Characteristics of Medicaid Recipients Receiving Persistent Antipsychotic Polypharmacy.

Antipsychotic polypharmacy (APP) is a common strategy despite guidelines advising against this practice. This article seeks to quantify the prevalence and correlates of APP using Medicaid Analytic eXtract files from 2003 to 2004. Nineteen percent of Medicaid recipients who received an antipsychotic were treated with APP. Individuals who received APP were more likely to be white, male, disabled, between the ages of 18-29, diagnosed with a psychotic disorder, and diagnosed with a higher number of psychiatric conditions. Geographic variation in APP rates was also observed. Quality improvement initiatives may help reduce APP for medically vulnerable patients.

Randomized Trial of a Mobile Personal Health Record for Behavioral Health Homes.

OBJECTIVE: Behavioral health homes, which provide onsite primary medical care in mental health clinics, face challenges in integrating information across multiple health records. This study tested whether a mobile personal health record application improved quality of medical care for individuals treated in these settings. METHODS: This randomized study enrolled 311 participants with a serious mental illness and one or more cardiometabolic risk factors across two behavioral health homes to receive a mobile personal health record application (N=156) or usual care (N=155). A secure mobile personal health record (mPHR) app provided participants in the intervention group with key information about diagnoses, medications, and laboratory test values and allowed them to track health goals. The primary study outcome was a chart-derived composite measure of quality of cardiometabolic and preventive services. RESULTS: At 12-month follow-up, participants in the mPHR group maintained high quality of care (70% of indicated services at baseline and at 12-month follow-up), in contrast to a decline in quality for the usual-care group (71% at baseline and 67% at follow-up), resulting in a statistically significant but clinically modest differential impact between the groups. No differences between the study groups were found in secondary self-reported outcomes, including delivery of chronic illness care, patient activation, and quality of life related to mental or general medical health. CONCLUSIONS: Use of a mPHR app was associated with a statistically significant but clinically modest differential benefit for quality of medical care among individuals with serious mental illness and comorbid cardiometabolic conditions.

Neighborhood Predictors of Outpatient Mental Health Visits Among Persons With Comorbid Medical and Serious Mental Illnesses.

OBJECTIVE: Individuals with serious mental illnesses are at risk of receiving inadequate outpatient mental health services, increasing the likelihood of medication nonadherence, readmission, and self-harm. The purpose of this study was to identify individual- and neighborhood-level factors associated with outpatient mental health visits. METHODS: This study included 418 participants from two randomized trials of patients with comorbid medical conditions and serious mental illnesses across two study sites between 2011 and 2017. On the basis of individual addresses, data were collected about participants' distance to the nearest mental health facility and 13 neighborhood characteristics from the American Community Survey. Three neighborhood-level factors were derived from factor analysis. Poisson regression was used to assess associations between individual- and neighborhood-level characteristics and the number of visits to mental health providers. Known individual-level risk factors for outpatient follow-up were mutually adjusted in a model with neighborhood covariates added. RESULTS: Male gender, older age, unemployment, and lower education level were associated with less outpatient mental health service utilization. Neighborhood-level residential mobility, defined as the combination of percentage of residents living in a different house in the past year and percentage of non-owner-occupied housing, was significantly associated with fewer mental health service visits even after controlling for other neighborhood- and individual-level factors. CONCLUSIONS: Among individuals with comorbid medical conditions and serious mental illnesses, living in neighborhoods with higher residential mobility was associated with fewer visits to outpatient mental health providers. This finding suggests the importance of recognizing social conditions that may shape clinical interactions.

Peer-Led Self-Management of General Medical Conditions for Patients With Serious Mental Illnesses: A Randomized Trial.

OBJECTIVE: Individuals with serious mental illnesses have high rates of general medical comorbidity and challenges in managing these conditions. A growing workforce of certified peer specialists is available to help these individuals more effectively manage their health and health care. However, few studies have examined the effectiveness of peer-led programs for self-management of general medical conditions for this population. METHODS: This randomized study enrolled 400 participants with a serious mental illness and one or more chronic general medical conditions across three community mental health clinics. Participants were randomly assigned to the Health and Recovery Peer (HARP) program, a self-management program for general medical conditions led by certified peer specialists (N=198), or to usual care (N=202). Assessments were conducted at baseline and three and six months. RESULTS: At six months, participants in the intervention group demonstrated a significant differential improvement in the primary study outcome, health-related quality of life. Specifically, compared with the usual care group, intervention participants had greater improvement in the Short-Form Health Survey physical component summary (an increase of 2.7 versus 1.4 points, p=.046) and mental component summary (4.6 versus 2.5 points, p=.039). Significantly greater six-month improvements in mental health recovery were seen for the intervention group (p=.02), but no other between-group differences in secondary outcome measures were significant. CONCLUSIONS: The HARP program was associated with improved physical health- and mental health-related quality of life among individuals with serious mental illness and comorbid general medical conditions, suggesting the potential benefits of more widespread dissemination of peer-led disease self-management in this population.

Lung cancer mortality in relation to age, duration of smoking, and daily cigarette consumption: results from Cancer Prevention Study II.

The magnitude of the effect of smoking duration on lung cancer mortality relative to that of intensity (cigarettes/day) has practical implications for both tobacco control policy and research. This issue was addressed by R. Doll and R. Peto (J. Epidemiol. Commun. Health, 32: 303-313, 1978) in their historic analysis of one of the few large cohort studies in which intensity and duration were estimated separately. Their findings have been interpreted to mean that smoking duration is much more important than smoking intensity in causing lung cancer. The separate contributions of smoking duration and intensity to lung cancer risk have not been evaluated in other large prospective studies. We studied participants in the Cancer Prevention Study II, followed from 1982 through 1988. After restricting to people 40-79 years old who smoked < or =40 cigarettes per day at enrollment, we fit Poisson models for four age groups and evaluated lung cancer mortality (M) in relation to smoking duration (D) and intensity (I) on a double-log scale, as suggested by the Armitage-Doll multistage carcinogenesis model. The age-specific mortality estimates for men (M(m)) and for women (M(w)), when transformed to the original scale, were: ages 40-49: M(m) = e(-17.9) x D(1.9) x I(0.95), M(w) = e(-20.2) x D(2.8) x I(0.96); ages 50-59: M(m) = e(-17.4) x D(2.6) x I(0.52), M(m) = e(-17.2) x D(2.2) x I(0.75); ages 60-69: M(m) = e(-15.7) x D(2.4) x I(0.37), M(m) = e(-14.1) x D(1.5) x I(0.78); ages 70-79: M(m) = e(-13.0) x D(1.8) x I(0.39), M(m) = e(-13.2) x D(1.3) x I(0.95). Our study confirms that years of cigarette smoking is far more important than the number of cigarettes smoked per day in predicting lung cancer risk in United States men, regardless of age, and provides new evidence that a qualitatively similar pattern holds for women. The results support measures to prevent the uptake of smoking by adolescents and increase cessation. We discuss reasons why the associations we observe are lower than those reported by R. Doll and R. Peto (J. Epidemiol. Commun. Health, 32: 303-313, 1978).