Mental illness and use of home care nationally in the U.S. Department of Veterans Affairs.

OBJECTIVE: To determine whether patients with mental health diagnoses are more likely to utilize home-based primary care (HBPC), and to identify characteristics associated with HBPC admission among elderly and nonelderly veterans, specifically. METHODS: Patients receiving treatment during fiscal year (FY) 2003 and having no evidence of home care utilization during FY2002 were followed through FY2005 using administrative claims data of the Veterans Health Administration of the U.S. Department of Veterans Affairs (VA). Participants were 4,411,677 VA patients with no prior HBPC use. Cox proportional hazard models were developed to identify correlates of HBPC use. RESULTS: Of VA patients with no prior use of HBPC, 24.2% received a mental health diagnosis, of whom 1.5% eventually used HBPC. Two in five new HBPC admissions were diagnosed with mental illness. Patients diagnosed with dementia were 66% more likely to be admitted. Patients diagnosed with nonschizophrenia psychoses (hazard ratio [HR]: 1.30), miscellaneous affective disorders (HR: 1.22), and schizophrenia (HR: 1.21) had the next highest probabilities. Risk of admission was highest for > or = 3 outpatient medical visits (HR: 2.61), followed by any inpatient medical/surgical days (HR: 1.79) or outpatient mental health visits (HR: 1.30). Elderly patients with any inpatient mental health days were less likely to be admitted; younger patients with nursing home use, community residential care, and mental health intensive care management were more likely to be admitted. CONCLUSION: Given that mental illness is independently associated with the likelihood of admission, it is critical that providers develop the skills and resources necessary to meet the psychiatric needs of home care recipients.     

Prevalence of liver disease in veterans with bipolar disorder or schizophrenia

Objective

To assess the prevalence of three liver diseases [hepatitis C virus (HCV), nonalcoholic fatty liver disease and alcohol-induced cirrhosis] in patients (veterans) with/without schizophrenia/schizoaffective disorder and bipolar disorder.

Methods

A retrospective electronic chart review of Veterans Integrated Services Network 20 facilities from January 1, 2001 to December 21, 2006 selected patients to one of two groups: schizophrenia/schizoaffective disorder or bipolar disorder. Patients in both groups were compared with veterans in an equal-sized random sample from the same data set of veterans without psychiatric diagnoses. Logistic regression models evaluated risk for overall liver diseases as well as HCV, nonalcoholic fatty liver disease and alcoholic-induced cirrhosis.

Results

Patients with schizophrenia (n=6521) had a higher prevalence of liver disease [22.4% versus 3.2%; odds ratio (OR)=8.73]; HCV (16.5% versus 1.9%; OR=10.21); and alcohol-related cirrhosis (1.6% versus 0.4%; OR=4.09) than matched controls. Patients with bipolar disorder (n=5319) had a higher prevalence of liver disease (21.5% versus 3.5%; OR=7.58); HCV (15.5% versus 2.1%; OR=8.60); and alcohol-related cirrhosis (1.6% versus 0.4%; OR=3.82) than matched controls. Risk factors for liver disease in patients with schizophrenia (versus matched controls) included diabetes (OR=1.29), hypertension (OR=1.27), HIV (OR=3.54), substance use disorder (SUD) (OR=2.28), alcohol use disorder (OR=3.05) and schizophrenia (OR=2.74). Risk factors for development of liver disease for patients with bipolar disorder: diabetes (OR=1.40), HIV (OR=3.66), SUD (OR=2.68), alcohol use disorder (OR=3.22) and bipolar disorder (OR=2.27).

Conclusions

This study in veterans shows that the presence of mental illness and its comorbidities represents a significant risk factor for the diagnosis of liver disease, including HCV and alcohol-related cirrhosis.     

Access to and satisfaction with care comparing patients with and without serious mental illness

OBJECTIVES: We compared perceived access to and satisfaction with health care between patients diagnosed with serious mental illness (SMI: schizophrenia or bipolar disorder) and among those with no SMI diagnosis. METHOD: We conducted a national, cross-sectional study of VA patients in Fiscal Year (FY) 1999 (N = 7,187) who completed the VA's Large Health Survey of Veteran Enrollees (LHSV) section on access and satisfaction and either received a diagnosis of schizophrenia or bipolar disorder, or did not and were randomly selected from the general non-SMI VA patient population (non-SMI group). We compared the probability of perceived poor access and dissatisfaction using multivariable logistic regression adjusting for patient covariates. RESULTS: Compared to non-SMI patients, patients diagnosed with bipolar disorder were more likely to report difficulty in receiving care they needed (adjusted OR = 1.36,p < .05) or seeing a specialist (adjusted OR = 1.44, p < .001). Patients diagnosed with schizophrenia were more likely to report dissatisfaction, including thoroughness by their provider (adjusted OR = 1.37, p < .001) and the provider's explanation of problems (adjusted OR = 1.54, p < .001) compared to non-SMI patients. CONCLUSIONS: Patients diagnosed with bipolar disorder reported greater problems with access to health care, while those diagnosed with schizophrenia were less satisfied with the process of care.     

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.     

Access to and Use of the Internet by Veterans with Serious Mental Illness

This study evaluated internet use among 239 veterans with serious mental illness who completed questionnaires assessing demographics and internet use in 2010–2011. The majority of individuals (70 %) reported having accessed the internet and among those, 79 % had accessed it within the previous 30 days. Those who were younger and more educated were more likely to have accessed the internet, as were those with a schizophrenia spectrum disorder, bipolar disorder, or major depressive disorder, compared to individuals with PTSD. Veterans with serious mental illness commonly use the internet, including to obtain health information, though use varies across demographic characteristics and clinical diagnosis.     

Pain conditions among veterans with schizophrenia or bipolar disorder

Objective

The purpose of this study was to assess the rates of chronic, noncancer pain conditions in patients with schizophrenia or bipolar disorder within the Veterans Health Administration (VHA) System.

Method

This cross-sectional study used administrative data extracted from VHA treatment records of all individuals receiving VHA services in fiscal year 2008 (N= 5,195,551). The associations between severe psychiatric disorders (schizophrenia and bipolar disorder) and chronic pain (arthritis, back pain, chronic pain, migraine, headache, psychogenic and neuropathic) were evaluated using a series of logistic regression analyses.

Results

Veterans with schizophrenia [odds ratio (OR)=1.21] and bipolar disorder (OR=2.17) were significantly more likely to have chronic pain overall relative to veterans without these psychiatric conditions. These associations were slightly lower than for the association between depression and pain in this sample (OR=2.61). The highest associations between specific psychiatric diagnosis and pain condition were found with chronic pain, headache and psychogenic pain.

Conclusions

Noncancer pain conditions occur in elevated rates among patients with schizophrenia and bipolar disorder. Future research could further examine possible barriers to adequate pain treatment among people with serious mental illness, as well as the extent to which chronic pain might impact mental health recovery.     

Gender differences in health-related quality of life for veterans with serious mental illness

OBJECTIVE: This study assessed gender differences in health-related quality of life (HRQOL) in a national sample of veterans with serious mental illness. METHODS: Data were analyzed from the Large Health Survey of Veterans, which was mailed to a national random sample of veterans in 1999. The linear and logistic multiple regression analyses included 18,017 veterans with schizophrenia, schizoaffective disorder, or bipolar disorder who completed the survey. HRQOL was measured by using the various subscales of the 36-Item Short Form of the Medical Outcomes Study (MOS SF-36) (mental component summary, physical component summary, and activities of daily living) and by questions assessing self-perceptions of health status. RESULTS: The sample was 7.3% female, 75.7% white, and 83.8% unemployed. Mean+/-SD age was 54.3+/-12.2 years. After the analysis adjusted for sociodemographic characteristics, health status, and other variables, compared with male veterans, female veterans with serious mental illness had lower scores on the SF-36 physical component summary (indicating worse symptoms), were more likely to report that they were limited "a lot" in activities of daily living, and had more pain. However, female respondents were more likely to have a positive outlook on their health. CONCLUSIONS: Among veterans who received a diagnosis of serious mental illness from providers of the Department of Veterans Affairs, women reported substantially poorer HRQOL than men across several domains but women reported better self-perceived health. Attention to the particular needs of female veterans with serious mental illness is imperative as the numbers of female veterans continue to increase.     

Nutrition and exercise behavior among patients with bipolar disorder

OBJECTIVES: There have been few comprehensive studies of nutrition and exercise behaviors among patients with bipolar disorder (BPD). Based on a national sample of patients receiving care in the Veterans Affairs (VA) health care system, we compared nutrition and exercise behaviors among individuals diagnosed with BPD, others diagnosed with schizophrenia, and others who did not receive diagnoses of serious mental illness (SMI). METHODS: We conducted a cross-sectional study of patients who completed the VA's Large Health Survey of Veteran Enrollees section on health and nutrition in fiscal year (FY) 1999 and who either received a diagnosis of BPD (n = 2,032) or schizophrenia (n = 1,895), or were included in a random sample of non-SMI VA patients (n = 3,065). We compared nutrition and exercise behaviors using multivariable logistic regression, controlling for patient socio-economic and clinical factors, and adjusting for patients clustered by site using generalized estimating equations. RESULTS: Patients with BPD were more likely to report poor exercise habits, including infrequent walking (odds ratio, OR = 1.33, p < 0.001) or strength exercises (OR = 1.28, p < 0.001) than those with no SMI. They were also more likely to self-report suboptimal eating behaviors, including having fewer than two daily meals (OR = 1.32, p < 0.001) and having difficulty obtaining or cooking food (OR = 1.48, p < 0.001). Patients with BPD were also more likely to report having gained >or=10 pounds in the past 6 months (OR = 1.59, p < 0.001) and were the least likely to report that their health care provider discussed their eating habits (OR = 0.84, p < 0.05) or physical activity (OR = 0.81, p < 0.01). CONCLUSIONS: Greater efforts are needed to reduce the risk of poor nutrition and exercise habits among patients diagnosed with BPD.     

Characteristics of patients attending an HIV-related psychiatric clinic

Demographic and clinical data were recorded for 324 patients who visited an AIDS-related psychiatric outpatient clinic over a three-year period. Seventy-five percent of the patients had a diagnosis of AIDS, AIDS-related complex, or asymptomatic HIV seropositivity. Intravenous drug use and heterosexual relations were the most common HIV transmission risk factors. Seventy-three percent of the patients were black or Hispanic; 51 percent were female. In all stages of HIV infection, adjustment disorder was the most common diagnosis; one third to one half of the patients had substance abuse diagnoses. Only 5 percent were diagnosed with dementia, with the incidence highest (12 percent) in patients with AIDS. On the basis of their experience with the clinic, the authors discuss issues that have proved important in the treatment of patients with the triple diagnoses of medical illness, mental illness, and substance abuse.     

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.     

Medical clinic characteristics and access to behavioral health services for persons with HIV

OBJECTIVE: Many persons with HIV do not receive needed behavioral health services. This study examined the impact of medical clinic characteristics on access to mental health and substance abuse care for persons with HIV. METHODS: This was a longitudinal survey of patients and clinic directors participating in the HIV Cost and Services Utilization Study, a national probability sample of persons in care for HIV between 1996 and 1998 (N=2,031). Primary outcomes were receipt of outpatient mental health specialist care, outpatient substance abuse care, and abstinence from substance use in the past 30 days. RESULTS: After adjustment for patient characteristics, the likelihood of care by a mental health specialist was higher for patients in HIV specialty clinics (odds ratio [OR]=2.1, 95% confidence interval [CI]=1.2-3.5) and clinics with a combination of on-site case management and affiliated mental health care (OR=2.3, CI 1.3-4.4, for off-site affiliated care; OR=2.1, CI=1.2-3.7, for on-site care). Outpatient substance abuse care also was more likely for patients in clinics with on-site case management and affiliated substance abuse care (OR=4.3, CI=1.5-12.2, for off-site affiliated care; OR=3.2, CI=1.3-8.0, for on-site care). In a subgroup of persons reporting active substance use, care in clinics with on-site case management predicted 30-day abstinence from substances at follow-up (OR=1.7, CI=1.1-2.5). CONCLUSIONS: The organizational structure of medical clinics can have an important effect on use of mental health and substance abuse specialist care.     

Sleep,suicide behaviors,and the protective role of sleep medicine

Objective/BackgroundSleep disturbance is associated with suicidal thoughts and behaviors. The relationship of specific sleep disorders to suicide attempts is less well established. Whether treating sleep disorders reduces suicide attempts remains controversial.MethodsSuicide attempts, treatment utilization, and psychiatric diagnoses were extracted from electronic medical records and a suicide attempt database from the U.S. Department of Veterans Affairs. The sample (N = 60,102) consisted of patients with any record of suicide attempt in FY13-14 and a 1:1 case-control of patients with no record of attempt, who were propensity score-matched based on age, gender, and prior year mental health treatment utilization. Associations among sleep disorders and suicide attempt were examined via logistic regression. Covariates included depression, anxiety, posttraumatic stress disorder (PTSD), bipolar, schizophrenia, substance use disorder (SUD), medical comorbidity, and obesity.ResultsInsomnia (OR = 5.62; 95% CI, 5.39–5.86), nightmares (odds ratio, OR = 2.49; 95% confidence interval, CI, 2.23–2.77), and sleep-related breathing disorders (OR = 1.37; 95% CI, 1.27–1.48) were positively associated with suicide attempt after accounting for age, gender, treatment utilization, and comorbid sleep disorders. Furthermore, when controlling for depression, anxiety, PTSD, bipolar, schizophrenia, substance use disorder (SUD), medical comorbidity, and obesity, insomnia (OR = 1.51, 95% CI, 1.43–1.59) remained positively associated with suicide attempt nightmares (OR = 0.96; 95% CI, 0.85–1.09) nor sleep-related breathing disorders (OR = 0.87, 95% CI = 0.79–0.94). Additionally, sleep medicine visits 180 days prior to index date were associated with decreased likelihood of suicide attempt for individuals with sleep disorders (OR = 0.86; 95% CI, 0.79–0.94).ConclusionInsomnia is associated with suicide attempt among veterans. Sleep medicine visits were associated with a reduced risk of suicide attempt in sleep disordered patients. The assessment and treatment of sleep disorders should be considered in context of strategies to augment suicide prevention efforts.     

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.     

Substance use in adolescents with mental illness in Durban,South Africa

Comorbid substance use in adolescents with mental illness is often an indicator of poor treatment outcome. This study aims to determine the prevalence of, and associated risk factors for, substance use in adolescents with mental illness attending a mental health service. Data was collected from hospital records of 162 adolescents, using a structured data sheet, over a two-year period. Substance use was more significant in older adolescents and those with severe mental illness. Sixty-two (38.3%) adolescents used substances. Thirty-seven (38.1%) male adolescents reported substance use compared to 25 (38.5%) female adolescents. Alcohol was the most commonly used substance (n = 48; 29.6%), followed by cannabis (n = 32; 19.8%). There were significant direct associations between substance use and history of abuse or neglect, forensic history, educational setting, admission status, and the psychiatric diagnoses of schizophrenia, other psychotic disorders, and bipolar mood disorder. Inverse associations were found between substance use and adjustment disorders, attention deficit hyperactivity disorder, and intellectual disability. The results of this study indicate an urgent need for substance misuse programmes for at risk youth, and the introduction of dual diagnosis intervention programmes in this age group.     

Dual diagnosis: HIV and mental illness, a population-based study

This is a cross-sectional, population-based (n = 378,710) study using hospital discharge abstract data to determine the relative risk associated with having a dual diagnosis of mental illness and HIV/AIDS. The analysis addresses issues of gender, race, and age, as well as types of mental illness. Persons with a mental illness are 1.44 times more likely to have HIV/AIDS. Women are at increased risk of being dually diagnosed. There are no risk differences by race. Those with a specific diagnosis of substance abuse or a depressive disorder are more likely to have a diagnosis of HIV/AIDS.     

Chronically mentally ill patients with and without substance use disorders: a pilot study

The study was designed to assess characteristics of chronic mentally ill patients with and without a substance use disorder. Study patients (n=48) had either psychiatric illness alone (they received conventional psychiatric rehabilitation) or dual diagnoses (they received mental illness and substance abuse services). All patients were administered the Brief Symptom Inventory (BSI), the Client Satisfaction Questionnaire, the Perceived Social Support Scales, and the Composite International Diagnostic Interview. Higher proportions of dually diagnosed patients had schizophrenia, had higher scores on the BSI, and were less satisfied with treatment.     

Obesity and associated complications in patients with severe mental illnesses: a cross-sectional survey

BACKGROUND: This naturalistic cross-sectional survey of patients with severe mental illnesses explores the association between important variables and obesity, extreme obesity, diabetes mellitus type 2, hypertension, and hyperlipidemia in the clinical environment. METHOD: Weight and height were obtained from 560 patients with severe mental illnesses (including DSM-IV schizophrenia, schizoaffective disorder, bipolar disorder, and major depressive disorder) at central Kentucky inpatient and outpatient facilities to estimate their body mass index (BMI). Chart diagnoses of diabetes mellitus, hypertension, and hyperlipidemia were obtained. RESULTS: When comparing the patients with severe mental illnesses with Kentucky adults from the general population, the odds ratio (OR) of obesity (BMI > or = 30 kg/m(2)) was 2.6 (95% confidence interval [CI] = 2.2 to 3.0), and the OR of diabetes mellitus was 2.9 (95% CI = 2.3 to 3.6). Female gender, African American race, early start of psychiatric medication, and long psychiatric medication duration were significantly associated with obesity. Current alcohol and nicotine use exhibited significant ORs of obesity lower than 1, particularly in males. Obesity was closely associated with hypertension, type 2 diabetes mellitus, and hyperlipidemia. These complications were closely associated with each other and may indicate a further progression of obesity after aging. CONCLUSIONS: These results suggest a complex pattern of variables that may influence the development of obesity and its complications in patients with severe mental illnesses, but they need replication. The major factors associated with obesity appear to be a long-term illness or treatment duration and substance use. The former may be more important in females, while the latter may be more important in males. Clinical diagnoses (schizophrenic or mood disorders) or current treatment did not appear to be fundamental factors.     

Use of mental health care and substance abuse treatment among adults with co-occurring disorders

OBJECTIVES: This study investigated patterns of use of mental health care and substance abuse treatment for a nationally representative sample of adults with co-occurring mental health problems and a substance use disorder and compared these patterns with those of persons with either a mental health problem or a substance use disorder. METHODS: Data were from the 2001 and 2002 National Surveys on Drug Use and Health. The study examined rates of substance use disorders and mental health problems among adults aged 18 years and older, rates of substance use disorders among adults with mental health problems, and rates of mental health problems among adults with substance use disorders. Next, rates of substance abuse treatment and mental health care use were calculated among five groups that were formed on the basis of the presence of a substance use disorder, mental health problems, or both in the past year. RESULTS: A total of 2,851 respondents had a substance use disorder only, 1,633 had a substance use disorder with one or more mental health symptoms and without serious mental illness, 1,872 had a substance use disorder with serious mental illness, 13,759 had one or more mental health symptoms only, and 7,530 had a serious mental illness only. A substantial proportion of adults with comorbid mental health problems and a substance use disorder did not receive any treatment (46 percent of those with serious mental illness and 65 percent of those with one or more mental health symptoms). Co-occurring substance use disorder was not associated with increased use of mental health care. The likelihood of receiving any substance abuse treatment increased with the presence and severity of mental health problems. Across all five groups, use of mental health care was more common than use of substance abuse treatment. Less than one-third of patients with comorbid mental health problems and a substance use disorder who used mental health care also received substance abuse treatment. CONCLUSIONS: The large proportion of untreated individuals with mental and substance use disorders reinforces existing concerns about barriers to beneficial treatment. Low rates of use of substance abuse treatment among patients who have comorbid mental health problems and a substance use disorder and use mental health care suggest that recommendations that substance use disorders be treated before, or concurrently with, mental disorders have not been widely adopted.