Use of electronic technologies to promote community and personal health for individuals unconnected to health care systems.

Ensuring health care services for populations outside the mainstream health care system is challenging for all providers. But developing the health care infrastructure to better serve such unconnected individuals is critical to their health care status, to third-party payers, to overall cost savings in public health, and to reducing health disparities. Our increasingly sophisticated electronic technologies offer promising ways to more effectively engage this difficult to reach group and increase its access to health care resources. This process requires developing not only newer technologies but also collaboration between community leaders and health care providers to bring unconnected individuals into formal health care systems. We present three strategies to reach vulnerable groups, outline benefits and challenges, and provide examples of successful programs.

Prevalence, correlates, and symptom profiles of depression among men with a history of military service.

PURPOSE: The purpose of this study was to examine the prevalence, correlates, and symptom profiles of depressive disorders in men with a history of military service. METHODS: Data were obtained from the 2006 Behavioral Risk Factor Surveillance System survey. Multivariable logistic regressions were used to identify correlates of lifetime and current depression. Regularly occurring symptom profiles were identified via cluster analysis. RESULTS: Prevalence of lifetime and current depression was similar in men with and without a history of military service. Younger age was positively, and black minority status, being in a relationship and self-reported good health were negatively associated with a lifetime diagnosis of depression. Other minority status (non-Hispanic, non-black) was positively, and older age, some college, being in a relationship, and self-reported good health were negatively associated with current depression. A cluster of younger men who experience significant depressive symptoms but may not report depressed mood or anhedonia was identified. CONCLUSIONS: Depression is as prevalent in men with a history of military service as it is in men without a history. Research should focus on subpopulations of men with a history of military service in which depression may be more prevalent or burdensome. Younger men with significant depressive symptoms may be missed by standard depression screens and still be at elevated risk for negative outcomes associated with depression.

The cost-effectiveness of the Manchester 'lung health checks', a community-based lung cancer low-dose CT screening pilot.

BACKGROUND: Previous evaluations of low-dose CT (LDCT) lung cancer screening programmes have taken very different approaches in the design of the informative trials and the methods applied to determine cost-effectiveness. Therefore, it has not been possible to determine if differences in cost-effectiveness are due to different screening approaches or the evaluation methodology. This study reports the findings of an evaluation of the first round of a community-based, LDCT screening pilot Manchester, applying previously published methodology to ensure consistency. METHODS: Using the economic evaluation method reported in the UKLS trial, applying Manchester specific evidence where possible, we estimate the cost-effectiveness of LDCT for lung cancer. Estimates of the total costs and quality adjusted life years (QALYs) were calculated. RESULTS: The Manchester programme cost £663,076, diagnosed 42 patients with lung cancer resulting in a gain in population health of 88.13 discounted life years, equivalent to 65.85 QALYs. This implied an incremental cost-effectiveness ratio of £10,069/QALY. CONCLUSIONS: We found the Manchester programme to be a cost-effective use of limited NHS resources. The findings suggest that further research is now needed not as to whether LDCT screening is cost-effective but under what conditions can it improve patient health by the most while remaining cost-effective.

The history of clozapine and its emergence in the US market: a review and analysis.

Clozapine is known as the first 'atypical' medication and is effective in people who have treatment-resistant schizophrenia. Its 1990 emergence in the USA was marked by considerable controversy over its high cost, due in large part to having been both the first new antipsychotic medication to come to market in over a decade and the need for comprehensive safety monitoring within a decentralized health system. This paper traces the history of clozapine's discovery and development in Europe, its part in the 1975 Finnish agranulocytosis scare, and its subsequent volatile emergence in the USA. Analyses examine peripheral forces at the time, particularly the influence of political, corporate, medical and societal forces which shaped its market course.

Prevalence of the metabolic syndrome among patients receiving clozapine.

OBJECTIVE: This study compared the prevalence of the metabolic syndrome among outpatients with schizophrenia and schizoaffective disorder receiving clozapine with a matched comparison group from the National Health and Nutrition Examination Survey. METHOD: Ninety-three outpatients and a matched group of 2,701 comparison subjects were compared according to National Cholesterol Education Program criteria. Outpatient data were obtained through physical assessments, laboratory testing, and reviews of medical records. RESULTS: The prevalence of the metabolic syndrome was significantly higher among clozapine patients (53.8%) than among the comparison group (20.7%). For clozapine patients, logistic regression analysis revealed significant associations with age, body mass index, and duration of clozapine treatment. Only age and body mass index were associated with the prevalence of metabolic syndrome in both groups. CONCLUSIONS: Patients receiving clozapine are at significantly increased risk for developing the metabolic syndrome. Psychiatrists and other providers should consider performing regular physical health monitoring to prevent long-term adverse health consequences.

Diabetes mellitus among outpatients receiving clozapine: prevalence and clinical-demographic correlates.

BACKGROUND: Treatment with antipsychotic drugs has been associated with increased risk for developing diabetes mellitus. Recent consensus statements suggest that clozapine may pose an especially high risk. The purpose of this study is to examine the prevalence and clinical-demographic correlates of diabetes among outpatients with DSM-IV-diagnosed schizophrenia or schizoaffective disorder receiving clozapine. METHOD: One hundred one outpatients receiving clozapine at the University of Rochester Department of Psychiatry, Rochester, N.Y., were evaluated between September 2002 and September 2003. Demographic data were collected from medical records, and body mass index (BMI) and body fat measurements were conducted. Diagnosis of diabetes was established through review of medical records and fasting blood glucose testing. Associations between clinical and demographic variables and diabetes were examined using t tests, Fisher exact tests, and logistic regression. RESULTS: Mean (SD) age of patients was 40.4 (9.5) years, and 79% were white. Mean (SD) dose and duration of clozapine treatment were 426 (164) mg/day and 5.7 (3.6) years, respectively. Point prevalence of diabetes was 25.7%. Mean (SD) BMI was 32.6 (8.0) kg/m(2), and mean (SD) body fat was 34.0% (11.0%). Logistic regression revealed significant associations between diabetes and nonwhite race/ethnicity and family history of diabetes (p = .02 and .002, respectively). No significant associations were found between diabetes prevalence and BMI or body fat. CONCLUSION: Patients receiving clozapine are at substantial risk for developing diabetes, although the level of risk relative to other antipsychotic medications has not been fully determined. Clinicians should monitor all severely mentally ill patients receiving antipsychotic drugs for diabetes, with closer monitoring of patients with established demographic risk factors.

Prevalence of diabetes mellitus among outpatients with severe mental disorders receiving atypical antipsychotic drugs.

BACKGROUND: Recent studies have suggested that patients receiving atypical antipsychotic drugs are at increased risk for developing diabetes mellitus. The purpose of this study is to examine the prevalence of diabetes in a group of adults with schizophrenia and other severe mental disorders receiving atypical antipsychotic drugs within a community mental health center setting. METHOD: A retrospective chart review was conducted on 436 outpatients receiving either atypical antipsychotic or decanoate antipsychotic drugs at a community mental health center. Diagnosis of diabetes was established through the presence of documentation in the medical record. Patients with a history of diabetes prior to age 18 years were excluded. Data were gathered from April 2001 through September 2002. RESULTS: The mean (SD) age of patients was 42.5 (10.8) years, and 57.3% were men. Patients were 61.5% white, 31.8% black, 5.3% Hispanic, and 2.3% other. Seventeen percent of patients had a positive family history of diabetes. Point prevalence of diabetes was 14.2% for the entire group. Chi-square analysis for the group revealed significant effects of age (chi(2) = 16.514, p <.001), family history of diabetes (chi(2) = 27.128, p <.001), and gender (chi(2) = 14.114, p <.001). A trend was noted toward a higher prevalence of diabetes among patients receiving atypical drugs (15.2%) compared with those receiving decanoate drugs (6.3%) (chi(2) = 2.984, p =.078). CONCLUSION: Prevalence of diabetes mellitus among outpatients with severe mental disorders receiving atypical antipsychotic drugs is substantially higher than that reported in the general population. Results of this study are limited by the retrospective methodology, which may underestimate actual prevalence by failing to detect undiagnosed cases.

Mental health services use and symptom prevalence in a cohort of adults on probation.

OBJECTIVE: This study examined the prevalence of mental disorder symptoms among adult probationers and the probability of mental health service use. METHODS: Data from the 2001 National Household Survey on Drug Abuse were used to obtain information on adults reporting mental disorder symptoms who had been on probation within the past year and those who had not. RESULTS: Twenty-seven percent of probationers (N=311 of 1,168) and 17% of nonprobationers (N=5,830 of 34,230) had mental disorder symptoms. Mental health service use was reported by 23% of both groups. Compared with persons who had not been on probation, probationers were more likely to report psychosis, mania, and posttraumatic stress disorder; both groups were as likely to report depression. CONCLUSIONS: The prevalence of mental disorder symptoms did not differ by probation status. However, the type and distribution of symptoms were significantly different in the two groups. These are important considerations when planning for service connection with mental health providers.

Predictors of arrest during forensic assertive community treatment.

OBJECTIVE: An emerging adaptation of the assertive community treatment model is forensic assertive community treatment (FACT), which aims to prevent criminal recidivism. This study examined predictors of arrest among patients in a prototype program and considered the implications of study findings for future development of the FACT model. METHODS: Demographic and clinical data from all 130 patients treated in Project Link from 1997 through 2003 were merged with a statewide criminal record database to identify variables associated with arrest. RESULTS: Poisson regression revealed a history of arrests for violent offenses before treatment and evictions from residential treatment, and antisocial traits were associated with arrest during treatment. Substance abuse was not associated with arrest, but the sample lacked heterogeneity for this factor. CONCLUSIONS: Variables associated with arrest were similar to those seen in the general population. In the absence of a standardized model of intervention, FACT programs should incorporate interventions that target modifiable risk factors in order to prevent criminal recidivism among high-risk patients.

Assessing patient preferences for delivery of reminders on scheduled visits in a psychiatry ambulatory service.

Reminder systems can improve compliance with care standards, yet reminder delivery parameters and associations with other success factors have not been fully understood. In this study, we assessed patient preferences for reminder delivery in a psychiatry ambulatory service, using both quantitative and qualitative analyses. Results from a survey showed that most patients had a positive attitude to reminders for both scheduled (76%) and missed (89%) visits. Phone call (61%) delivered two days before an appointment (47%) was the most preferred type and time of reminder delivery. Logistic regressions on survey data showed that preferences of reminder delivery parameters were associated with service types and patient populations, which was cross-validated by follow-up interviews with the staff at two study sites. A single-mode reminder delivering method cannot satisfy different types of patients. Intervention designs that involve building a system with a variety of methods customized to patient needs and balanced with administrative simplicity need to be further studied.