Incidence and consistency of antiretroviral use among HIV-infected medicaid beneficiaries with schizophrenia

OBJECTIVE: To investigate the incidence and consistency of antiretroviral (ARV) treatment in the period before the introduction of protease inhibitors among Medicaid beneficiaries in New Jersey who had both the human immunodeficiency virus (HIV) and schizophrenia. METHOD: HIV-infected Medicaid beneficiaries were identified using the HIV and acquired immunodeficiency syndrome (AIDS) registries for New Jersey; claims histories were used to identify patients diagnosed with ICD-9-CM schizophrenia and affective psychoses and to examine use of ARV drugs. RESULTS: Bivariate and multivariate analysis found no difference in the likelihood of receiving ARV drugs between patients with HIV and schizophrenia and HIV-infected patients without schizophrenia. However, once the therapy was initiated, patients with schizophrenia were more consistent users of ARV drugs. CONCLUSION: Results do not indicate that HIV-seropositive (HIV+) patients with schizophrenia are less adherent to HIV therapies than HIV+ patients without schizophrenia. In our study population, consistency of use was actually higher among HIV+ patients with schizophrenia, perhaps because their multiple diagnoses place them under closer medical scrutiny.     

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.     

Treatment for co-occurring mental and substance use disorders in five state Medicaid programs

OBJECTIVES: This study described the locations and patterns of psychiatric and substance abuse treatment for Medicaid beneficiaries with co-occurring mental and substance use disorders in five states. METHODS: Medicaid beneficiaries aged 21 to 65 with psychiatric or substance use disorders were identified with claims and encounter records. Groups were further divided into those with and those without a diagnosed substance use disorder. Adjusted odds of treatment in community-based settings, inpatient facilities, emergency departments, and hospital outpatient departments were calculated. RESULTS: A total of 92,355 persons had a psychiatric disorder, 34,158 had a substance use disorder, and 14,256 had co-occurring psychiatric and substance use disorders. In all five states, beneficiaries with severe mental illness (schizophrenia, bipolar disorder, or major depression) and a substance use disorder had higher odds of inpatient, emergency department, and hospital-based outpatient psychiatric treatment, compared with those with severe mental illness alone. In four of five states, both severe and less severe mental illness and a co-occurring substance use disorder were associated with lower odds of community-based treatment compared with those with the respective mental illness alone. Compared with those with less severe mental illness alone, individuals with less severe psychiatric disorders and a co-occurring substance use disorder had higher odds of inpatient treatment in all states and of emergency department use in three of five states. Odds of inpatient and outpatient hospital use and emergency department use for substance abuse treatment were higher for persons with severe mental illness and a co-occurring substance use disorder in most states, compared with odds for those with a substance use disorder alone. CONCLUSIONS: Heavy inpatient and emergency department use by Medicaid beneficiaries with co-occurring substance use disorders is a consistent cross-state problem. Co-occurring disorders may decrease the likelihood of community-based treatment for those with less severe mental disorders and for those with severe mental illness, suggesting that policies focusing only on these settings may miss a significant proportion of people with these co-occurring disorders.     

Understanding associations between serious mental illness and HIV among patients in the VA Health System

OBJECTIVE: This study compared the recorded prevalence of HIV among veterans with and without serious mental illness. METHODS: This cross-sectional study examined data from a national sample of veterans who received a diagnosis of serious mental illness (schizophrenia, bipolar disorder, and other, nonorganic psychoses) in fiscal year 2002 (FY2002) (N=191,625) and from a national random sample of veterans in FY2002 who did not receive serious mental illness diagnoses (N=67,965). Logistic regression was used to evaluate the recorded prevalence and predictors of HIV. RESULTS: HIV diagnoses were recorded for 1.0% of patients with serious mental illness and .5% of patients without serious mental illness. Multivariate analyses indicated that individuals with bipolar disorder were no more likely than those without serious mental illness to have a recorded HIV diagnosis (OR=1.08, CI=.93-1.24), whereas those with other psychoses were more likely to have one (OR=1.18, CI=1.01-1.38). An interaction was observed between schizophrenia and substance use disorder. Compared with patients who had neither schizophrenia nor a substance use disorder, those with schizophrenia without a substance use disorder were less likely to have a recorded HIV diagnosis (OR=.49, CI=.42-.58), whereas those with a substance use disorder were more likely to have a recorded HIV diagnosis (OR=1.22, CI=1.04-1.43). CONCLUSIONS: Despite the elevated crude recorded prevalence of HIV, multivariate analyses suggested that HIV-related risk factors underlie the associations between HIV and the serious mental illness diagnoses. For patients with schizophrenia, this study is the first to demonstrate reduced HIV risk in the absence of a substance use disorder.     

Use of general medical services among Medicaid patients with severe and persistent mental illness

OBJECTIVE: The aim of this study was to examine patterns of use of general medical services among persons with a severe and persistent mental illness enrolled in Medicaid from 1996 to 1998. METHODS: A total of 669 persons with a severe and persistent mental illness were identified by using statewide clinical criteria. A three-year database of Medicaid claims was developed to examine service use. The main outcome measures were use of outpatient services for a general medical problem, use of dental and vision services, and use of screening tests for women. Service use was examined by primary psychiatric diagnosis (schizophrenic, affective, paranoid, and anxiety disorders), and analyses controlled for the presence of a chronic medical condition, age, race, and sex. RESULTS: This study found high levels of service use for outpatient services but very low levels for primary and preventive services. Although 78 percent of persons with a schizophrenic disorder had an office-based visit during the three-year period, all persons with an anxiety disorder had such a visit. Sixty-nine percent of persons with a schizophrenic disorder had at least one emergency department visit, whereas 83 percent of those with an anxiety disorder had such a visit. Dental and vision visits and the use of mammograms and pap tests followed the same pattern; persons with a schizophrenic disorder had fewer visits and had less overall use than the other diagnostic groups. The use patterns across the four groups were significantly different in outpatient service use, dental and vision service use, and screening tests for women. Compared with persons with a schizophrenic disorder, those with an anxiety disorder were more likely to have had an office-based visit and to have received vision services, those with a paranoid disorder were more likely to have used dental services or received a mammogram, and those with an affective disorder were more likely to have had a pap test. CONCLUSION: Although this group of Medicaid patients with severe and persistent mental illness had access to providers, they received an unacceptably low level of preventive care. Use of health services for general medical problems differed somewhat by primary psychiatric illness.     

Cost of care for Medicaid recipients with serious mental illness and HIV infection or AIDS

OBJECTIVE: To assist in developing public policy about the feasibility of HIV prevention in community mental health settings, the cost of care was estimated for four groups of adults who were eligible to receive Medicaid: persons with serious mental illness and HIV infection or AIDS, persons with serious mental illness only, persons with HIV infection or AIDS only, and a control group without serious mental illness, HIV infection, or AIDS. METHODS: Claims records for adult participants in Medicaid fee-for-service systems in Philadelphia during 1996 (N=60,503) were used to identify diagnostic groups and to construct estimates of reimbursement costs by type of service for the year. The estimates included all outpatient and inpatient treatment costs per year per person and excluded pharmacy costs and the cost of nursing home care. Persons with severe mental illness, HIV infection, or AIDS had received those diagnoses between 1985 and 1996. RESULTS: Persons with comorbid serious mental illness and HIV infection or AIDS had the highest annual medical and behavioral health treatment expenditures (about $13,800 per person), followed by persons with HIV infection or AIDS only (annual expenditures of about $7,400 per person). Annual expenditures for persons with serious mental illness only were about $5,800 per person. The control group without serious mental illness, HIV infection, or AIDS had annual expenditures of about $1,800 per person. CONCLUSIONS: Given the high cost of treating persons with comorbid serious mental illness and HIV infection or AIDS, the integration of HIV prevention into ongoing case management for persons with serious mental illness who are at risk of infection may prove to be a cost-effective intervention strategy.     

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.     

Health care utilization by persons with severe and persistent mental illness

Claims for physical health care among 220 Medicaid enrollees with severe mental illness and 166 Medicaid enrollees who were not enrolled in the public mental health system were compared. Claims for the mentally ill group were 18 percent less than for the group without severe mental illness. Twenty-eight percent of claims for mentally ill patients were for treatment in emergency rooms and ambulances, compared with 11 percent for patients without mental illness; 26 percent of claims for patients without mental illness were for care in outpatient surgical and outpatient hospital settings, compared with 14 percent for mentally ill patients. Results suggest inefficient use of the health care system by mentally ill patients and highlight the need for coordination of care.     

Using drug claims data to assess the relationship of medication adherence with hospitalization and costs

OBJECTIVE: This naturalistic study used claims data to examine the relationship of medication nonadherence to hospital use and costs among severely mentally ill clients in Wisconsin. METHODS: Data for 619 clients were obtained from Medicaid drug and hospital claims, county records, and case managers as part of a larger study in eight county-based mental health systems. Study participants were eligible for Medicaid, had a severe and persistent mental illness, were 18 years or older, and were receiving neuroleptics, lithium, or antidepressants. Drug claims were analyzed for a 12-month period to determine how regularly clients obtained their medications. Regression analyses were used to assess the effects of irregular medication use on any hospitalization for psychiatric problems, the number of days hospitalized, and hospital costs. The analyses controlled for several risk factors. RESULTS: Among clients with schizophrenia or schizoaffective disorder, 31 percent used medications irregularly. The rates were 33 percent among those with bipolar disorder and 41 percent among those with other severe mental illnesses. In the total sample, irregular users had significantly higher rates of hospitalization than regular users (42 percent versus 20 percent), more hospital days (16 days versus four days), and higher hospital costs ($3,992 versus $1,048). Irregular medication use was one of the strongest predictors of hospital use and costs even after the analyses controlled for diagnosis, demographic characteristics, baseline functioning, and previous hospitalizations. CONCLUSIONS: The availability of drug claims data and the ability to use them in predictive analyses make them a potentially useful data source in studies of medication adherence among persons with severe mental illness.     

Use of antipsychotic medications among HIV-infected individuals with schizophrenia

Persons with schizophrenia face elevated risk of infection with HIV. While HIV therapy is demanding, patients diagnosed with both conditions also require appropriate and consistent management of their psychiatric illness, for the same reasons that generally apply to persons with schizophrenia and because untreated psychiatric illness can interfere with full participation in HIV care. This study examines the correlates of use of and persistence on antipsychotic medications among HIV-infected individuals with schizophrenia, using merged New Jersey HIV/AIDS surveillance data and paid Medicaid claims. Persistence was defined as at least 2 months of medication use in a quarter. We identified 350 individuals who were dually diagnosed with HIV and schizophrenia. Overall, 81% of these beneficiaries had at least one claim for an antipsychotic medication at some point between 1992 and 1998. Multivariate techniques were used, including simple logistic regressions on use and robust longitudinal regressions that controlled for repeated observations on the same individual and treatment gaps. Among users of antipsychotic medications, persistence was very low at 37%. Racial/ethnic minorities were less likely to receive atypical antipsychotic medications. Use of atypical antipsychotics was associated with higher persistence. Our study confirmed past findings of racial disparities in the receipt of atypical antipsychotic medications. Findings suggest that use of atypical medications may benefit individuals dually diagnosed with HIV and serious mental illness.     

Medication adherence and utilization in patients with schizophrenia or bipolar disorder receiving aripiprazole, quetiapine, or ziprasidone at hospital discharge: A retrospective cohort study

ABSTRACT: BACKGROUND: Schizophrenia and bipolar disorder are chronic debilitating disorders that are often treated with second-generation antipsychotic agents, such as aripiprazole, quetiapine, and ziprasidone. While patients who are hospitalized for schizophrenia and bipolar disorder often receive these agents at discharge, comparatively little information exists on subsequent patterns of pharmacotherapy. METHODS: Using a database linking hospital admission records to health insurance claims, we identified all patients hospitalized for schizophrenia (ICD-9-CM diagnosis code 295.XX) or bipolar disorder (296.0, 296.1, 296.4-296.89) between January 1, 2001 and September 30, 2008 who received aripiprazole, quetiapine, or ziprasidone at discharge. Patients not continuously enrolled for 6 months before and after hospitalization ("pre-admission" and "follow-up", respectively) were excluded. We examined patterns of use of these agents during follow-up, including adherence with treatment (using medication possession ratios [MPRs] and cumulative medication gaps [CMGs]) and therapy switching. Analyses were undertaken separately for patients with schizophrenia and bipolar disorder, respectively. RESULTS: We identified a total of 43 patients with schizophrenia, and 84 patients with bipolar disorder. During the 6-month period following hospitalization, patients with schizophrenia received an average of 101 therapy-days for the second-generation antipsychotic agent prescribed at discharge; for patients with bipolar disorder, the corresponding figure was 68 therapy-days. Mean MPR at 6 months was 55.1% for schizophrenia patients, and 37.3% for those with bipolar disorder; approximately one-quarter of patients switched to another agent over this period. CONCLUSIONS: Medication compliance is poor in patients with schizophrenia or bipolar disorder who initiate treatment with aripiprazole, quetiapine, or ziprasidone at hospital discharge.     

Accuracy of diagnoses of schizophrenia in Medicaid claims.

Medical insurance claims are increasingly important as a source of data in monitoring health care utilization and patient outcomes and in identifying patient cohorts for research. In a study that attempted to verify that those with Medicaid claims for treatment of schizophrenia did indeed have the disorder, two psychiatrists evaluated clinical information obtained from primary mental health care providers in relation to DSM-III-R criteria. The psychiatrists classified 86.8 percent of 319 patients with claims for treatment of schizophrenia and 27.5 percent of 156 patients with claims for treatment of other psychiatric diagnoses as definitely or probably having schizophrenia. The authors conclude that most diagnoses of schizophrenia listed on Medicaid claims are accurate, but that a substantial number of individuals with schizophrenia may not be identified by claims data.     

General-medical conditions in older patients with serious mental illness.

OBJECTIVE: The burden of medical comorbidities was compared between older (> or =60 years) and younger patients with serious mental illness. METHODS: Patients (N=8,083) diagnosed with schizophrenia, schizoaffective disorder, or bipolar disorder in 2001 were identified from VA facilities in the mid-Atlantic region. Medical comorbidities were identified by an ICD-9-based clinical classification algorithm. RESULTS: Older, versus younger, patients were more likely to be diagnosed with cardiovascular or pulmonary conditions, and less likely to be diagnosed with substance-use disorders or hepatic conditions. CONCLUSIONS: More aggressive detection and management of general-medical comorbidities in older patients with serious mental illness is paramount.     

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.     

Acute and transient psychotic disorder: a 1-year follow-up study

A study sample consisting of 51 patients suffering from acute and transient psychotic disorder (ATPD) (ICD-10) on initial examination was evaluated at 1-year follow-up. The findings show a diagnostic change in half of the patients (48%), most often to schizophrenia (15%) and affective disorder (28%). From index admission to follow-up, patients with an unchanged diagnosis of ATPD manage fairly well with regard to psychosocial functioning, and no deteriorating development is observed. In the majority of cases no personality disorder (PD) (ICD-10, 54%; DSM-IV, 71%) is apparent, and the ATPD is not related to any specific PD. With regard to diagnostic stability, no significant demographic, social or clinical predictors were found. The findings highlight the need for validation of the concept of ATPD, and point to the fact that brief psychotic episodes with an acute onset may be an early manifestation of severe mental disorder (schizophrenia and affective disorder).     

Medical morbidity,mental illness,and substance use disorders

OBJECTIVE: Previous research on the prevalence of medical disorders among adults with mental illness has been inconclusive. In general, studies have found higher rates among persons with mental illness, but these studies did not account for comorbid substance use disorders. The authors examined whether certain medical disorders are more prevalent among adults with severe mental illness and whether a comorbid substance use disorder increases prevalence beyond the effect of severe mental illness alone. METHODS: Administrative data from the Massachusetts Division of Medical Assistance were used in a cross-sectional observational study design. The sample consisted of 26,332 Medicaid beneficiaries 18 to 64 years of age. Of these, 11,185 had been treated for severe mental illness. Twelve-month prevalence rates were computed, and logistic regression was used to estimate the effect of a substance use disorder or another mental illness on the risk of having a medical disorder. RESULTS: Compared with Medicaid beneficiaries who were not treated for severe mental illness, those with severe mental illness had a significantly higher age- and gender-adjusted risk of the medical disorders considered in the study. Those with a comorbid substance use disorder had the highest risk for five of the disorders. CONCLUSIONS: The higher treated prevalence of certain medical disorders among adults with severe mental illness has three implications: substance use disorder is an important risk factor and requires early detection; integration of the treatment of medical disorders and severe mental illness should receive higher priority; and efforts should be made to develop specialized disease self-management techniques.