Age and physical health as predictors of family contact among adults with severe psychiatric illness.

We assessed the association of frequency of family contact with age and physical health for a sample of adults with severe psychiatric illness (N = 171). This cross-sectional, observational study measured frequency of face-to-face and telephone contact with family members; satisfaction with family relations; and severity of participants' chronic or permanent physical health conditions. In this sample of adults with severe psychiatric illness, having a physical health condition and advancing age correlated negatively with frequency of face-to-face contact with family members. However, a hierarchical regression analysis controlling for residence in a family member's home, and participants' ratings of satisfaction with family relations, showed that the combination of being older and having more severe health conditions was associated with a more frequent rate of family contact than would be expected based on age or physical health considered alone. Because almost all older participants in this heterogeneous sample had serious physical health conditions, as well as frequent telephone and face-to-face contact with their family members, we recommend the recruitment of family members as collaborators in illness management interventions for aging and mid-life adults with psychiatric illness.

A four-year retrospective study of Assertive Community Treatment: change to more frequent, briefer client contact.

The authors explored the feasibility of providing frequent, brief client contact as a strategy for reallocating Assertive Community Treatment (ACT) staff time to new clients, while preserving relationships with current clients and ACT program fidelity standards. A retrospective analysis of 4 years of service records for a high-fidelity ACT team revealed gradual increases in staff-client contact frequency, and corresponding decreases in contact duration. During these years, fidelity to ACT standards remained moderately high, and clients' employment and hospitalization outcomes improved.

Preference in random assignment: implications for the interpretation of randomized trials.

Random assignment to a preferred experimental condition can increase service engagement and enhance outcomes, while assignment to a less-preferred condition can discourage service receipt and limit outcome attainment. We examined randomized trials for one prominent psychiatric rehabilitation intervention, supported employment, to gauge how often assignment preference might have complicated the interpretation of findings. Condition descriptions, and greater early attrition from services-as-usual comparison conditions, suggest that many study enrollees favored assignment to new rapid-job-placement supported employment, but no study took this possibility into account. Reviews of trials in other service fields are needed to determine whether this design problem is widespread.

When programs benefit some people more than others: tests of differential service effectiveness.

Practitioners need to know for whom evidence-based services are most or least effective, but few services research studies provide this information. Using data from a randomized controlled comparison of supported employment findings for two multi-service psychiatric rehabilitation programs, we illustrate and compare procedures for measuring program-by-client characteristic interactions depicting differential program effectiveness, and then illustrate how a significant program-by-client interaction can explain overall program differences in service effectiveness. Interaction analyses based on cluster analysis-identified sample subgroups appear to provide statistically powerful and meaningful hypothesis tests that can aid in the interpretation of main effect findings and help to refine program theory.

Supported employment outcomes of a randomized controlled trial of ACT and clubhouse models.

OBJECTIVE: In a randomized controlled trial, a vocationally integrated program of assertive community treatment (ACT) was compared with a certified clubhouse in the delivery of supported employment services. METHODS: Employment rates, total work hours, and earnings for 121 adults with serious mental illness interested in work were compared with published benchmark figures for exemplary supported employment programs. The two programs were then compared on service engagement, retention, and employment outcomes in regression analyses that controlled for background characteristics, program preference, and vocational service receipt. RESULTS: Outcomes for 63 ACT and 58 clubhouse participants met or exceeded most published outcomes for specialized supported employment teams. Compared with the clubhouse program, the ACT program had significantly (p<.05) better service engagement (ACT, 98 percent; clubhouse, 74 percent) and retention (ACT, 79 percent; clubhouse, 58 percent) over 24 months, but there was no significant difference in employment rates (ACT, 64 percent; clubhouse, 47 percent). Compared with ACT participants, clubhouse participants worked significantly longer (median of 199 days versus 98 days) for more total hours (median of 494 hours versus 234 hours) and earned more (median of $3,456 versus $1,252 total earnings). Better work performance by clubhouse participants was partially attributable to higher pay. CONCLUSIONS: Vocationally integrated ACT and certified clubhouses can achieve employment outcomes similar to those of exemplary supported employment teams. Certified clubhouses can effectively provide supported employment along with other rehabilitative services, and the ACT program can ensure continuous integration of supported employment with clinical care.

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.