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.     

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.     

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.     

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.     

HIV and people with serious mental illness: the public sector's role in reducing HIV risk and improving care.

OBJECTIVE: The paper discusses issues related to the detection, prevention of transmission, and treatment of human immunodeficiency virus (HIV) infection among persons with serious mental illness and suggests ways public mental health systems can address these issues. METHODS: MEDLINE was searched from 1980 through 1998, and all pertinent references were reviewed. RESULTS: Persons with severe mental illness are at greatly increased risk of HIV infection due to increased likelihood of high-risk sexual behaviors and injection drug use. The formidable barriers to detection and effective treatment of HIV that exist in this population can be attributed to the unique characteristics of this population, lack of knowledge and expertise among mental and physical health care providers, and fragmented mental and physical health care systems. CONCLUSIONS: In the last five years, treatments for HIV that are far more efficacious than earlier treatments have become available, making it more important for HIV infection be detected and treated among persons with serious mental illness. Public mental health systems need to implement active prevention policies and practices, educate both mental health and physical health care providers about key treatment issues, and develop effective linkages between mental and physical health care providers and systems.     

Health status of individuals with serious mental illness

We examined indices of the health of persons with serious mental illness. A sample of 100 adults with schizophrenia and 100 with major mood disorder were recruited from randomly selected outpatients who were receiving community-based psychiatric treatment. Participants were surveyed about health indicators using items from the National Health and Nutrition Examination Study III and the National Health Interview Survey. Their responses were compared with those of matched samples from the general population surveys. A total of 1% of persons with serious mental illness, compared with 10% from the general population sample, met criteria for all 5 of selected health indicators: nonsmoker, exercise that meets recommended standards, good dentition, absence of obesity, and absence of serious medical co-occurring illness. Within the mentally ill group, educational level, but not a diagnosis of schizophrenia versus mood disorder, was independently associated with a composite measure of health behaviors. We conclude that an examination of multiple health indicators may be used to measure overall health status in persons with serious mental illness.     

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.     

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.     

Relationship between service effectiveness and satisfaction among persons receiving Medicaid mental health services

Relationships between service satisfaction, life satisfaction, and self-reported mental health status were examined for Iowa Medicaid mental health service recipients. Of the 16,579 persons who received services in 1993, a mail-out survey was sent to 2,520 persons and returned by 815 (32.3 percent). Persons with schizophrenia reported greater service satisfaction and life satisfaction than persons with other diagnoses, and their ratings of their mental health were higher. A relationship between service satisfaction and current life satisfaction was observed for persons with schizophrenia, affective disorder and adjustment disorder, but not for persons with anxiety disorder.     

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.     

Responding to the threat of HIV among persons with mental illness and substance abuse

PURPOSE OF REVIEW: This article discusses current knowledge regarding the threat of HIV among persons with mental illness and substance abuse, and strategies for reducing this threat. It contains a review of the prevalence and consequences of dual/triple diagnosis, HIV risk behaviour and current HIV risk-reduction interventions among persons with dual diagnosis and interventions for triply diagnosed individuals. RECENT FINDINGS: Many persons with dual diagnosis remain undetected and there is a high prevalence of sexual risk behaviours among persons with dual diagnosis. Case management and supportive housing programmes are feasible options for the delivery of HIV risk-reduction interventions among such patients, and the adaptation of integrated behavioural treatment interventions can improve behavioural and healthcare utilization outcomes. SUMMARY: The developing world continues to see an escalation in HIV incidence. A more complete understanding of mental health, substance use and HIV serostatus interactions is needed to serve vulnerable populations. Mental health status not only mediates HIV risk behaviours, but positive serostatus has various effects on mental health. Co-morbid substance abuse is common among HIV-positive individuals with mental illness, resulting in serious adverse effects. Separate services for individuals with co-occurring substance abuse are less effective than integrated treatment programmes.     

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

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

Correlates of vocational recovery for persons with schizophrenia

The correlates of vocational recovery and vocational success among persons with schizophrenia were examined to identify prospective attributes that might be malleable and accessible to intervention. A national, non-representative sample of 109 individuals with a selfreported diagnosis of a schizophrenia spectrum disorder that met criteria for vocational recovery completed a survey on sustained employment of people with serious mental illness. Eighty-two participants (75%) had uninterrupted employment during the two years prior to entering the study while the rest sustained employment for at least 12 months during the same period of time. Respondents worked from 10 to 64 hours per week in jobs ranging from unskilled to professional and managerial positions. In multivariate analyses, previous work history and current receipt of Supplemental Security Income (SSI)/Social Security Disability Income (SSDI) were correlated with current work hours per week; educational level and employment in consumer self-help/advocacy settings were associated with occupational status; and current receipt of SSI/SSDI was correlated with current salary per hour.This study provides evidence that some individuals with a schizophrenia spectrum disorder have the capacity to achieve and maintain successful employment despite the challenges presented by this serious mental illness.     

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.     

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.     

The impact of realignment on the client population in California's public mental health system

This study examined whether decentralization of California's public mental health system under program realignment has changed the composition of the client population, with greater attention toward inclusion of persons with a severe mental illness. Clients' demographic and clinical status were compared before and after realignment. The study sample consisted of 75,951 clients, representing 1.5 million adults who accessed the public mental health services in California during a 6-year study period. The post-realignment client population had lower functional status, more unemployment, and lower levels of education—all indicating greater functional impairment. They were more likely to suffer from an affective disorder, but they were less likely to have either a non-psychotic disorder or schizophrenia. The study found no evidence suggesting that realignment jeopardized access to the public mental health system in California, and it indicated at least the possibility that it promoted greater access by clients with greater functional impairment.