduced reliance on state psychiatric hospitalization and demonstrated that persons with serious mental illness can be effectively treated and maintained in the community.     

Parental age and risk of schizophrenia: a case-control study

BACKGROUND: Advanced paternal age has been suggested as a possible risk factor for schizophrenia. It is not known whether this is explained by known risk factors for schizophrenia, including sibship characteristics, death of a parent before first hospital admission, season and place of birth, and family history of psychiatric illness, or by socioeconomic factors. We investigated the risk of schizophrenia associated with parental age, adjusting for known risk factors for schizophrenia, including family psychiatric history, and controlling for socioeconomic and demographic factors. METHODS: We performed a national population, nested, case-control study based on Danish longitudinal register data. The sample included 7704 patients with an ICD-8 or ICD-10 diagnosis of schizophrenia admitted to a psychiatric facility between 1981 and 1998 in Denmark, and 192 590 individually time-, age-, and sex-matched population controls, their parents, and siblings. The risk of schizophrenia associated with increasing parental age was investigated using conditional logistic regression and controlling for family socioeconomic and demographic factors and family psychiatric history. RESULTS: Advanced paternal and maternal age was associated with increased risk of schizophrenia in univariate analyses. Controlling for socioeconomic factors and family psychiatric history, increased risk of schizophrenia was identified in those with a paternal age of 50 years or older. Sex-specific analyses revealed that the risk of schizophrenia was increased for males with fathers 55 years or older (incidence rate ratio [IRR], 2.10; 95% confidence interval [CI], 1.35-3.28); for females, the risk associated with paternal age was substantial for fathers aged 50 to 54 years (IRR, 2.22; 95% CI, 1.44-3.44) and 55 years or older (IRR, 3.53; 95% CI, 1.82-6.83). CONCLUSION: Increased risk of schizophrenia was associated with advanced paternal age, particularly in females, lending support to the theory that de novo mutations, possibly X-linked, associated with increased parental age might be responsible for some cases of schizophrenia.     

Prevalence, severity, and co-occurrence of chronic physical health problems of persons with serious mental illness

OBJECTIVES: This study examined Medicaid claims forms to determine the prevalence, severity, and co-occurrence of physical illness within a representative sample of persons with serious mental illness (N=147). METHODS: Representativeness of health problems in the study sample was established through comparison with a larger sample of persons with serious mental illness enrolled in Medicaid within the same state. Standardized annual costs were then assigned to Medicaid claims diagnoses, and individual health problem severity was measured as the sum of estimated treatment costs for diagnosed conditions. RESULTS: Seventy-four percent of the study sample (N=109) had been given a diagnosis of at least one chronic health problem, and 50 percent (N=73) had been given a diagnosis of two or more chronic health problems. Of the 14 chronic health conditions surveyed, chronic pulmonary illness was the most prevalent (31 percent incidence) and the most comorbid. Persons with chronic pulmonary illness were second only to those with infectious diseases in average annual cost of treatment ($8,277). Also, 50 percent or more of participants in eight other diagnostic categories had chronic pulmonary illness. A regression analysis identified age, obesity, and substance use disorders as significant predictors of individual health problem severity. CONCLUSIONS: Risk adjustment for physical health is essential when setting performance standards or cost expectations for mental health treatment. Excluding persons with chronic health problems from mental health service evaluations restricts generalizability of research findings and may promote interventions that are inappropriate for many persons with serious mental illness.     

Predicting inpatient length of stay with the expanded version of the Brief Psychiatric Rating Scale (version 4.0)

This study examined whether assessment data from administration of the extended version of the Brief Psychiatric Rating Scale (BPRS-E) to state hospital patients within 72 hours of their admission could be used to predict length of hospital stay. BPRS-E data for 222 first-admission patients, for whom the mean length of stay was 118.4+/-88.6 days, were factor analyzed, yielding a model with four factors: patient's resistance to treatment, positive symptoms, mood, and negative symptoms. Discriminant analysis showed that the negative symptoms factor (blunted affect, emotional withdrawal, motor retardation, self-neglect, and disorientation) correctly predicted whether length of stay would exceed the mean in 94 percent of cases. The findings suggest that the severity of negative symptoms can be a useful predictor of length of stay among patients with severe and persistent mental illness.     

Clinical characteristics and length of hospital stay among older adults with bipolar disorder, schizophrenia or schizoaffective disorder, depression, and dementia

Although many older adults with serious psychiatric illnesses share common concerns, such as medical comorbidity, personal loss, greater propensity for adverse medication effects, and greater dependence on others for basic needs such as transportation, individualized treatment needs must be differentiated by underlying psychiatric disorders. This retrospective study evaluated clinical characteristics and resource use among 137 older adults with bipolar disorder, schizophrenia or schizoaffective disorder, depression, and dementia who were discharged from an urban, academic medical center's inpatient geropsychiatric unit. The authors found women to be significantly overrepresented among individuals with schizophrenia or schizoaffective disorder compared to those with bipolar disorder, depression, and dementia (P=.034). Among those with bipolar disorder, anticonvulsant medications were predominantly used as mood stabilizers, with only the rare use of lithium. Individuals with schizophrenia or schizoaffective disorder were the youngest group of patients; individuals with dementia were the oldest group (P<.001). This shows significant differences in clinical characteristics among hospitalized older adults with serious mental illnesses. Additional studies are needed on outcomes of serious chronic psychiatric illnesses in later life to optimize care environments for older adult psychiatric patients.     

Elevated cancer incidence among adults with serious mental illness

OBJECTIVE: Research is increasingly focusing on the health status of adults with serious mental illness. This study examined databases in Vermont to determine the incidence of cancer in this population. METHODS: Probabilistic statistical methods were used to determine the overlap between the Vermont Cancer Registry and Vermont mental health treatment databases. RESULTS: The incidence of cancer for adults with mental illness was 1.6 percent, more than twice (2.5 times) that of the general population. Among persons with mental illness, elevated risk was greatest for men younger than 50 years (6.6 times the risk of a comparable group in the general population) and lowest for women aged 50 years and older (1.8 times the risk of a comparable group). CONCLUSIONS: These findings raise important questions about the relationship between serious mental illness and cancer. Future research should consider the effect of lifestyle factors, and potential effects of first- and second-generation antipsychotics should be investigated.     

Use of claims data to examine the impact of length of inpatient psychiatric stay on readmission rate

OBJECTIVE: This study analyzed the impact of length of stay for inpatient treatment of psychiatric disorders on readmission rates. METHODS: Hospitalization data were obtained from the MarketScan data set collected by Medstat. The instrumental variable method, an econometric technique, was used to estimate the impact of length of stay on the rate of readmission for 5,735 persons who had at least one discharge with a primary diagnosis of a psychiatric disorder during 1997 and 1998. RESULTS: Decreasing length of stay below ten days led to an increase in the readmission rate during the 30 days after discharge. Decreasing the length of stay from seven to six days increased the expected readmission rate from.04 to.047 (17.5 percent), whereas decreasing length of stay from four to three days increased the readmission rate from.09 to.136 (51.1 percent). CONCLUSION: Decreasing length of stay for inpatient psychiatric treatment increased the readmission rate. The use of instrumental variables could help better estimate the value of mental health services when using observational data.