Diabetes treatment among VA patients with comorbid serious mental illness

OBJECTIVE: Patients with serious mental illnesses, such as schizophrenia, bipolar disorder, and other psychoses, may be less likely to receive adequate care for chronic medical conditions than patients without serious mental illness. The quality and outcomes of diabetes care were compared in an observational study among patients with and without serious mental illness. METHODS: National data were studied for 36,546 individuals receiving care within the U.S. Department of Veterans Affairs (VA) health care system. Widely used diabetes quality-of-care measures and intermediate outcomes were compared for patients with diabetes and serious mental illness and age-matched patients with diabetes who did not have a serious mental illness. Patients' use of health services was also examined. RESULTS: During fiscal year 1998, patients with diabetes and serious mental illness were as likely as patients with diabetes alone to have their hemoglobin A1c, low-density lipoproteins (LDL), and cholesterol measured; both groups had comparable A1c, LDL, and cholesterol values. Patients with diabetes and serious mental illness had more outpatient visits, both primary care and specialty visits, and made more multiclinic visits, including visits to both primary care and mental health services on the same day. CONCLUSIONS: In the VA, patients with diabetes and serious mental illness appear to receive diabetes care that is comparable with the care that other patients with diabetes receive, possibly because of increased levels of contact with the health system and the VA's integration of medical and mental health services.     

Access to HAART and utilization of inpatient medical hospital services among HIV-infected patients with co-occurring serious mental illness and injection drug use

OBJECTIVE: Among HIV-infected individuals, we examined whether having co-occurring serious mental illness (SMI) and injection drug use (IDU) impacts: (a) receipt of highly active antiretroviral therapy (HAART), and (b) utilization of inpatient HIV services, compared to those who have SMI only, IDU only or neither SMI nor IDU. METHOD: Demographic, clinical and resource utilization data were collected from medical records of 5119 patients in HIV primary care at four US HIV care sites in different geographic regions with on-site mental health services in 2001. We analyzed receipt of HAART using multivariate logistic regression and the number of medical hospital admissions using multivariate logistic and Poisson regression analyses, which controlled for demographic factors, receipt of HAART, CD4 count and HIV-1 RNA. RESULTS: Those with co-occurring SMI and IDU [adjusted odds ratio (AOR)=0.52; 95% confidence interval (95% CI)=0.41-0.81] and those with IDU alone (AOR=0.64; 95% CI=0.58-0.85) were significantly less likely to receive HAART than those with neither SMI nor IDU, controlling for demographic and clinical factors. Those with co-occurring SMI and IDU were more likely to use any inpatient medical services (AOR=2.22; 95% CI=1.64-3.01) and were significantly more likely to use them more frequently (incidence rate ratio=1.33; 95% CI=1.13-1.55) than those with neither SMI nor IDU, SMI only or IDU only. CONCLUSION: HIV-infected individuals with co-occurring SMI and IDU are significantly more likely to utilize HIV-related medical inpatient services than individuals with no comorbidity or with only one comorbidity. Individuals with both SMI and IDU did not differ from those with IDU only in receipt of HAART. Inpatient hospitalizations are expensive, and efforts should be targeted towards these populations to reduce potentially avoidable inpatient care.     

Mental disorders and quality of diabetes care in the veterans health administration

OBJECTIVE: The population of persons with mental disorders is potentially vulnerable to poor quality of medical care. This study examined the relationship between mental disorders and quality of diabetes care in a national sample of veterans. METHOD: Chart-abstracted quality data were merged with outpatient and inpatient administrative database records for a sample of veterans with diabetes who had at least three outpatient visits in the previous year (N=38,020). Mental health diagnoses were identified by use of the administrative data. Quality of diabetes care was assessed with five indicators by chart documentation: annual foot inspection, pedal pulses examination, foot sensory examination, retina examination, and glycated hemoglobin determination. RESULTS: Approximately a quarter of the sample had a diagnosed mental disorder (23.7% with psychiatric disorder only, 1.3% with substance use disorder only, and 2.6% with a dual diagnosis). Overall rates of receipt for the indicators were higher than national benchmarks for all patient subgroups, ranging from 70.8% for retina examination to 95.0% for foot inspection. Rates for both retina examination and foot sensory examination differed significantly by mental health status, mainly because of lower rates among those with a substance use disorder. The associations remained significant in multivariate generalized estimating equation analyses that controlled for demographic characteristics, health status, use of medical services, and hospital-level characteristics. CONCLUSIONS: Rates for secondary prevention of diabetes were remarkably high at Department of Veterans Affairs medical centers, although patients with mental disorders (particularly substance use disorders) were somewhat less likely to receive some of the recommended interventions.     

Hepatitis C Services and Individuals with Serious Mental Illness

Although individuals with serious mental illness have been shown to be at increased risk for hepatitis C viral (HCV) infection, there is growing concern regarding limited dissemination of recommended HCV related services to this population. This paper presents rates of receipt of HCV prevention services among a cohort of seriously mentally ill adults and reports rates of recommended follow-up care among the subset who tested HCV positive in a pilot study. Previous HCV screening was low and indicated medical follow-up among those who tested positive was also limited. Results stress the need for increased screening and counseling and delivery of preventive and follow-up medical services.     

Bridges to Better Health and Wellness: An Adapted Health Care Manager Intervention for Hispanics with Serious Mental Illness

This study examined the feasibility, acceptability, and initial impact of bridges to better health and wellness (B2BHW), a culturally-adapted health care manager intervention for Hispanics with serious mental illness (SMI). Thirty-four Hispanics with SMI and at risk for cardiovascular disease were enrolled. Mixed-linear models were used to examine changes over 12-months on patient activation, self-efficacy, patient-rated quality of care, receipt of preventive primary care services, and quality of life. The majority of participants completed the intervention (85%) with high satisfaction. Significant improvements were found for patient activation, self-efficacy, patients’ ratings of quality of care, and receipt of preventive primary care.     

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 mental health and substance abuse treatment services among adults with HIV in the United States

BACKGROUND: The need for mental health and substance abuse services is great among those with human immunodeficiency virus (HIV), but little information is available on services used by this population or on individual factors associated with access to care. METHODS: Data are from the HIV Cost and Services Utilization Study, a national probability survey of 2864 HIV-infected adults receiving medical care in the United States in 1996. We estimated 6-month use of services for mental health and substance abuse problems and examined socioeconomic, HIV illness, and regional factors associated with use. RESULTS: We estimated that 61.4% of 231 400 adults under care for HIV used mental health or substance abuse services: 1.8% had hospitalizations, 3.4% received residential substance abuse treatment, 26.0% made individual mental health specialty visits, 15.2% had group mental health treatment, 40.3% discussed emotional problems with medical providers, 29.6% took psychotherapeutic medications, 5.6% received outpatient substance abuse treatment, and 12.4% participated in substance abuse self-help groups. Socioeconomic factors commonly associated with poorer access to health services predicted lower likelihood of using mental health outpatient care, but greater likelihood of receiving substance abuse treatment services. Those with less severe HIV illness were less likely to access services. Persons living in the Northeast were more likely to receive services. CONCLUSIONS: The magnitude of mental health and substance abuse care provided to those with known HIV infection is substantial, and challenges to providers should be recognized. Inequalities in access to care are evident, but differ among general medical, specialty mental health, and substance abuse treatment sectors.     

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.     

Mental health need and access to mental health services by youths involved with child welfare: a national survey

OBJECTIVE:This study assessed the relationship between the need for and use of mental health services among a nationally representative sample of children who were investigated by child welfare agencies after reported maltreatment. METHOD: Data were collected at study entry into the National Survey of Child and Adolescent Well-Being and were weighted to provide population estimates. RESULTS: Nearly half (47.9%) of the youths aged 2 to 14 years (N = 3,803) with completed child welfare investigations had clinically significant emotional or behavioral problems. Youths with mental health need (defined by a clinical range score on the Child Behavior Checklist) were much more likely to receive mental health services than lower scoring youth; still, only one fourth of such youths received any specialty mental health care during the previous 12 months. Clinical need was related to receipt of mental health care across all age groups (odds ratio = 2.7-3.5). In addition, for young children (2-5 years), sexual abuse (versus neglect) increased access to mental health services. For latency-age youths, African-American race and living at home significantly reduced the likelihood of care. Adolescents living at home were also less likely to receive services, whereas having a parent with severe mental illness increased (odds ratio = 2.4) the likelihood of service use. CONCLUSIONS: Routine screening for mental health need and increasing access to mental health professionals for further evaluation and treatment should be a priority for children early in their contact with the child welfare system.     

Work interest as a predictor of competitive employment: policy implications for psychiatric rehabilitation

Consumers with serious mental illness (N=166) enrolling in two community-based mental health programs, a vocational Program of Assertive Community Treatment and a clubhouse certified by the International Center for Clubhouse Development (ICCD), were asked about their interest in work. About one third of the new enrollees expressed no interest in working. Equivalent supported employment services were then offered to all participants in each program. Stated interest in work and receipt of vocational services were statistically significant predictors of whether a person would work and how long it would take to get a job. Two thirds of those interested in work and half of those with no initial interest obtained a competitive job if they received at least one hour of vocational service. Once employed, these two groups held comparable jobs for the same length of time. These findings demonstrate the importance of making vocational services continuously available to all people with serious mental illness, and the viability of integrating these services into routine mental health care.     

Health care utilization and receipt of cholesterol testing by veterans with and those without mental illness

OBJECTIVE: We examined the relationship between mental illness, health care utilization and rates of cholesterol testing. METHODS: We conducted a retrospective cohort study using Veterans Affairs (VA) administrative data on 64,490 United States veterans who used VA New England Health Care System outpatient services between January 1998 and June 2001. A total of 10,100 veterans (15.7%) had a mental illness treated with medication. We examined the interaction between mental illness and outpatient service utilization with respect to the likelihood of receiving a cholesterol test, adjusting for major demographic and clinical covariates. RESULTS: Among veterans using VA outpatient services infrequently, those with mental illness were less likely than non-mentally ill control subjects to receive a cholesterol test during the study period (first quartile adjusted OR=0.45, 95% CI=0.37-0.54; second quartile adjusted OR=0.50, 95% CI=0.45-0.57). Mentally ill subjects with more frequent utilization of VA services were as likely as (third quartile adjusted OR=1.01, 95% CI=0.91-1.13) or more likely than (fourth quartile adjusted OR=2.73, 95% CI=2.46-3.03) non-mentally ill subjects to receive cholesterol testing. CONCLUSIONS: Mental illness was associated with a lower likelihood of cholesterol testing in subjects who used fewer VA outpatient services. The observed disparity attenuated at higher levels of service utilization.     

Improving medical care for persons with serious mental illness: challenges and solutions

A critical step in addressing excess medical morbidity and mortality in persons with serious mental illness is to better understand and seek to improve the medical care that they receive. Medical quality deficits for persons with serious mental illness include problems related to overuse of certain medical services, such as emergency room care; underuse of some evidence-based general medical services; and misuse, or medical error. The origins of poor quality care for persons with mental disorders are rooted in interrelated contributory factors from patients, providers, and the medical and mental health care systems. At a system level, at least 4 types of separation between mental and medical health care may exacerbate the problems for persons with serious mental illnesses: (1) geographic (lack of co-located medical and mental health services), (2) financial (separate funding streams for medical and mental health services), (3) organizational (difficulty in sharing information and expertise across these systems), and (4) cultural (providers' focus on particular symptoms or disorders, rather than on the patients with those problems). Research studies and demonstration programs for improving medical care in this population have spanned a continuum of medical provider involvement from psychiatrist and patient training to on-site consultation by medical staff, multidisciplinary collaborative care approaches, and facilitated linkages between community and mental health and medical providers. Ultimately, it will be important to develop, test, and implement a range of models for improving the medical care of persons with serious mental disorders that are tailored to patients' needs, mental health system capacities, and local community resources.     

Use of alcohol treatment and mental health services among adolescents with alcohol use disorders

OBJECTIVE: This study examined the use of and perceived need for alcohol treatment services among adolescents (aged 12 to 17 years) who received mental health services in the previous year compared with same-aged adolescents who did not receive such services. METHODS: Study data were drawn from the 2000 and 2001 National Household Surveys on Drug Abuse. The authors conducted logistic regression analyses to identify the characteristics associated with the receipt of and perceived need for alcohol services among adolescents with alcohol use disorders. RESULTS: Adolescents who received mental health services were much more likely than those who did not to meet criteria for alcohol use disorders in the previous year (10 percent compared with 4 percent). Among adolescents with alcohol use disorders, 15 percent of those who received mental health services used any alcohol services, compared with only 6 percent of those who did not receive mental health services. Of adolescents with alcohol use disorders who did not receive any alcohol services, only 3 percent reported a need for alcohol treatment. Among adolescents with alcohol use disorders who received mental health services, Hispanics were significantly less likely than whites to receive any alcohol services. CONCLUSIONS: These findings from a nationally representative sample of adolescents reveal a largely unrecognized and underserved population at risk. Factors related to the underutilization of alcohol services by adolescents with alcohol use disorders deserve greater research attention.     

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.     

Quality of care in a Medicaid population with bipolar I disorder

OBJECTIVE: This study examined whether presenting diagnosis and treatment in intensive settings (hospitalization, partial hospitalization, or residential programs) are correlated with the subsequent treatment of bipolar I disorder. METHODS: Claims data were studied retrospectively (fiscal years 1994-2000) for 2,644 patients with bipolar I disorder who had been enrolled in Medicaid at least six months before their first observed bipolar diagnosis. Logistic regression models estimated the association between the presenting diagnosis and initial treatment setting and the subsequent treatment up to one year after the first observed bipolar diagnosis. Measures included receipt of guideline-recommended care (antimanic agent plus psychotherapy) or care discouraged by guidelines (an antidepressant without an antimanic agent). RESULTS: Only one-third of enrollees received both guideline-recommended treatments after the first observed bipolar diagnosis. Patients were less likely to receive both recommended treatments if the first observed mental health service occurred in an intensive setting. Enrollees presenting with a bipolar diagnosis were less likely to receive psychotherapy, whereas rates of antimanic medication use were similar to those with other presenting diagnoses. Presenting with depression or anxiety or other, nonbipolar diagnoses was associated with a higher likelihood of receiving pharmacotherapy discouraged by guidelines. CONCLUSIONS: This study raises general concerns for the treatment quality of bipolar I disorder in this medically complicated, largely disabled Medicaid population. Also, how bipolar I patients enter treatment can be associated with subsequent differences in treatment quality--information that can be useful to clinicians and policy makers when planning quality improvements to treatment programs.     

Factors predicting choice of provider among homeless veterans with mental illness

OBJECTIVE: Homeless persons with serious mental illness are especially likely to lack access to comprehensive medical and psychiatric care. This study examined the relative importance of predisposing factors, illness factors, and enabling factors as determinants of the use of Veterans Affairs (VA) health care services by mentally ill homeless veterans seeking services from a non-VA program. Predisposing factors included demographic characteristics and wartime service; illness factors were related to the type of medical problem and the need to seek medical care; and enabling factors included entitlement to VA medical services and location of VA facilities. METHODS: Logistic regression analysis was used to analyze data for 698 homeless veterans with mental illness who were enrolled in the Access to Community Care and Effective Services and Supports (ACCESS) program. RESULTS: About 56 percent of the mentally ill homeless veterans had used VA services at some time in their lives. Homeless veterans were almost twice as likely as other poor veterans to use VA services; those with a dual diagnosis were also more likely to use VA services. Enabling factors were more important than either predisposing or illness factors in predicting VA service use. Veterans most likely to use VA services were those who received VA benefits that gave them priority access to VA services and those who lived near a VA medical center. CONCLUSIONS: Specific characteristics of the service system and of veterans' entitlement were more important than clinical needs or predisposing factors in predicting service use.     

Relationship between diabetes and mortality among persons with co-occurring psychotic and substance use disorders

OBJECTIVE: Individuals with diabetes and individuals with serious mental illness are more likely than the general population to die prematurely. The study examined the impact of diabetes on mortality among 197 individuals with co-occurring psychotic and substance use disorders who participated in a randomized controlled study of integrated mental health and substance abuse treatment. METHODS: The authors examined Medicaid claims for evidence of diabetes and applied survival analyses to examine whether time from study entry until death was different for individuals with and without evidence of diabetes. RESULTS: Of individuals with co-occurring psychotic and substance use disorders, 21% had evidence of diabetes. In a 12-year period, 41% of those with evidence of diabetes died compared with 10% of those without evidence of diabetes. CONCLUSIONS: Interventions targeted for diabetes prevention and diabetes management are critical for persons with serious mental illness, particularly among those who also abuse substances.     

Comorbidity of medical illnesses among adults with serious mental illness who are receiving community psychiatric services

We studied the medical comorbidity among individuals with serious mental illness who were receiving community-based psychiatric treatment. A total of 200 psychiatric outpatients divided between those with schizophrenia and affective disorder diagnoses were recruited from samples receiving outpatient care at two psychiatric centers. Interviews used questions from national health surveys. Logistic regression analyses compared responses from each sample with those of matched subsets of individuals from the general population. Both patient groups had greater odds of having many medical conditions. The odds of respiratory illnesses remained elevated in the patient groups even after controlling for smoking, as did the odds of diabetes in the affective disorder group after controlling for weight. Persons with serious mental illness who are in outpatient care are more likely to have comorbid medical conditions than persons in the general population. The odds of diabetes, lung diseases, and liver problems are particularly elevated. These findings underscore the need for intensified preventive health interventions and medical services for this population.     

Challenges and solutions to integrating mental and physical health care

A critical step in addressing excess medical morbidity and mortality in persons with serious mental illness is to better understand, and seek to improve, the medical care that they receive. Medical quality deficits for persons with serious mental illnesses include problems including overuse of certain medical services such as emergency room care; underuse of some evidence-based general medical services; and misuse, or medical error. The origins of poor quality care for persons with mental disorders are rooted in interrelated contributory factors from patients, providers, and the medical and mental health systems. At a system level, at least 4 types of separation between mental and medical health care may exacerbate the problems for persons with serious mental illnesses: 1) geographic (lack of co-located medical and mental health services), 2) financial (separate funding streams for medical and mental health services), 3) organizational (difficulty in sharing information and expertise across these systems), and 4) cultural (providers' focus on particular symptoms or disorders, rather than on the patients with those problems). Research studies and demonstration programs for improving medical care in this population have spanned a continuum of medical provider involvement from psychiatrist and patient training, to on-site consultation by medical staff, multidisciplinary collaborative care approaches, and facilitated linkages between community and mental health and medical providers. Ultimately, it will be important to develop, test, and implement a range of models for improving the medical care of persons with serious mental disorders tailored to patients' needs, mental health system capacities, and local community resources.