Outcomes of the peer-taught 12-week family-to-family education program for severe mental illness.

OBJECTIVE: Family-to-Family Education Program (FFEP) is a 12-week course for family members of adults with serious mental illness (SMI). This study evaluates the effectiveness of FFEP for several family member outcomes. METHOD: The FFEP enrollees on a > or =3-month waiting list were eligible; 95 consenting family members agreed to four interviews (waitlist, pre-FFEP, post-FFEP, and 6 months post-FFEP) regarding subjective and objective burden, empowerment, and depression. Mixed effects ANOVA models tested hypotheses of decreased burden and increased empowerment after FFEP. RESULTS: The FFEP was associated with reduced subjective burden (P < 0.01) and increased empowerment (P < 0.01) without changes in objective burden. Knowledge about SMI, understanding the mental health system, and self-care also improved. There was no significant decay at 6-month followup. CONCLUSION: This study provides evidence that FFEP is helpful to relatives of persons with SMI by reducing subjective burden and worry, and increasing empowerment, knowledge about SMI, understanding the mental health system, and self-care.

Variables associated with disparities in treatment of patients with schizophrenia and comorbid mood and anxiety disorders.

OBJECTIVE: The study compared self-reported comorbid affective and anxiety disorder diagnoses and treatments of African-American and Caucasian subjects in a large sample of patients who had a diagnosis of schizophrenia. METHODS: A total of 685 patients receiving treatment for schizophrenia were interviewed as part of the Schizophrenia Patient Outcomes Research Team study. The associations of race with past and current diagnoses and with current treatment for depression, mania, and anxiety disorders were assessed with multivariate analyses. RESULTS: African Americans were significantly less likely than Caucasians to report having a past or current diagnosis of depression, manic-depression, or anxiety disorder and to be receiving current treatment for these disorders. Gender, education, and marital status were also associated with presence of a comorbid diagnosis and receipt of treatment. CONCLUSIONS: The study suggests the possibility of racial and other disparities in the diagnosis and treatment of patients with schizophrenia and comorbid affective and anxiety disorders. Although various causal explanations are plausible, all point toward the need for enhanced cross-cultural competence at all levels of mental health care, especially in the diagnosis and treatment of comorbid psychiatric illnesses.

Use and costs of ambulatory care services among Medicare enrollees with schizophrenia.

OBJECTIVE: The objective of this study was to identify predictors of the use and cost of ambulatory care services among Medicare recipients with schizophrenia. METHODS: The design was a cross-sectional analysis of Medicare claims in 1991. The study subjects were a 5 percent random sample of all persons in the United States who had at least one Medicare service claim in 1991 and who were diagnosed as having schizophrenia in any care setting. Outcome measures included use and cost of any ambulatory care service, individual therapy, psychiatric somatotherapy, group therapy, or family therapy. RESULTS: For nearly 25 percent of the total sample of 12,440, no claims were filed for ambulatory care services in 1991. The mean+/-SD number of ambulatory care visits during the year was 7.9+/-21. The most frequently used type of therapy was individual therapy (5+/-14 visits). The mean+/-SD yearly cost of care for persons who received ambulatory care services was $470+/-$1,028. Among persons under 65 years of age, Caucasians were about 1.5 times as likely as African Americans to have received an ambulatory care service and 1.3 times as likely to have received individual therapy. Persons who were 65 or older were less likely to have received any service. Among service recipients, costs of care were lower for African Americans and for older people. CONCLUSIONS: The use of Medicare-funded ambulatory care services by persons with schizophrenia varied by race and age. Further investigation is required to determine whether subgroups of individuals who do not have additional insurance coverage or access to services are receiving substandard care.

Differences in rates of depression in schizophrenia by race.

The purpose of this study was to determine whether demographic and clinical factors are associated with a diagnosis of depression among persons with schizophrenia and to determine the association of depression with subjective quality of life. A consecutively admitted sample of psychiatric inpatients diagnosed with schizophrenia (n = 123) were assessed for depression and quality of life. Logistic regression was used to determine factors associated with a diagnosis of depression. Multiple regression analyses were used to determine the relationship between depression and quality of life. The odds of being diagnosed with depression were seven times greater in Caucasians than in African-Americans, and three times greater in persons who were ever married. Depression was significantly associated with reduced life satisfaction in Caucasians but not African-Americans. This suggests the importance of race as a predictor of a diagnosis of depression in schizophrenia and the possibility of underdiagnosis of depression among African-Americans. The absence of the expected association between depression and quality of life in African-Americans casts doubt on the validity of the depression diagnosis using conventional diagnostic tools.

Prevalence and correlates of diabetes in national schizophrenia samples.

People with schizophrenia may be at increased risk for Type II diabetes because of the side effects of antipsychotic medication, poorer overall physical health, less healthy lifestyles, and poorer health care. The present study uses data bases collected by the Schizophrenia Patient Outcomes Research Team (PORT) to assess the prevalence and demographic and clinical correlates of diabetes within large populations of persons receiving treatment for schizophrenia. In the Schizophrenia PORT, Medicaid and Medicare data from 1991 and more recent interview data were collected regarding the comorbidity of schizophrenia and diabetes: prevalence, quality of life, physical health, and services utilization and costs. The study found that rates of diagnosed diabetes exceeded general population statistics well before the widespread use of the new antipsychotic drugs. Risk factors for diabetes were similar to those observed in the general population. The linkage of diabetes to poor physical health, medical morbidity, and increased service use and cost requires attention. This study of diabetes in the early 1990s suggests that even before the widespread use of the atypical antipsychotic drugs, diabetes was a major problem for persons with schizophrenia.

The association of medical comorbidity in schizophrenia with poor physical and mental health.

This study determined the prevalence of medical comorbidities in a cohort of persons receiving treatment for schizophrenia and the association of medical comorbidity with physical and mental health status. A total of 719 persons with schizophrenia sampled from a variety of community and treatment settings as part of the schizophrenia Patient Outcomes Research Team (PORT) participated in a survey interview. Multiple regression analyses were used to assess sociodemographic factors associated with the number of current medical comorbidities and the association of medical comorbidity count with patient ratings of physical health, mental health, symptoms, and quality of life. The majority of patients reported at least one medical problem. Problems with eyesight, teeth, and high blood pressure were most common. A greater number of current medical problems independently contributed to worse perceived physical health status, more severe psychosis and depression, and greater likelihood of a history of a suicide attempt. This study underscores the need to attend to somatic health care for persons with schizophrenia as well as the linkage of physical and mental health status.

Services to families of adults with schizophrenia: from treatment recommendations to dissemination.

OBJECTIVE: Data from the Schizophrenia Patient Outcomes Research Team project were examined to determine the extent to which families of adults with schizophrenia receive services and whether training staff in the provision of family services increases service availability. METHODS: For patients with a diagnosis of schizophrenia, paid claims for family therapy were identified in 1991 in a nationally representative sample of Medicare data and one state's Medicaid data. In a field study in two states, 530 patients were asked about services received by their families. A quasiexperimental dissemination of a family intervention was done at nine agencies; staff at four agencies received a standard didactic presentation, and staff at five received that standard presentation paired with intensive training. RESULTS: In the representative national Medicare sample of 15,425 persons with schizophrenia, .7 percent (N=108) had an outpatient claim for family therapy. This figure was 7.1 percent in the Medicaid sample of 5,393 persons with schizophrenia in one state. Of the 530 patients in the field study who reported having contact with their families, 159 (30 percent) reported that their families had received information, advice, or support about their illness, and 40 (8 percent) responded that their families had attended an educational or support program. At the four agencies where staff received only didactic training, no changes in family services were found after one year. Three of the five agencies where staff participated in intensive training enhanced their family services. CONCLUSIONS: A minority of families of persons with schizophrenia receive information about the illness from providers. Implementation of model family interventions is possible with considerable technical assistance. A gap exists between best practices and standard practices for families of persons with schizophrenia.

A randomized trial of assertive community treatment for homeless persons with severe mental illness.

BACKGROUND: This experiment evaluated the effectiveness of an innovative program of assertive community treatment (ACT) for homeless persons with severe and persistent mental illnesses. METHODS: One hundred fifty-two homeless persons with severe and persistent mental illness were randomized to either the experimental ACT program or to usual community services. Baseline assessments included the Structured Clinical Interview for DSM-III-R, Quality-of-Life Interview, Colorado Symptom Index, and the Medical Outcomes Study 36-Item Short Form Health Survey. All assessments (except the Structured Clinical Interview) were repeated at the 2-, 6-, and 12-month follow-up evaluations. RESULTS: Subjects in the ACT program used significantly fewer psychiatric inpatient days, fewer emergency department visits, and more psychiatric outpatient visits than the comparison subjects. The ACT subjects also spent significantly more days in stable community housing, and they experienced significantly greater improvements in symptoms, life satisfaction, and perceived health status. CONCLUSIONS: Relative to usual community care, the ACT program for homeless persons with severe and persistent mental illness shifts the locus of care from crisis-oriented services to ongoing outpatient care and produces better housing, clinical, and life satisfaction outcomes.

Quality of life and clinical predictors of rehospitalization of persons with severe mental illness.

OBJECTIVE: The study examined whether rehospitalization of patients with severe and persistent mental illness could be predicted by patients' quality of life. The predictive ability of two clinical factors associated with rehospitalization--history of hospitalizations and severity of symptoms--was also examined. METHODS: A total of 559 patients were assessed at two follow-up points, two and 12 months after an index hospital discharge. Patients who were rehospitalized and those who were not rehospitalized between the two follow-up points were compared on subjective and objective quality of life, symptom severity at first follow-up, and previous rehospitalization. Multivariate analysis was used to determine the best predictors of rehospitalization. RESULTS: Compared with patients who were not rehospitalized, those who were rehospitalized had more severe symptoms and were more likely to have a history of hospitalization. Rehospitalized patients reported more dissatisfaction with family relations and were more likely to report an arrest in the past two months. The two groups did not differ in other quality-of-life domains and in global quality of life. CONCLUSIONS: The best predictors of rehospitalization were previous rehospitalization, more severe symptoms, and dissatisfaction with family relations. Interventions should promote positive relationships between patients with severe mental illness and their families to reduce the risk of relapse and rehospitalization.

Continuity of care and client outcomes in the Robert Wood Johnson Foundation program on chronic mental illness.

The impact on services and outcomes of the local mental health authorities (LMHAs) developed under the RWJF Program on Chronic Mental Illness (CMI) was evaluated in Baltimore, Cincinnati, Columbus, and Toledo. Two cohorts of clients with CMI discharged from an episode of acute 24-hour care were recruited in each city: the first cohorts were drawn shortly after the demonstration began and the second, two years later. The LMHAs in the three Ohio cities increased case management for the second cohorts at two months, but not at 12 months, after hospital discharge. The second cohorts in Baltimore and Cincinnati experienced lower turnover among case managers during the year after discharge, but there was no significant improvement in client outcomes. Creation of LMHAs may be a necessary, but not sufficient, step toward improving outcomes and should be followed by improvement in the quantity and quality of services.

Convergent validation of quality of life assessments for persons with severe mental illnesses.

The impact of interventions on the quality of life (QOL) experienced by persons with severe and persistent mental illnesses (SPMI) has attracted considerable political, clinical and research attention over the past decade, and continues to do so. This study examines the convergent validity of two commonly used QOL measures for this group of patients, the Lehman Quality of Life Interview and the Heinrichs-Carpenter Quality of Life Scale, computing the correlations between comparable constructs from the two measures administered at the same time and 2 months apart. Correlations were positive and significant although low to moderate in magnitude. Considering the considerable differences in the methods of assessment employed by the two measures, the lack of precise congruence between their constructs, and the 2-month time interval, these findings support their convergent validity. Various conceptual issues regarding the validity and interpretation of QOL assessments for persons with SPMI are discussed.

Effectiveness in delaying the initiation of sexual intercourse of girls aged 12-14. Two components of the Girls Incorporated Preventing Adolescent Pregnancy Program.

PIP: The Girls Incorporated, formerly Girls Clubs of America, program in Preventing Adolescent Pregnancy, which was initiated in 1985, was evaluated to obtain information about sexual behavior and attitudes related to pregnancy, educational and career expectations, and sociodemographic characteristics, and to ascertain the effectiveness of 2 components for girls aged 12-14 in delaying early sexual involvement. The theoretical base of intervention is discussed and delineation of 3 themes recurrent in the literature. Program interventions are also described. The 2 program components evaluated were Will Power/Won't Power which taught skill in general and specific assertiveness, and Growing Together, which facilitated communication between parents and daughters. The sample consisted of 412 virgin girls 12-14 years, of which 25% did not participate in either program, from communities in which the adolescent pregnancy rate was higher than the national average. Participants were required to have completed 1 complete year which included before and after surveys. 257 participated in Will Power/Won't Power; 84 in Growing Together; and 46 in both programs. Participants and nonparticipants were similar in background characteristics. The profile was one of primarily African American 12 year olds of a Protestant religion. Growing Together participants were slightly different and less likely to engage in early sexual intercourse. The findings of the bivariate and logistic regression analyses were that nonparticipants were 2.5 times more likely to initiate sexual intercourse during the study year than participants in Growing Together, but this was only marginally statistically significant. It is suggested however that when controlling for age, religion, race and having contact with a pregnant teen that Growing Together participation contributed to a delay in the initiation of sexual intercourse. Participation in Will Power did not account for any differences in likelihood of initiating sexual activity, although those who participated for a short time were 3 times more likely to initiate sexual activity than those participating longer. Analysis of selection bias among the 3 groups found that at best there was a weak indication of selection bias on the academic performance variable, but no relationship on the contact with a teen pregnancy variable. The authors concluded that the findings were consistent, although not always statistically significant, and that the Will Power, and particularly both programs, delayed initiation of sexual activity. Affiliate implementation occurred before evaluation with some minor changes. Further refinements are expected based on continual analysis of impact.^ieng