Externally caused deaths for adults with substance use and mental disorders

For decades, there have been reports of shorter life expectancy among those with mental illness, especially those with more serious psychiatric disorders. The purpose of this study was to compare the risk of mortality among Medicaid beneficiaries, aged 18–64 years, treated for mental illness to a comparable group who were not mentally ill and to the general population. The data used were from the Massachusetts Division of Medical Assistance and records of deaths from the Department of Public Health in Massachusetts. Individuals treated for both psychiatric illness and substance use disorders (dual diagnoses) were compared separately from those whose treatment was only for a psychiatric disorder. For all Medicaid beneficiaries, the most common causes of death were attributed to heart disease and cancer. When compared to the general population, adjusted odds ratios estimated death by injury to be twice as likely among the mentally ill when compared to the general population. Medicaid beneficiaries with dual diagnoses are 6–8 times more likely to die of injury, primarily poisoning, than their counterparts treated for medical conditions only.     

Persons with dual diagnoses of substance abuse and major mental illness: their excess costs of psychiatric care.

OBJECTIVES. This study examined the costs of psychiatric treatment for seriously mentally ill people with comorbid substance abuse as compared with mentally ill people not abusing substances. METHODS. Three different sources of data were used to construct client-level files to compare the patterns of care and expenditures of 16,395 psychiatrically disabled Medicaid beneficiaries with and without substance abuse: Massachusetts Medicaid paid claims; Department of Mental Health state hospital inpatient record files; and community support service client tracking files. RESULTS. Psychiatrically disabled substance abusers had psychiatric treatment costs that were almost 60% higher than those of nonabusers. Most of the cost difference was the result of more acute psychiatric inpatient treatment. CONCLUSIONS. Although the public health and financial costs of high rates of comorbidity are obvious, the solutions to these problems are not. Numerous bureaucratic and social obstacles must be overcome before programs for those with dual diagnoses can be tested for clinical effectiveness.     

An integrated, multidimensional treatment model for individuals living with HIV, mental illness, and substance abuse

The challenge of providing effective treatment services for the growing population of HIV-positive individuals who are also dually diagnosed with substance use and mental disorders has only recently been recognized as an important public health concern affecting both HIV treatment and prevention. This article describes a treatment model that was created for a study of integrated treatment for HIV-positive individuals with substance use and mental disorders. The treatment model was based on the transtheoretical model of behavior change as well as evidence-based practices that are widely used in the treatment of individuals dually diagnosed with substance use and mental disorders.The model involved collaboration between medical and behavioral health care professionals and emphasized the importance of goal reinforcement across disciplines. Furthermore, it included the development and enhancement of client motivation to modify medical and behavioral health-risk behaviors using individual readiness for change and offered comprehensive care addressing a continuum of client needs that may influence treatment outcomes. Treatment modalities included individual therapy, group therapy, and psychiatric medication management. This treatment intervention was associated with positive outcomes in the integrated treatment study and can be adapted for use in a variety of psychiatric or medical treatment settings.     

Are psychological disorders most prevalent among older adults? Examining the evidence

A persistent popular and professional perception is the high rate of psychological disorders among older adults (age 65+), especially higher than among younger adults. To examine the perception's accuracy, data from all psychiatric epidemiology studies conducted since 1950 with random community samples were reviewed. The studies were divided into categories according to type of disorder and instrument used. Prevalence rates were recalculated to compare those under 65 and over with those aged 65 and over. The review reveals that in none of the impairment categories do the preponderance of studies document more disorders among older than younger adults. In contrast, studies indicate more disorders reported by younger than older adults for depressive symptoms, major depression (clinical), and clinical affective disorders. While several methodological caveats are warranted, available data do not support the prevailing perception that psychological disorders are most prevalent among older adults. Despite these findings, future policies should consider older adults a high priority for outpatient mental health services. Older persons use disproportionately fewer outpatient services than other adults; over-utilization of primary care services occurs among all age groups, including older persons; and finally, the co-occurrence of psychological and physical disorders often results in elders' mental disorders not being recognized or treated appropriately in the primary care sector.     

Characteristics of older adults referred to a psychiatric emergency outreach service

Although older adults typically underutilize mental health services, problems associated with dementing illnesses, chronic medical illnesses, affective disorders, social isolation, and multiple medication use, among other phenomena, have increased referrals of the elderly to psychiatric emergency services. The present study reviewed characteristics of elderly adults referred to a psychiatric emergency outreach/screening service. Of all individuals for whom a referral was made, 24% were aged 60 or older. Among those older adults referred, 63% were seen by screening service personnel; 37% did not meet screening criteria or voluntarily sought mental health services. Diagnoses of individuals evaluated included dementia (27%), affective disorders (27%), schizophrenia (16%), psychosis (12%), alcohol abuse (7), and diagnosis deferred (11%). Findings highlight the limited options available for mental health care of the aged.     

Risk adjustment alternatives in paying for behavioral health care under Medicaid

OBJECTIVE: To compare the performance of various risk adjustment models in behavioral health applications such as setting mental health and substance abuse (MH/SA) capitation payments or overall capitation payments for populations including MH/SA users. DATA SOURCES/STUDY DESIGN: The 1991-93 administrative data from the Michigan Medicaid program were used. We compared mean absolute prediction error for several risk adjustment models and simulated the profits and losses that behavioral health care carve outs and integrated health plans would experience under risk adjustment if they enrolled beneficiaries with a history of MH/SA problems. Models included basic demographic adjustment, Adjusted Diagnostic Groups, Hierarchical Condition Categories, and specifications designed for behavioral health. PRINCIPAL FINDINGS: Differences in predictive ability among risk adjustment models were small and generally insignificant. Specifications based on relatively few MH/SA diagnostic categories did as well as or better than models controlling for additional variables such as medical diagnoses at predicting MH/SA expenditures among adults. Simulation analyses revealed that among both adults and minors considerable scope remained for behavioral health care carve outs to make profits or losses after risk adjustment based on differential enrollment of severely ill patients. Similarly, integrated health plans have strong financial incentives to avoid MH/SA users even after adjustment. CONCLUSIONS: Current risk adjustment methodologies do not eliminate the financial incentives for integrated health plans and behavioral health care carve-out plans to avoid high-utilizing patients with psychiatric disorders.     

Is there any correlation between psychiatric disease and the teaching profession?

BACKGROUND: Some professional categories are at risk for burnout due to job-related stressors. Burnout is characterized by physical and emotional exhaustion, apathy, cynical attitude, low personal accomplishment and reduced self-control. Several studies on occupational stress have demonstrated that burnout has a strong impact on certain professions and in particular on teachers. OBJECTIVES: The purpose of the study was to highlight and compare differences among clinical disorders diagnosed in four different classes of workers in the Public Administration sector, with particular focus on job-related and mental disorders. MATERIALS AND METHODS: Based on the data collected in 3,447 medical examinations, performed by the Milan Health District from January 1992 to December 2003, in order to assess work fitness, researchers compared four categories of state employees (teachers, clerks, health care professionals and blue collars). RESULTS: The findings revealed that the risk of teachers to develop psychiatric disorders is 2-, 2.5-, and 3-fold higher than that of clerks, health care professionals and blue collars, respectively. Age or sex did not represent a confounding factor for increased rate of psychiatric disorders. Interestingly, teachers also presented an approximately 1.5-2 fold higher risk of developing neoplasms, compared with clerks and blue collars. CONCLUSIONS: The increased prevalence of psychiatric disorders among teachers that was detected in this cohort of state employees applying for a disability pension is striking and warrants further investigation. This finding points to the need for job-related interventions aimed at preventing teachers' psychiatric disorders, a multidimensional issue which requires active debate among institutions, unions, school authorities, the scientific community, professional associations and, last but not least, students and their families.     

Cost of schizophrenia: direct costs and use of resources in the State of São Paulo

OBJECTIVE: To estimate the direct costs of schizophrenia for the public sector. METHODS: A study was carried out in the state of S?o Paulo, Brazil, during 1998. Data from the medical literature and governmental research bodies were gathered for estimating the total number of schizophrenia patients covered by the Brazilian Unified Health System. A decision tree was built based on an estimated distribution of patients under different types of psychiatric care. Medical charts from public hospitals and outpatient services were used to estimate the resources used over a one-year period. Direct costs were calculated by attributing monetary values for each resource used. RESULTS: Of all patients, 81.5% were covered by the public sector and distributed as follows: 6.0% in psychiatric hospital admissions, 23.0% in outpatient care, and 71.0% without regular treatment. The total direct cost of schizophrenia was US $191,781,327 (2.2% of the total health care expenditure in the state). Of this total, 11.0% was spent on outpatient care and 79.2% went for inpatient care. CONCLUSIONS: Most schizophrenia patients in the state of S?o Paulo receive no regular treatment. The study findings point out to the importance of investing in research aimed at improving the resource allocation for the treatment of mental disorders in Brazil.     

Psychiatric symptoms and substance use disorders in a nationally representative sample of American adolescents involved with foster care

PurposeTo ascertain the prevalence of psychiatric symptoms and substance use disorders among adolescents with a lifetime history of foster care placement, using data from a nationally representative sample of U.S. adolescents.MethodsWe studied adolescents aged 12–17 years in the public use file of the 2000 National Household on Drug Abuse (n = 19,430, including 464 adolescents with history of foster care placement). Psychiatric symptoms and substance use disorders were ascertained through direct interviewing of adolescents. Logistic regression analyses were used to estimate the odds of past-year psychiatric symptoms and substance use disorders among adolescents involved with foster care, as compared to those without a lifetime history of foster care placement (comparison group).ResultsAdolescents involved with foster care had more past-year psychiatric symptoms, and especially more conduct symptoms, and past-year substance use disorders than those never placed in foster care. Adolescents involved with foster care were about four times more likely to have attempted suicide in the preceding 12 months (adjusted odds ratio [AOR] 3.95; 95% confidence interval [CI] 2.78, 5.61), and about five times more likely to receive a drug dependence diagnosis in the same period (AOR 4.81; 95% CI 3.22, 7.18).ConclusionsAdolescents involved with foster care have a higher prevalence of psychiatric symptoms and drug use disorders than those never placed in foster care. Additionally, the results of this study suggest that they may be at elevated risk for suicide attempts.     

Shelter-based convalescence for homeless adults

OBJECTIVES: Homelessness is associated with increased hospital costs and length of stay, and medical or surgical conditions are typically complicated by secondary diagnoses of substance abuse or mental illness. Convalescence care to provide timely treatment has not been analyzed. This is a retrospective study of diagnoses and utility of shelter-based convalescence in a cohort of homeless subjects. METHODS: A 20-bed shelter-based unit providing up to 3 months stay post hospital discharge, or for treatment of addictions or for those too ill to remain in the general shelter was studied. Charting was by the use of an electronic health record developed for the project. Demographics, reason for admission and outcomes are retrospectively described. RESULTS: 140 men had 181 admissions from July 2000-April 2003; 23.8% were post hospital discharge, 57.4% were from the general shelter. Average length of stay was 40 days. 83.4% were treated for a medical or surgical condition, 83.6% for psychiatric disease and 29.8% for addictions. Medication adherence was >80% in the majority. During admission, 20% obtained a new health card, 43.6% a new drug card, 89.3% received transportation to appointments, 60% applied for housing and 24.3% obtained housing. CONCLUSION: A shelter-based convalescence unit can provide health care to homeless persons, treat medical and mental illness, ensure adherence to treatment regimes, decrease substance abuse and assist with housing.     

Psychiatric diagnoses of medical service users: evidence from the Epidemiologic Catchment Area Program.

Based on data from the five sites of the National Institute of Mental Health-sponsored Epidemiologic Catchment Area (ECA) Program, this paper examines the prevalence of psychiatric disorder among recent medical service users versus nonusers, with a particular focus on affective disorders, substance abuse/dependence, and phobias. The rate of current Diagnostic Interview Schedule (DIS) disorders among medical users in all five ECA sites is 21.7 per cent (slightly higher than general population rates) versus 16.7 per cent among nonusers; there is generally no difference between users and nonusers with past DIS diagnoses. Affective disorders were among the most common mental disorders of medical service users, especially among females, with little variation between sites: females: users: 6.9 per cent to 9.3 per cent, nonusers: 3.4 per cent to 6.4 per cent, and males: users: 3.3 per cent to 6.5 per cent, nonusers: 1.2 per cent to 4.1 per cent. Rates of phobias among persons using medical services are also higher than among nonusers. Substance abuse disorders are at least as common among persons who use medical services (8 per cent to 14 per cent of male users) as among those who do not (9 per cent to 11 per cent of male nonusers). The high rates of affective disorders among women and of substance abuse among male medical service users underscore the need to increase the ability of general medical practitioners to recognize and manage or refer these conditions.     

The effects of homelessness on Veterans' health care service use: an evaluation of independence from comorbidities

ObjectivesThis study evaluates the prevalence of Multiple Comorbid Chronic Disease (MCCD) within homeless and non-homeless Veterans and the association between MCCD and inpatient medical care.MethodsAll individuals seen in the VA North Texas Health Care System between October 1, 2009 and September 30, 2010 (n = 102,034) were evaluated. Homelessness during the year and the number of common chronic diseases were evaluated for an association with likelihood of medical and psychiatric hospitalizations, bed days of care, inpatient substance treatment, rehabilitation admissions, and emergency department visits.ResultsHomeless Veterans had higher all-cause mortality rates and rates of use of almost all resources after controlling for chronic disease burden using the Charlson Comorbidity Index, psychiatric illnesses, substance use disorders, and demographic variables.ConclusionsHomelessness Veterans are vulnerable to a high use of resources and mortality, independent of medical and psychiatric conditions. This finding should focus additional attention on reducing homelessness.     

Impulsive-aggressive traits and suicidal adolescents and young adults with alcoholism

Suicidal behavior and alcohol use disorders among adolescents and young adults are serious public health problems. In the study of suicidal behavior among young people with alcoholism, it has been shown that aggression and impulsivity are higher among those who attempted suicide. Impulsivity has been related to suicidal and self-destructive behaviors within different psychiatric conditions, i.e. alcohol and substance use disorders, mood disorders, conduct disorder, impulse control disorders, antisocial personality disorder, and borderline personality disorder. The term impulsivity has been used to define different constructs such as (1) personality trait or cognitive style in which disinhibition is the core characteristic, (2) a tendency to act immediately in response to external or internal stimuli, and (3) a group of psychiatric disorders with behavioral dyscontrol. Among adolescents suicidal behavior is transmitted in families independently of psychiatric conditions, but not independently of impulsivity/aggression. Two causal links between impulsiveness and alcoholism have been proposed: (1) adolescents who develop alcoholism possess higher premorbid levels of impulsiveness than those who do not develop alcoholism, and (2) levels of impulsiveness differentiate both populations only after the development of alcoholism, with higher levels of impulsiveness among those adolescents who developed alcoholism. Cognitive behavioral techniques have shown promising results in the treatment of adolescents with alcohol and substance use disorder and suicidality. The relative frequency of suicidal behavior among adolescents and young adults suffering from alcoholism and its subsequent devastating effects on individuals, families and society merits further research and development of prevention strategies.     

Psychiatric morbidity, service use, and need for care in the general population: results of The Netherlands Mental Health Survey and Incidence Study

OBJECTIVES: This study examined the use of primary health care, mental health care, and informal care services, as well as unmet care needs, by individuals with different psychiatric diagnoses. METHODS: Data were derived from the Netherlands Mental Health Survey and Incidence Study and were based on a representative sample (n = 7147) of the general population (aged 18-64 years). RESULTS: In a 12-month period, 33.9% of those with a psychiatric disorder used some form of care; 27.2% used primary care, and 15.3% used mental health care. Patients with mood disorders were the most likely to enlist professional care; those with alcohol- and drug-related disorders were the least likely to do so. Higher educated persons who live alone, single parents, unemployed persons, and disabled persons were more likely to use mental health care. Unmet need for professional help was reported by 16.8% (men 9.9%, women 23.9%) of those with a disorder. CONCLUSIONS: Care use varies widely by diagnostic category. The role of general medical practitioners in treating persons with psychiatric disorders is more limited than was anticipated. Patients in categories associated with extensive use of professional care are more likely to have unmet care needs.     

Chronic Medical Conditions among Jail Detainees in Residential Psychiatric Treatment: A Latent Class Analysis

Studies of incarcerates with serious mental illnesses have found elevated rates of chronic medical conditions such as asthma and diabetes, and of infectious diseases such as tuberculosis compared with general population rates. This study explored the pattern of chronic medical conditions in a sample of adult detainees in psychiatric treatment in a large urban jail to develop a clinical profile encompassing the full range of medical conditions. A total of 431 male and female detainees were sampled with certainty from admissions to a residential psychiatric treatment program (overall recruitment rate = 67%). Interviews used the World Mental Health version of the Composite International Diagnostic Interview to assess psychiatric and substance use disorders per DSM-IV criteria and chronic medical conditions. Latent class analysis was conducted using 17 medical conditions as class indicators, yielding a 3-class model composed of: a latent class with a high to intermediate probability of multiple medical conditions (HMC; 12.5% of the sample); an intermediate class with a lower probability of having a smaller number of medical conditions (MMC; 43.2%); and a class with a low probability of any medical condition (44.3%). Those in the HMC class were more likely to report respiratory problems, severe headaches, musculoskeletal pain, hypertension, and arthritis, have greater functional impairment, and have a higher number of co-occurring psychiatric disorders. Being older (50+ years) and female were associated with higher odds of being in the HMC or MMC classes. The policy implications for providing medical care to incarcerates with complex mixtures of medical conditions and psychiatric disorders are considered.     

Arrest Types and Co-occurring Disorders in Persons with Schizophrenia or Related Psychoses

This study examined the patterns of criminal arrest and co-occurring psychiatric disorders among individuals with schizophrenia or related psychosis that were receiving public mental health services and had an arrest history. Within a 10-year period, 65% of subjects were arrested for crimes against public order, 50% for serious violent crimes, and 45% for property crimes. The presence of any co-occurring disorder increased the risk of arrest for all offense categories. For nearly all offense types, antisocial personality disorder and substance use disorders conferred the greatest increase in risk for arrest. Among anxiety disorders, post-traumatic stress disorder was associated with a greater risk of arrest for serious violent crimes but not other offense types. Criminal risk assessments and clinical management in this population should focus on co-occurring antisocial personality disorder and substance use disorders in addition to other clinical and non-clinical factors.     

The patient health questionnaire for adolescents: validation of an instrument for the assessment of mental disorders among adolescent primary care patients.

PURPOSE: To investigate the validity of the Patient Health Questionnaire for Adolescents (PHQ-A), a self-administered instrument that assesses anxiety, eating, mood, and substance use disorders among adolescent primary care patients. METHODS: A total of 403 adolescents from California, New Jersey, New York, and Ohio completed the PHQ-A and the Medical Outcomes Study Short-Form General Health Survey (SF-20) during or shortly after a visit to a primary care clinic or a school nurse's office. A few days later, clinical psychologists who were blind to the results of the PHQ-A administered a semi-structured clinical interview to assess the same psychiatric disorders and to conduct a global assessment of functioning (GAF) among 403 patients. Diagnostic agreement coefficients were computed and analyses of covariance were conducted. RESULTS: Findings support the diagnostic validity of the PHQ-A. The PHQ-A and the clinical interview produced similar estimates of the prevalence rates of anxiety, eating, mood, and substance use disorders. The PHQ-A demonstrated satisfactory sensitivity, specificity, diagnostic agreement, and overall diagnostic accuracy, compared with the clinical interview. Adolescents with PHQ-A diagnoses experienced significantly poorer mental and overall functioning, more physical pain, and poorer overall health compared with those without psychiatric disorders. These differences remained significant after patients' age, gender, ethnicity, and site were controlled statistically. CONCLUSION: The PHQ-A may be used to assist primary care practitioners in identifying psychiatric disorders among their adolescent patients. The PHQ-A is the first such tool to be tested for use in adolescents and offers an acceptable and efficient tool for early detection and recognition of mental disorders in this high-risk group.